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Is It Ethical for a Nurse to Decline the H1N1 Vaccine?

August 26, 2009

By Douglas Olsen, PhD, RN. Olsen is an AJN contributing editor who co-coordinates the journal’s Ethical Issues department and a nurse ethicist with the National Center for Ethics in Health Care at the Veterans Health Administration in Washington, DC. The views he expresses here are meant to stimulate discussion of this topic and not to serve as pronouncements guiding what nurses should or shound not do. The views are his alone and should not be construed as representing those of AJN or of the National Center for Ethics in Health Care or the Veterans Health Administration.

MailOnlineFluJabScreenshotPublic health experts advocate widespread flu vaccination for people who give direct care to patients. However, in the past less than 40% of health care workers have been vaccinated for flu, and in a recent Nursing Times survey from the UK 30% of nurses said they would decline H1N1 vaccine and only 37% said “Yes” they would take the vaccine. Here are some thoughts on how to sort out the question from an ethical perspective.

Nurses, as patients, should be accorded the same respect for their decisions about health care, including the right to refuse a treatment, that is due to all patients. In ethics this is called respect for patient autonomy.

Professional obligation. However, nurses have a professional obligation to do as much as is reasonably possible to care for their patients. This includes incurring a certain amount of personal risk in giving care. Nurses incur risk on the job all the time from infections, violent patients, and many other sources.

In 2006 the American Nurses Association (ANA) put out a position paper that gives some guidance on the degree of risk that’s reasonable for nurses to accept in giving patient care: “[t]he benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse.”

Risk versus benefit. And so, the question is whether the degree of benefit expected for patients outweighs the degree of risk from the vaccine. 

Regarding risk, most flu vaccines have in the past had an excellent safety track record overall. H1N1 vaccines are currently in clinical trials; while they are being fast-tracked for production and distribution, they will be closely monitored for safety concerns.

Regarding benefit, evidence shows that vaccination of health care workers results in fewer patients getting the flu. Further, it is those patients most in need of protection, the elderly, newborn, and immunocompromised, that vaccination of nurses protects.

If one accepts the findings of mainstream science, the assessment of the cost-benefit ratio isn’t even close. Benefit far outweighs risk, meaning that nurses have a strong obligation to get vaccinated.

Reputation problem. But vaccines have a reputation problem, in spite of the evidence. Take a look at the comments posted to the British daily paper The Mail in response to a story on the Nursing Times survey mentioned above. “John in Glasgow” writes, “Jane . . . is an Austrian investigative journalist who has filed charges with the FBI against the World Health Organisation and Baxters International, claiming that mass genocide is being planned and swine flu vaccination is the vehicle for this.” In the UK survey 60% of those who say they would decline the vaccine give safety concerns as a reason.

Is refusal of vaccine ethical if it’s based on an inaccurate interpretation of the safety data? If refusal only affected the nurse, then the reason would be irrelevant—but refusal affects the well-being of others to whom the nurse has an obligation of care. And so society has a legitimate interest in the nurse’s decision. Whether society’s interest is great enough to mandate vaccination is a question I won’t address here.

Social and perceptual context. Really understanding an ethical situation like this one requires looking at more than ethical principles (in this case respect for autonomy versus professional obligation) and the evidence (in this case flu vaccine is safe and prevents patient harm). We need to look at the social and perceptual context. The heart of the problem is that a sizable minority of people are making an assessment of the risks and benefits of vaccination dramatically at odds with the expert community. Why? I don’t know, but I know the answer helps explain this situation.

Intuitive individual risk assessment by humans is anything but logical. We overvalue dramatic events with a low probability, give more weight to personal experience than data, devalue risk in the future, and overvalue a sense of control over events among other inherent biases. As an illustration, up until a month ago I considered the vaccine deniers a sort of fringe—and then my cat was diagnosed with a form of terminal cancer well known to be caused by vaccination. I am not quite ready to join the ranks of the deniers, but my own index of suspicion about vaccines is at an all-time high.

Also, nurses are accustomed to seeing the concrete benefits of their efforts and risks in individual patients. In this case, the benefit is diffuse and theoretical. We may be able to show that fewer patients get the flu, but we can’t say that elderly Mr. Smith in room 210 with COPD didn’t get the flu because I got vaccinated. The benefit to patients doesn’t feel quite real while the risk to one’s self does.

I feel that the evidence of benefit and risk is credible enough that there’s a moral obligation for nurses to get vaccinated.

PS – The cat is currently doing well and getting a little extra pampering, but I wish I had declined the vaccine, which really wasn’t needed for an indoor cat.

Editor’s note: for a follow-up post on this topic, with more reader comments, click here.

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32 comments

  1. It should be the nurses choose to get the H1N1 vaccine. The vaccine is pretty new and still on a trial period. We don’t know the true risks that may be involve once you get vaccinated. It might have a negative affect for you, your family, and/or your patients. I read that many hospitals in the U.S. where trying to make the H1N1 vaccine mandatory. If the employees decline to receive it they would have to wear a mask at all times and some hospital even states they will let go of employees. Why can’t nurses or other health care employees make up their own mind on what they want to have injected in their body.

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  2. I feel flu/H1N1 should not be mandatory. Other things we are vaccinated for are once in a life time or if needed to repeat, not annually. I choose to get the vaccination as I feel it is my duty to my family to not bring home any more viruses than necessary or to pass on flu to my patients. I leave my shoes outside, my scrubs get washed seperately, I wash my hands diligently. It’s all occupational hazard.

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  3. I believe it is not unethical for nurses to decline the H1N1 vaccine. I feel that people’s autonomy should be respected. Nurses are people just like everyone else and forcing them to take a medication, infringes in their personal freedoms. This vaccine has been mass produced and I feel that there has not been enough research to prove its’ safety. Different laboratories were utilized to mass produce this vaccine and methods for replication need to be verified. I feel that already nurses place their lives at risk to help others. Forcing them to take a medication, some feel is unproven, is asking for too much from them. Nurses are people with similar issues as everyone else, and as such, their autonomy needs to be respected. Time will tell whether all the H1N1 vaccines were safe for human comsumption. There needs to be continuing research to prove this. Regardless whether or not these vaccines were safe, autonomy is a right for everyone, including nurses. Nurses are health care professionals that are exposed illnesses’ as well as medications’ effects. They are qualified enough to make their own health choices in their personal lives. No, I do not feel it is unethical for nurses to decline the H1N1 vaccine.

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  4. Are you aware that the H1N1 vaccination has not been tested for saftey in pregnant women? This is clearly acknowledged on the manufacturers insert leaflet. A copy of the package inserts are available to view online at the fda web site.
    sanofi pasteur 10 September 2009_v0.3
    449/454 Influenza A (H1N1) 2009 Monovalent Vaccine LE5860-5862
    his is taken from the
    8.1 Pregnancy
    Pregnancy Category C: Animal reproduction studies have not been conducted
    with Influenza A (H1N1) 2009 Monovalent Vaccine or FLUVIRIN. It is also not known
    whether Influenza A (H1N1) 2009 Monovalent Vaccine or FLUVIRIN can cause fetal
    harm when administered to a pregnant woman or can affect reproduction capacity.
    Influenza A (H1N1) 2009 Monovalent Vaccine should be given to a pregnant woman
    only if clearly needed.

    http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm182404.pdf

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  5. I don’t want to be treated by any health care ‘professionals’ that refuses vaccination since they are putting myself and my unborn baby at risk! People should be told if they have health care staff who have refused the vaccince so they are able to make a completely ‘informed’ decision about their care!

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  6. [...] been articles, blog posts, a court ruling in New York State halting mandatory H1N1 vaccinations for health care workers, and [...]

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  7. [...] from comments we’ve received in response to other posts (here, here, and here) about the H1N1 vaccine, we surmise that not every nurse who answered no is actually opposed to [...]

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  8. Renee is absolutely correct.

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  9. Mandating any injection to anyone is far more serious than people realize. Once this is followed thru we will never have control of our personal lives again. Including life and death. Wake up and smell the future! The ramifications of someone having the power of passing mandatory treatment is total abuse of power.

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  10. Any suggestions on how to ‘ethicaly’ advise a well informed, healthy robust pregnant woman,(who happens to be a nurse) who would be very unlikely to have adverse complications from the flu itself, of the validity of accepting an immunisation that contains two antibiotics that “clinical trials” have confirmed to be contraindicated during pregnancy?

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  11. I have recently been hired by a health care facility. I have never done the flu shot as it’s well known that there really isn’t any cure for influenza as it changes or mutates every year. I am not a doctor or nurse nor do I have direct contact with patients. I deal mostly with notifying the docs and nurses on consults and follow-up appts for patients. I am a robust healthy female and am not in any of the risk groups. I also don’t believe in medicating more than one needs to. So I want to decline based on this and another person who is at high risk can receive it instead. Can the health care facility threaten me by saying or implying that I could lose my job or that in order to work here I must take this shot? What are the legal ramifications? I understand this shot is not federally mandated, and it’s by a state by state basis — I’m told New York it’s mandated. What can I do?

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  12. Perhaps you could do the same research to learn how rigorous and well studies flu vaccines are and how safe they are. Flu vaccines vary every year depending on the strain of flu circulating. This vaccine is targeting the this particular flu and is manufactured the same way, tested the same way with the exception that it was tested in pregnant women as well because of the clinical data obtained. Of one hundred pregnant women treated in ICUs for H1N1 38 died. Still want to tell them not to get the vaccine? We rely on government clinical trial data all the time with the treatments that we use on patients and on treatments that have not been subjected to rigorous research at all. Why all the vitriol and scepticism about this issue?

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  13. I think the “nonsense” here is due to the fact that someone can claim the H1N1 vaccine has had “rigorous” testing. The H1N1 vaccine trial in adults did not even begin until late July (http://www3.niaid.nih.gov/news/QA/vteuH1N1qa.htm), in children the vaccine testing did not begin until late August(http://www3.niaid.nih.gov/news/newsreleases/2009/H1N1pedvax.htm), and in pregnant women not until Sept.did testing begin.
    That is certainly not “rigorous” testing.

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  14. The nonsense being written by nurses on these comments is disturbing. I can only hope that you are not sharing this with your patients. There were several clinical trials of the H1N1 vaccine done in this country AND in other countries all rigorously done and looking at efficacy and effectiveness as well as at side effects. In addition, there were clinical trials on pregnant women. Plus there is a rigorous and extensive ongoing reporting mechanism for any reports of adverse effects that will continue throughout the use of the vaccine. Those concerned about thimerosal should have an understanding about ethyl mercury and not assume that all mercuries are the same. If you can cogently explain the difference and what you think it does that is proven by peer reviewed research to do that is detrimental then perhaps you can keep using it as a reason not to vaccinate. And for those who are mothers, since this is disproportionately affecting children you should be more inclined to get the vaccine. If you get exposed and bring the virus home to your children it could be their health or life that you greatly affect. Our pediatric beds are full with PICU beds, vents and ECMO all being used to treat H1N1 cases. There is no uproar when you are required to get Hepatitis vaccine, MMR, or the other ones that titers are checked for upon hire in most hospitals. The logic is the same. As nurses we do have an obligation to the health of those we are caring for.

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  15. [...] Nurses Express Safety Concerns About H1N1 Vaccine Is It Ethical for a Nurse to Decline the H1N1 Vaccine? [...]

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  16. The vaccine may or may not be safe, only time will tell. What bothers me is that there is no accountability. If it turns out to be unsafe the manufacturers, the state and our employers have been given immunity. Where does that leave us if we can’t work? This opens the door to being physically mandated to take all kinds of preventative measures in the future. How many people will elect to go into healthcare if we have no control over our own bodies?

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  17. I think you are very wise to protest your mandated H1N1 vaccine. Each 0.5ml dose contains 25 mcg of thimerisol, not to mention many other toxic ingredients. I would like to know if physicians are mandated to take any vaccines. When I was in nursing school, it was only nurses. If your hospital does not require physicians to get this vaccine, I would use that in your protest. Good luck.

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  18. I am a nursing student. The hospital I am doing a rotaion at is mandating all students to receive H1N1 vaccines, even if it conflicts with our personal and health concersn. I am very upset with this news and plan to address it and at least challenge it. Has anyone read the ingredient listing? It is a shame that mercury is still used as a preservative in multi-dose vaccines.

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  19. If the author feels nurses have a responsibility to take the flu vaccine, why doesn’t the government feel a responsibility to provide doses for the elderly, which he lists are at high risk? I’ve been told we are expecting immunity to exist. This means I would not be taking the vaccine for their sake, or certainly they would be offered the vaccination. Does anyone else see the inconsistancy here?

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  20. Having been involved in clinical research for the last 13 years, I can assure you, I WILL be getting the H1N1 flu vaccine as soon as it is available (and so will the rest of my family).

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  21. What’s all the talk about? Don’t you know that if the regular seasonal influenza had not already been in production, we would now be getting the H1N1 strain in our regular flu shot!! Too bad they had to produce 2 batches of flu vaccine this year. Next year the H1N1 will be included in the seasonal flu vaccine.

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  22. I work at a major medical research center where our patients have the option to take part in clinical trials of drugs without known side effects. This clinical trials procedure is encouraged but always optional.

    I see the H1N1 vaccine to be a clinical trial and the same consideration we give to our patients should be available to the medical staff in our hospitals and offices.

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  23. There is no testing done on this vaccine, therefore that is all I need to know to make my decision.

    Yes, I am a nurse and need to protect my patients, but I agree with Lin. I am a patient first, then a mother, then a nurse. Who will be here to take care of my children if I am not, bc something happens to me after I receive this vaccine? I am sorry but I also have a moral obligation to care for my children first and I will care for them by drefusing this vaccination.

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  24. [...] from responses to a recent post we ran on the topic (”cancel my subscription” appeared more than [...]

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  25. ““John in Glasgow” writes, “Jane . . . is an Austrian investigative journalist who has filed charges with the FBI against the World Health Organisation and Baxters International, claiming that mass genocide is being planned and swine flu vaccination is the vehicle for this.” In the UK survey 60% of those who say they would decline the vaccine give safety concerns as a reason.

    Is refusal of vaccine ethical if it’s based on an inaccurate interpretation of the safety data?”

    It is a huge leap to connect conspiracy fears of a few with the safety concerns of a large group of nurses.

    Because I am being offered the vaccine, my PRIMARY role is that of patient. I have to weigh the risk of the h1n1 vaccine versus its benefit. There is no one that can say that it IS proven safe, because that data is not available yet for obvious reasons. According to the CDC, prelim results will barely be available by the time the vaccines are rolled out. We all know the story of the 70’s swine flu vaccine campaign and it’s removal from the market due to GBS. The CDC acknowledges this now, and has safety monitoring in place (I recently viewed a power point on their website regarding safety monitoring and challenges that will be posed. GBS is one adverse side effect they are concerned about.).

    In sum, when we are left with the risk versus benefit equation–we have no solid information to plug into the risk side. How, as a patient, am I to make an rational decision. Whether I choose vaccination or not, it will be inuitive, emotional, or something not wholly reliant on an easy a + b = c.

    I am still searching for answers. I wonder to myself why Tamiflu has not been pushed more. As far as drug safety goes, this has already been through trials and x years of patient use.

    I’m sorry, but first, I’m a patient, second, I’m a mom, and third, I’m a nurse.

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  26. I don’t think a nurse should have to take the shot. They are exposed to so many viruses and bacteria, that they should have common sense and the proper mind set to keep up with good hygiene. Yes, I know that won’t completely prevent the flu or H1N1, but it’s a bit much to cause such a scare into an otherwise somewhat stable nursing lifestyle.

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  27. I am cancelling my subscription b/c I disagree with the ridiculous spread of propaganda and the notion that a nurse who has the sense not to get this barely tested vaccine is dodging a “moral obligation”. Give me a break.

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  28. This article demonstrates reasoned debate, respect for science and respect for individual concerns and decisions.

    Nurses who don’t take the vaccine will be exposed to the virus and could die.

    Those who must cancel subscriptions because they don’t agree with an opinion can’t be very well read at all.

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  29. PS.
    I will be cancelling my subscription.

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  30. How anyone can state that the H1N1 vacine is safe is beyond my comprehension when it has barely been tested and contains adjuvants that are banned. Nurses have a “moral obligation” to their safety and the safety of their families. If the vaccine is so safe, why do a large majority of TOP neurologists state they will NOT receive it?? Take it at your own risk!

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  31. Actually, the current season flu vaccine will offer no protection against swine flu according to the CDC. I believe that as nurses we have a professional obligation to protect our patients and act as good public health role models.

    I also believe that everyone, whether a nurse or not, should have the right to decline health treatment provided they have had accurate information about the risks and benefits. There are undoubtably risks, however small, to any vaccination. But there are also a huge number of crazy conspiracy theories being disseminated about the vaccination program, which appear to have very little evidence to support them. I would hope that any nurse considers carefully what is fact and what is fiction before making the choice to decline flu vaccination.

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  32. I believe I heard that this year’s flu shot will serve just as well as the swine flu vaccine.

    I have an obligation to my family as well as to my job. There has to be a compromise. The flu vaccine is just that for me.

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