Ethical Dilemmas Associated with Vaccinations: A Public Health Perspective
>> Friday, April 30, 2010
The H1N1 Pandemic Influenza outbreak of 2009 is the fourth major medical pandemic in the past 100 years. The Centers for Disease Control emphasize that vaccination is the best way to provide protection from influenza. Research indicates that flu shots are almost 88% effective at reducing the risk of flu infection and that they reduced by one-half the number of deaths among hospital patients from the disease. Despite recommendations, rates of vaccinations are seen as falling short of their full potential to reduce morbidity and mortality in the United States and abroad. Personal autonomy, an important value within the ethical framework of our society, is viewed as a roadblock in accomplishing greater vaccination rates.
Many strategies used to improve vaccination rates are ethically and economically mandated. On average, health care workers (HCW) usually do not have greater than 40% response rate to flu vaccinations each year (March, 2005). With low incidence of health care worker vaccination, mandatory HCW vaccination has been invoked by some states as it relates specifically to H1N1 influenza.
In a study of reasons why HCWs fail to receive vaccinations, Takayanagi, Cardoso, Costa, Araya, & Machado (2006) found that noncompliance was related to perceptions that vaccines are ineffective, produced adverse effects, and were inconvenient. Non-compliant study participants felt they were given insufficient time for vaccination and disliked medications.
Public health history indicates that vaccinations are recognized as the most efficient and cost-effective means of preventing and ameliorating infectious diseases. This has raised ethical concerns about compulsory immunization requirements, which are used to achieve sufficient comprehensive protection for the community, because they restrict personal autonomy. According to Marckman (2008), restrictions of personal autonomy may be ethically justified if the following five conditions are met: (1) there is proven benefit, (2) there is a favorable benefit-risk-ratio, (3) the cost-benefit ratio is acceptable, (4) restrictions are minimized so far as is possible and (5) decision procedures are fair and transparent. How these five criteria are met may depend on the strength of the recommendation of each immunization program. There are ethical and pragmatic arguments against compulsory vaccination enforced by law. It is widely recognized that governmental organizations should attempt to strengthen public support and trust in vaccination programs by developing a proactive and persuasive information policy.
As with many concerns regarding the provision of public health, there are conflicts that develop between the private benefits to the individual and the greater good of society. Historically, personal self-interest and individual choice have produced lower vaccination rates, often much lower than public health agencies perceive as the optimum level. Yet, as the concept of herd immunity suggests, societal benefits are greater than individual benefit. Persons with faith based concerns, health and medical matters or social reasons are often given exemption from vaccination. Controversies exist over the effectiveness of public intervention compared to the free choice outcome of vaccination (Sadique, 2006).
In social strategic response, discussion continues whether vaccinations should be mandated. Since a mandate is an authoritative order, which carries a stronger meaning than a recommendation or a standard of care, many feel that minimally a mandate should provide an opportunity to opt-out and include some penalty for refusing to abide by it. Health care organizations have allowed their employees to opt out of vaccination, but the employee must sign waivers and wear a mask at all times when engaging in patient care.
Use of the word mandate and relaxing the opt-out provisions could eventually pose a risk to efforts towards public health interventions. Efforts like childhood vaccination have provided significant decreases of morbidity and mortality alike for the past 50 years. However, confusion exists in the minds of many about (a) what a mandate is, and (b) the criteria that should be used when determining the public health intervention that should be mandated. This confusion may lead to inappropriate policy decisions (Wynia, 2007).
References
March, D. (2005). Johns Hopkins flu expert calls for mandatory vaccination of health care workers. Johns Hopkins Medicine. Retrieved on October 17, 2009, from http://www.hopkinsmedicine.org/Press_releases/2005/11_09_05.html
Marckmann, G. (2008). Vaccination programs between individual autonomy and common welfare. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsshutz, 51(2):175-83. Retrieved on November 24, 2009, from http://www.ncbi.nlm.nih.gov/pubmed/18227984.
Sadique, M. (2006). Individual freedom versus collective responsibility: an economic epidemiology perspective. Emerging Themes in Epidemiology, 3(12), pp. 1-2. Retrieved on November 25, 2009, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1609166/pdf/1742-7622-3-12.pdf
Takayanagi, I., Cardosa, M., Costa, S., Araya, M., & Machado, C. (2007). Attitudes of Health care workers to influenza vaccination: why are they not vaccinated? American Journal of Infection Control, 35, 56-61.
Wynia, M. (2007). Mandating vaccination: What counts as a mandate in public health and when should they be used? American Journal of Bioethics, 7 (12), 2-6. Retrieved on November 23, 2009, from http://www.ncbi.nlm.nih.gov/pubmed/18098005ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=4&log$=relatedarticles&logdbfrom=pubmed
0 comments:
Post a Comment