Deciding Without Evidence: Does Margaret need to be vaccinated? Using Public Health Ethics in Developing a Decision-Making Framework

for Fair Mandatory Vaccination of Health Care Personnel By Jean-Christophe Bélisle Pipon, PhD Student in Bioethics & Marjolaine Frenette, RN, Masters Student in Bioethics, Université de Montréal

Background Nosocomial seasonal influenza is associated with deaths and prolonged hospitalizations, and a known vector of transmission is healthcare personnel (HCP). Attaining specific vaccination targets for seasonal influenza campaigns likely drives health institutions decision-makers to a slippery slope with two possible inclinations: it can lead either to mass vaccination of all staff, or following the invocation of either a strong or weak version of the precautionary principle, to inaction and thus to no vaccination of some/all staff.

Scope In the absence of strong evidence regarding the efficiency of the vaccination to prevent nosocomial influenza infection, where should we draw the line between mass vaccination and no vaccination? To empower decision-makers with pragmatic ethical rationales, we suggest a working model to support institutional decision-making.

Results Neither end of the slippery slope (mass vaccination and no vaccination) is ethically justifiable; one will harm the most vulnerable patients and the other will recklessly affect too many individuals. To avoid falling into either extreme situations, we need to define what kind of risk is acceptable (and for whom?). Two conditions must be met in order to vaccinate: 1) enforceability of vaccination policies and 2) proximity with patients.

Methodology Based on Antonmaria’s public health ethics analysis (AJOB, 2013), we analyse the applicability of mandatory influenza vaccination programs (MVP) for HCP (anyone working within the boundaries of a healthcare institution) by suggesting a working model for fair mandatory vaccination of all health care personnel. The particular case of Margaret, a unit clerk at the local hospital, will be used to illustrate the explanation.

Discussion Should Margaret be vaccinated? Can the vaccination policies be applied to Margaret? Yes they can, since she is a hospital employee. What is her proximity with patients? Margaret’s job do not require any contact with the patients or the patients’ room, but she is in direct contact with the nursing and medical teams that work with patients. We can say that she has 2 degrees of separation with the patients. The fact that she works so closely with the care teams, make her an potential important vector of influenza. Therefore, following this model for fair vaccination, she must be part of the MVP. The model’s strengths are that: 1. It builds on fair application by

targeting for vaccination only those people who need to be included for patient protection;

2. It is easily adaptable to the particular realities of different institutions.

Conclusion Applying this model to all HCP (clinical and non-clinical) will help decision-makers to avoid getting onto a slippery slope. Considering the risks at stake, we need to remain cognisant that mandatory programs are not designed to be punitive or to restrict unduly individual liberty; rather, they should focus on what precaution demands in a health institution, ensuring patient safety.

Enforceability of vaccination policies Notion of control by health institutions over the actions that occur within their physical boundaries (i.e., employees’ having obligations, whether or not inscribed in a professional code, to fulfill their work responsibilities).

Proximity with patients Degree of separation between a person with a patient. This condition is bound to the degree of risk that the institution will accept in their MVP and should be established on the basis of studies demonstrating the relationship between distance and risk of transmission.

References Antommaria, A. H. M. (2013). An ethical analysis of mandatory influenza vaccination of health care personnel: Implementing fairly and balancing benefits and burdens. American Journal of Bioethics, 13(9): 30–37. Pipon JC, Frenette M. (2013). Mandatory influenza vaccination: how far to go and whom to target without evidence? American Journal of Bioethics, 13(9):48-50.

HCP Vaccination Slippery Slope