Ask the Ethicist: Should health care organizations mandate influenza vaccinations for staff members as a condition of employment?

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It’s that time of year again: flu season. Every year at this time influenza vaccinations for health care workers becomes a hot topic of conversation, and this year is no exception. In fact the topic is even hotter this year as a result of a growing movement in Ontario to mandate annual influenza vaccinations for health care workers.

Public Health Ontario recently revised its best practice guidelines for infection prevention and control programs to state that annual influenza vaccinations should be a condition of continued employment in, or appointment to, health care organizations in Ontario (with exceptions for workers with medical contraindications). Toronto’s board of health has sent a letter to the CEOs of all Toronto health care organizations urging them to adopt mandatory influenza vaccination policies. So I thought this would be a good time to explore the ethics of such a mandatory vaccination policy.

Before we evaluate the ethics of a mandatory policy, let’s first look at the reasons why it is important for health care workers to get vaccinated annually for influenza. What we know is that influenza outbreaks in health care organizations cause harm to patients and long term care residents through increased morbidity and mortality.

Many patients and residents in health care organizations are vulnerable to influenza infections because they are immune-compromised. As a result, influenza can hit them much harder than it does people who are otherwise healthy. Health care workers who aren’t vaccinated run the risk of infecting their patients or residents with influenza, especially since they can be contagious for several days before showing symptoms.

A single health care worker infected with influenza can put a dozen or more patients at risk of infection before even realizing he or she is sick. There is also a growing body of evidence that vaccination of health care workers does reduce the rates of hospital acquired influenza and mortality of long term care residents. Since the primary ethical obligation of all health care providers is to promote the interests of their patients, there is a strong ethical reason for getting vaccinated as a health care worker.

The problem is that relying on individual health care workers (HCW) to fulfill their ethical obligations by getting vaccinated hasn’t worked.  Despite intensive efforts on the part of health care organizations to increase their staff vaccination rates, those rates continue to be exceedingly low.  In 2011/2012, the median influenza immunization coverage rate among HCWs in Toronto was 48 per cent (ranging from 25 to 67 per cent) for acute care facilities, 60 per cent (ranging from 21 to 87 per cent) for complex continuing care facilities, and 72 per cent (5 to 100 per cent) among long term care homes (Medical Officer of Health bulletin, June 7, 2012).  One of the ethical principles that governs decisions to interfere with people’s liberty is that less intrusive means should always be attempted first; what the data shows is that the less intrusive means have not been successful at raising the health care worker vaccination rates to an acceptable level. Thus, the push for mandatory vaccination policies.

What are the ethical concerns with a mandatory vaccination policy? For one thing, there is the well-entrenched right to refuse medical treatment that stems from our deeply held moral values of personal autonomy and bodily integrity. This is particularly relevant in the vaccination context as there is a segment of the population that strongly objects to the injection of vaccines into their bodies. That said, violations of personal autonomy can be ethically justified if there is a compelling reason to do so, such as risk of harm to others (quarantine in an infectious disease outbreak is an example). One could also argue that making vaccinations a condition of employment doesn’t represent forced medical treatment because health care workers would be given a choice: accept the vaccination or work somewhere else (or pursue another line of work altogether). There are also analogous cases of medical requirements for employment in the health care sector, such as demonstration of immunity to MMR and a negative TB test.

There are other considerations to take into account, however. One is that any attempt to impose a mandatory policy would no doubt result in union grievances and legal challenges, which can have resource implications for the organizations. Another consideration, especially if individual organizations are left to impose their own policies, is that such policies can have potentially detrimental effects on morale in those organizations. While many of the 50 per cent may simply acquiesce and get vaccinated, a mandatory policy runs the risk of alienating the workers who have strong objections to vaccinations. This impact on morale can have significant downstream consequences for an organization. I think we would all agree that the ideal scenario would be for health care organizations and health care providers to work together to find an effective way of protecting the health of our patients and residents.