PoPulationand Public HealtH etHics

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policy Case discussion in response to ManDatory iMMunization oF local Public HealtH autHorities Kumanan Wilson, M.D., M.sc. Department of Medicine, Ottawa Hospital Research Institute Canada Research Chair in Public Health Policy Ottawa ON kwIlson@oHRI.Ca The case study by Murti highlights the ethical challenges related to mandatory vaccination policies for health care workers. On the one hand, such policies are necessary to protect the health of patients. On the other hand, requiring individuals to undergo a medical intervention could be perceived as an infringement of their rights. The case study in particular describes several ethical principles, many of which come into conflict in this particular case. These include autonomy, justice and the need to use minimally intrusive or least-coercive measures. The case study highlights how ethical and legal dilemmas can be at least partly resolved by examining the scientific aspects of the problem. The vaccination issues the case study puts forth are complex and varied and best to disaggregate. To illustrate the challenges of working through these issues, let us start with looking at mandatory influenza vaccination for healthcare workers — perhaps the most contentious vaccination issue at present. * To many in the public health field, it is apparent that the status quo is unacceptable. Currently, most workplace influenza policies are voluntary but permit sending unvaccinated workers home in times of outbreak. This strategy is problematic for two reasons: first, it may result in a high percentage * For a detailed discussion of the legal and scientific arguments for mandatory influenza vaccination please see: Rodal, R., Ries, N. M., Wilson, K. (2009). Influenza vaccination for health care workers: Towards a workable and effective standard. Health Law Journal;17:297–337. PoPulation anD Public HealtH etHics 118
of workers being absent when the facility needs them most. Second, by the time the worker is sent home, he or she may have asymptomatically already transmitted the virus to co-workers and vulnerable patients. 1 While it would be least coercive for hospitals and other facilities to encourage vaccination policies on a voluntary basis, relying on voluntary compliance and educational programs may create gaps in patient protection, as evidenced by studies demonstrating suboptimal uptake. 2 Facilities could take the initiative to implement employment standards that reflect the importance of vaccination to the health of patients. If such initiatives prove insufficient, governmental authority may be needed to create appropriate legislation — i.e., mandatory vaccination policies. These policies would have the effect of increasing patient health and safety, and at the same time saving costs and reducing worker illness and absenteeism. However, health-care workers have been resistant, and the legality of such an option would be contentious. When considering the legality of measures, it is apparent that the legal principles involved are based on ethical values and that conflicts are resolved through evaluation of the scientific evidence. Any mandatory vaccination legislation would likely be challenged under s. 7 of the Charter of Rights and Freedoms (the Charter). Section 7 states “Everyone has the right to life, liberty, and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” Mandatory vaccination, if considered to be a possible violation of s. 7 because it involves an intrusion on bodily security, could be found to be justified within s. 7 of the Charter as being in accordance with the principles of fundamental justice particularly as it protects the sanctity of human life in a non-arbitrary manner. Furthermore, it could otherwise be upheld under s. 1 as a reasonable and justifiable measure to promote health, safety and confidence in the Canadian health-care system. 3 Section 1 ensures that, where the state has compelling and legitimate reasons to infringe rights, it has the authority to act, though these infringements must be proportional and justified. Some of the legal tests to ensure that this is the case are embodied in the Oakes test, based on a decision by the Supreme Court where the standards necessary for the use of s. 1 to limit an individual’s rights are described. According to this test the infringement, in this case the vaccination policy, must meet a pressing and substantial objective. In addition, the choice to vaccinate must be rationally connected to the objective of preserving health among patients; the policy must be minimally impairing of rights; the policy must be proportional to Mandatory immunization of local public health employees 119
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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
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policy 18 Chapman, S. and Freeman,
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policy through outdoor smoking, any
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practice Second, the process of oil
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practice How might the decision and
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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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