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Edmund D. Pellegrino

Requiring Immunizations for Health Care Workers: Fair and Just? Lisa M Lee, PhD, MS 2014 HEAL Conference April 11, 2014. Edmund D. Pellegrino. Approaching the Question. What we are able to do. What we should do. What we are permitted to do. Action. Working Thesis.

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Edmund D. Pellegrino

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  1. Requiring Immunizations for Health Care Workers: Fair and Just?Lisa M Lee, PhD, MS2014 HEAL ConferenceApril 11, 2014

  2. Edmund D. Pellegrino

  3. Approaching the Question • What we are able to do • What we should do • What we are permitted to do • Action

  4. Working Thesis • We should protect the vulnerable • We should implement a comprehensive approach to ensure vulnerable populations (e.g., ill persons) are protected from seasonal influenza • Hand hygiene • Respiratory hygiene and cough etiquette • Isolation of infected patients and sick days for ill workers • Full vaccination of staff and patients • Unless medically contraindicated

  5. Which Lens of “Should”? Clinical ethics lens HCW Immunization

  6. Which Lens of “Should”? Public health ethics lens HCW Immunization

  7. Which Lens of “Should”? Justice lens HCW Immunization

  8. Clinical Ethics • Focus • Provider & patient interaction • Fiduciary duty to patient • Principles • Respect for autonomy • Respect choices based on personal values and beliefs • Nonmaleficence • Obligation not to inflict harm • Beneficence • Provide benefits to others • Justice (distributive) • Fair access to or allocation of resources

  9. Unresolved Tensions: Clinical Ethics Framework • Fiduciary duty versus HCW autonomy • Stems from Mill’s harm principle • Takes on special significance when one individual is healthy HCW & other is medically fragile patient • Attempts to resolve: Professional obligation, special social status • Reciprocal benefits assumption not met with influenza immunization • Population intervention, not individual intervention • Benefits accrue to individuals only when population is protected (herd immunity)

  10. Herd Immunity Ill Immune Susceptible

  11. Public Health Ethics • Focus: Community or population as ‘patient’ • Duty to community’s health • Principles • Least restrictive intervention to meet goal • Evidence-based action, precautionary principle • Health equity (reducing disparities) • Community engagement • Reciprocity • When asked to act in the interest of the greater good, this act is facilitated

  12. Additional Work and Unresolved Tensions of PH Ethics Frameworks • Takes us further than clinical ethics framework • Helps us with herd immunity • Addresses reciprocity resistance • Addresses health equity concerns • Allowable under precautionary principle • Fails to fully address our obligations to contribute to the greater whole

  13. Justice Justice is the first virtue of social institutions, as truth is of systems of thought. Rawls J. A Theory of Justice, p 3.

  14. Justice • Focus • Plurality, solidarity • Doing together what we cannot do alone • Principles • Equity (different than health equity) • How I would like to be treated if I were you • Obligation to follow the law • Discretion to do only what one prefers nullifies the state’s ability to protect citizens • Fairness essential for cooperative schemes • Role for every party, all responsible for their part • Whole is greater than sum of its parts

  15. The 4-Way Stop

  16. The 4-Way Stop

  17. The 4-Way Stop

  18. Implications of Applying Justice • Protection for self depends on full participation of all • Benefits of cooperation far exceed individual action • Exemptions • Challenging to acquire • Promotes solidarity, fair distribution of burden • Equitable in the just sense • Medical only • Declared or reassigned to protect vulnerable

  19. Working Thesis • We should implement a comprehensive approach to ensure vulnerable populations (e.g., ill persons) are protected from seasonal influenza • Hand hygiene • Respiratory hygiene and cough etiquette • Isolation of infected patients and sick days for ill workers • Full vaccination of staff and patients • Unless medically contraindicated • Requiring all components is ethically justified to reach the goal of protecting vulnerable patient populations

  20. Ethics and “Should” Ethics is a social technology, one for which there are no experts. There is only the possibility of conversation, ideally free of factual mistakes and imbued with mutual sympathy. -- Philip Kitcher, Science in a Democratic Society (2011) p 12.

  21. Questions & discussion

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