Professional Responsibility, Ethics and Influenza Immunization of Health Care Workers

Hoven MA*

Department of Philosophy and Religious Studies, Utrecht University, Netherlands

*Corresponding author: Hoven MA, Ethics Research Institute for Philosophy and Religious Studies (OFR), Utrecht University, Janskerkhof 13A, 3512 BL Utrecht, The Netherlands

Received: June 01, 2015; Accepted: June 03, 2015; Published: June 04, 2015

Abstract

In this contribution arguments in favor of Health Care Worker (HCW) immunization are reviewed. It is noticed that most arguments strongly rely on evidence to support claims why HCW have a moral responsibility to be immunized. Evidence is often easily contested, but can also lead to assumptions regarding the strength of the moral duty. Instead, professional responsibility is put forward as evidence-free argument in favor of immunization that can lead to strong moral responsibilities.

Introduction

The CDC recommends Health Care Workers (HCW) to be immunized against influenza [1]. Arguments to support this advice derive from various studies that focus on e.g. the vector that staff can be to spread the virus in institutions [2]; the benefit for the health of patients [3] and the decrease in mortality rates when staff has been immunized [4]. At the same time, for many HCW immunization is not default practice. Several studies show low uptake in nurses [5], and reviews on the effects of staff immunizations are not unilateral in favor of immunization [6]. In this contribution I will argue that most arguments in the debate strongly rely on evidence, namely the effectiveness of the immunization of HCW. This focus leads to serious limitations and has assumptions that can be disputed. Another option is to focus on professional responsibility as a promising line of argumentation.

A Focus on Effects of Immunization

Not surprising, most arguments offered in favor of staff vaccination focus on the effects of immunization. Statistics are used to show the burden of illness due to influenza infection (hospital admittance, mortality, the serious effects of influenza illness amongst certain patient groups, etc.), and are balanced against of immunization, like side effects of the vaccine, and the free choice of HCW. Since the early ‘90’s evidence is found between HCW and the introduction of influenza viruses in institutions, the vector function of HCW and a decrease of mortality when staff is immunized [6,7,8]. A recent study shows a relation between increasing immunization rates of HCW and lower influenza rates among patients [9]. It is also demonstrated that vaccination also protects unvaccinated persons [9]. The underlying argument goes as follows: if harm can be prevented, namely protecting serious consequences of influenza illness among vulnerable patients, there is a moral responsibility for HCW to be immunized [10]. The argument also applies if it is not focused on prevention of harm, but on additional benefit – herd immunity – although intuitively this is morally less binding. The argument in general focuses on the balance of positive and negative consequences, hence the side effects and persuasion of staff seems to be outweighed by considerations that benefit or prevent harm among patients and residents.

This focus on consequences – namely positive effects - has great intuitive appeal, yet is limited in some serious ways. One is that facts or foreseeable consequences can be disputed. If review studies are unable to find much support for positive effects of HCW immunization (Cole et al.) or conclude that the overall quality of evidence is moderate, this will easily lead to criticism and rejection of moral responsibility [4]. Offley argues that all evidence is normatively laden, both arguments in favor and against. He points out that the burden of disease is generally overestimated and needs to be adjusted to ‘real influenza deaths’, and the number of influenza illnesses is difficult to establish, but probably much lower than the occurrence of influenza-like illnesses, against which a vaccine will not help [11].

Surprisingly, nobody has questioned the assumptions underlying this utilitarian type of reasoning. It seems that the stronger the evidence, the stronger the moral responsibility, thus a loose correlation will not lead to strict duties. Because of the poor overall evidence so far, authors have a hard time to determine what the responsibility of HCW should consist of, and what type of evidence is required to support this. Griffin simply argues that even though evidence is not as strong as one might like, on balance it can be concluded that ‘vaccination of HCW …should be viewed as and evidence-basedrecommendation’ [12] Mandatory immunization seems a most cost-effective way to organize immunization of staff, thus mandatory immunization seems justifiable. Yet, this argument is not convincing when evidence is weak.

Arguments from Professional Responsibility

Some authors offer other arguments in favor of immunization. One is to focus on a deontological duty no to harm people. Mostly, though, this argument is offered as an argument of professional responsibility: HCW should prevent to do harm to their patients. This argument still strongly relies on evidence that HCW influence the harm done to patients in case of influenza illness. Some authors have little confidence in arguments based on professional responsibility, because only a small number of employees is actually a professional [12]. We will argue that such arguments are more promising than has been acknowledged so far. It is an important moral responsibility for HCW to look after the wellbeing and health of patients and to refrain from harming them. Even though this argument still relies on some evidence that HCW are able to prevent harm and support the wellbeing of patients by being immunized, weak evidence already leads to strong moral responsibilities. A different type of argument is even less vulnerable to evidence, which we call an argument for constitutional professional solidarity: ‘Even if the effects of immunization of HCW are not fully clear, the norm ‘better safe than sorry’ should apply within institutional care, as a kind of deontic norm. It is an argument to show solidarity with humans who are more vulnerable and have no choice but to be institutionalized.’ [13]. Lantos and Jackson make a similar claim, stating that it is an argument from intra staff justice and fairness that will be most convincing in HCW immunization debates. Staffs will ‘voluntarily make compromises and sacrifices for the good of the patient… it is the price (of curtailment of individual liberty) (MvdH added) we must pay for living together in a safe community.’ ([9] Some might argue that this is a communitarian type of argument and that it is not effective if you don’t embrace it as such. But this is not the case. Everyone who is employed in a health care facility has to accept the core aim(s) of these facilities, which is to protect and stimulate the health and wellbeing of patients and residents. It is inherent part of your professional occupation, which cannot be neglected or rejected. Finally, would such a professional responsibility be strong enough to support mandatory immunization? We think that it is a different debate to argue for mandatory or optional immunization, as voluntary schemes can be highly effective as well as is shown in immunization rates in the Netherlands. It would be interesting to explore what ‘nudges’ could do to support uptake between HCW in voluntary schemes, as this could lead to a situation where HCW are gently pushed towards immunization leaving them to opt out. All we have established so far is that it is hard to ignore a moral responsibility to be immunized.

Conclusion

It is argued that many, if not most arguments strongly rely on evidence; effects that show a relation between HCW vaccination and prevention of harm among patients. These arguments have serious limitations. Arguments from professional responsibility are less relying on evidence to be convincing and are therefore a more promising line of argumentation.