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.
Public 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.