PoPulationand Public HealtH etHics

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ManDatory iMMunization oF local Public HealtH eMPloyees Michelle Murti, M.D. University of Toronto Toronto ON MICHelle.MuRtI@utoRonto.Ca Introduction 114 Lisa Berger, M.D. Toronto Public Health Toronto ON A local public health unit wants to ensure that all of its employees are adequately immunized according to National Advisory Committee on Immunization (naCI) recommendations. 1 The planned policy mandates each employee to provide documentation that his or her immunizations are up-to-date. Employees with medical or religion/creed-based exemptions must provide documentation of their exclusion. These employees would be re-assigned in the event of a known exposure, to protect their health. Employees refusing immunization without an exemption must sign a declination statement attesting to the fact that they choose not to be immunized. In the event of a known exposure, these employees would be placed on leave without pay to protect their health. The health unit’s employees have a variety of interactions with the public, including with potentially vulnerable clients such as pregnant and breastfeeding women and patients in hospitals and long-term care facilities. A risk assessment of potential exposures and harms was used as the basis for mandated immunizations by job function. For example, hepatitis B vaccination is required to protect employees who may have occupational blood-borne exposures. Varicella (chickenpox) is universally required because any nonimmune employee may expose clients or co-workers before they are aware that they are infectious.
Case Mandatory immunization is contentious in any setting. While most public health practitioners support vaccination as a public good, implementing a policy requiring immunization of employees raises issues of autonomy, leading to resistance to such a policy. An ethical analysis can help identify potential issues and suggest ways to mitigate them. Ensuring that employees are immune to vaccine-preventable diseases (VPDs) provides a wide range of benefits for the public health unit. It prevents both illness in employees and transmission of VPDs from employees to friends, family or clients. Employees who are health-care professionals may already require immunizations as part of their duty to protect clients under the policies of their college or regulatory body. With well-established safety profiles of routinely recommended vaccines, the potential harms of vaccination are outweighed by the benefits to the individual employee and the community. Although the benefits are apparent, the need for a mandatory immunization policy to protect employee health should be carefully weighed against less-coercive measures. Occupational health and safety policies addressing other mechanisms to reduce the risk of employee exposure to VPDs, such as personal protective equipment, should be in place. Immunization policies also depend on the target disease. Because some VPDs such as chickenpox, for instance, can be contagious before the individual is ill, immunization is the only way for employees to fully prevent acquiring or transmitting the infection. For influenza, a single immunization appears less coercive than requiring employees to take daily antiviral prophylaxis for extended periods. A mandatory policy must be fairly, reasonably and consistently applied within the unit. Only applying the mandatory policy to new employees as a precondition of employment, for instance, when these employees are performing the same duties as existing employees is deemed unjust. Additionally, the justification that the policy is needed to protect employee health would be undermined by its differential application to the same job function. The most significant consideration to a mandatory policy is the infringement of individual rights in imposing immunization. Employees may refuse immunization by claiming a violation of their right to “life, liberty and security of the person” under Section 7 of the Charter of Rights and Freedoms. 2 Allowing Mandatory immunization of local public health employees 115
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PoPulationand Public HealtH etHics
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contents Acknowledgements - page 5
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acknowleDgeMents The Partners would
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» Create a tool to support instruc
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Each of the discussants took on thi
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Twenty years on, things have change
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intervention (say reduction in mort
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ethics understands dilemmas not onl
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priority setting. 17 Once more, usi
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6 See for example the WHO Commissio
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obesity surveillance in scHool cHil
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esearch 2 Inevitably children will
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esearch Case discussion in response
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It would be ideal to get active inf
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esearch participation, leading to a
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to sHare or not to sHare? Secondary
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esearch Scenario shift » What if t
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esearch Many different parties have
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esearch of his concern for people w
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esearcH etHics anD conFlicts oF int
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esearch and non-public information
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esearch reFerences 1 Public Health
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esearch Key ethical dimensions Perh
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esearch such support, seen across t
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esearch Proposed resolution Enablin
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a tool For etHical analysis oF Publ
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esearch are explicit. In Quebec, su
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esearch reFerences 1 Bayer, R. and
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Part two Policy
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policy being increasingly introduce
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policy behaviour. Therefore, the et
Page 64 and 65: policy 18 Chapman, S. and Freeman,
Page 66 and 67: policy through outdoor smoking, any
Page 68 and 69: policy that this is an injustice. W
Page 70 and 71: DeFerring blooD Donation FroM Men w
Page 72 and 73: policy 26 per cent of new infection
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Page 76 and 77: policy public trust might also incl
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Page 82 and 83: policy Case description For nearly
Page 84 and 85: policy 3 Economic conditions could
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Page 88 and 89: policy lMICs. Evidence-based introd
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Page 98 and 99: policy Core issue Case study author
Page 100 and 101: policy Additional issues It may be
Page 102 and 103: policy Arguably, an exception might
Page 104 and 105: policy Case Following the pharmaceu
Page 106 and 107: policy 3 What potential harms may b
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Page 110 and 111: policy adults may choose for themse
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Page 116 and 117: policy for exemptions and declinati
Page 118 and 119: policy Case discussion in response
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Page 122 and 123: Part tHree Practice
Page 124 and 125: practice Case The Inquiry found tha
Page 126 and 127: practice Questions for discussion 1
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Page 132 and 133: practice that the professional plac
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Page 138 and 139: practice In what follows, I will de
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Page 142 and 143: practice Getting Clear on What’s
Page 144 and 145: using PersonalizeD letters oF invit
Page 146 and 147: practice Cervical cancer is relativ
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alberta oil sanDs A toxic mixture o
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practice resolution calling for the
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practice Case discussion in respons
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practice Second, the process of oil
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practice contributing to “contrac
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practice How might the decision and
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wHose role is it to Deal witH socie
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practice same artisanal miners to d
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practice Case discussion in respons
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practice The ethical principle of b
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practice Identify the options avail
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