1 Requiring Immunizations for Health Care Workers: Fair and Just? Lisa M Lee, PhD, MS 2014 HEAL Conference April 11, 2014

2 Edmund D. Pellegrino

3 Action What we should do What we are able to do What we are permitted to do Approaching the Question

4 We should protect the vulnerable We should implement a comprehensive approach to ensure vulnerable populations (e.g., ill persons) are protected from seasonal influenza –Hand hygiene –Respiratory hygiene and cough etiquette –Isolation of infected patients and sick days for ill workers –Full vaccination of staff and patients Unless medically contraindicated Working Thesis

5 Which Lens of “Should”? HCW Immunization Clinical ethics lens

6 Which Lens of “Should”? Public health ethics lens HCW Immunization

7 Which Lens of “Should”? Justice lens HCW Immunization

8 Focus –Provider & patient interaction –Fiduciary duty to patient Principles –Respect for autonomy Respect choices based on personal values and beliefs –Nonmaleficence Obligation not to inflict harm –Beneficence Provide benefits to others –Justice (distributive) Fair access to or allocation of resources Clinical Ethics

9 Fiduciary duty versus HCW autonomy –Stems from Mill’s harm principle –Takes on special significance when one individual is healthy HCW & other is medically fragile patient Attempts to resolve: Professional obligation, special social status Reciprocal benefits assumption not met with influenza immunization –Population intervention, not individual intervention –Benefits accrue to individuals only when population is protected (herd immunity) Unresolved Tensions: Clinical Ethics Framework

10 Herd Immunity Ill Susceptible Immune

11 Focus: Community or population as ‘patient’ Duty to community’s health Principles –Least restrictive intervention to meet goal –Evidence-based action, precautionary principle –Health equity (reducing disparities) –Community engagement –Reciprocity When asked to act in the interest of the greater good, this act is facilitated Public Health Ethics

12 Takes us further than clinical ethics framework –Helps us with herd immunity –Addresses reciprocity resistance –Addresses health equity concerns –Allowable under precautionary principle Fails to fully address our obligations to contribute to the greater whole Additional Work and Unresolved Tensions of PH Ethics Frameworks

13 Justice is the first virtue of social institutions, as truth is of systems of thought. Rawls J. A Theory of Justice, p 3. Justice

14 Focus –Plurality, solidarity –Doing together what we cannot do alone Principles –Equity (different than health equity) How I would like to be treated if I were you –Obligation to follow the law Discretion to do only what one prefers nullifies the state’s ability to protect citizens –Fairness essential for cooperative schemes Role for every party, all responsible for their part Whole is greater than sum of its parts Justice

15 The 4-Way Stop

16 The 4-Way Stop

17 The 4-Way Stop

18 Protection for self depends on full participation of all –Benefits of cooperation far exceed individual action Exemptions –Challenging to acquire Promotes solidarity, fair distribution of burden Equitable in the just sense –Medical only Declared or reassigned to protect vulnerable Implications of Applying Justice

19 We should implement a comprehensive approach to ensure vulnerable populations (e.g., ill persons) are protected from seasonal influenza –Hand hygiene –Respiratory hygiene and cough etiquette –Isolation of infected patients and sick days for ill workers –Full vaccination of staff and patients Unless medically contraindicated Requiring all components is ethically justified to reach the goal of protecting vulnerable patient populations Working Thesis

20 Ethics is a social technology, one for which there are no experts. There is only the possibility of conversation, ideally free of factual mistakes and imbued with mutual sympathy. -- Philip Kitcher, Science in a Democratic Society (2011) p 12. Ethics and “Should”

21 Questions & discussion