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Is there an Ethical Obligation to be Vaccinated?

The New York State Health Department’s attempt at mandatory healthcare worker vaccination for both the seasonal flu and H1N1 this year met with significant opposition and was ultimately overturned. NY State chose this route based on the World Health Organization’s declaration of a global pandemic alert for H1N1 influenza A in June 2009, coupled with national data indicating that only 42 percent of all healthcare workers get an annual flu shot. This is well below the approximate 90 percent vaccination rate needed to achieve herd immunity.

The National Foundation of Infectious Diseases reports that volunteer programs usually top out at 50-60 percent compliance. Resistance to vaccination is primarily ascribed to attitudinal barriers and misinformation. Many workers firmly believe they are generally healthy and that the risks of adverse events following vaccination outweigh the benefits. With the H1N1 vaccine, there is also public perception that it has been rushed to market without adequate testing. Since the H1N1 vaccine is similar in design to the seasonal vaccine, its risk profile is expected to be similar to the seasonal vaccine. It should be noted that the most frequently cited side effect for both vaccines is mild pain/swelling at the injection site.

In terms of efficacy, published data from previous seasonal flu vaccines would suggest that a well-matched seasonal vaccine is 85-90 percent effective in preventing the flu among heath workers. It has been shown that vaccinated workers have decreased rates of staff illness and absenteeism, and that vaccination indirectly benefits patients by decreasing their chance of being infected. It is also important to note that health workers are already required, as a condition of employment, to be immunized against measles, mumps, and polio. Thus, it would appear that from both a scientific and logical analysis, a compelling case can be made for health workers to be vaccinated.

Even in the absence of a flu vaccination mandate, do healthcare workers have an ethical obligation to their patients? The nature of their work puts them in daily contact with the populations most vulnerable to the flu. They electively place themselves at some potential personal risk, and therefore are selected to be one of the initial target populations for a vaccine in limited supply. One could argue that this position is an honor and demonstrates society’s acknowledgment of the medical community’s inherent commitment to the service of others. The guiding principles of beneficence and nonmaleficence can help clarify the benefit/burden ratio for healthcare workers seeking an ethical justification for vaccination.


Nonmaleficence is the duty to do no harm. Applied practically, this infers that healthcare workers will not deliberately place their patients at risk. With respect to the flu vaccine, they are obligated to take any and all reasonable

steps to prevent flu transmission. Good hand-washing and staying home from work with flu symptoms are certainly reasonable measures. However, the flu is known to have the potential to be transmitted to others in the presymptomatic phase of the illness. Vaccination is the most effective way to minimize the chances that a healthcare worker will transmit the flu prior to the onset of symptoms.

Beneficence is the duty to act in the best interests of patients. This obligation clearly has limits and does not require that workers place themselves at great personal risk in the course of their daily routines. With regards to the flu vaccine,

this could include forgoing vaccination for medical reasons such as egg allergies. However, being ignorant or misinformed is not a satisfactory rationale for failing to take reasonable steps in an effort to maximize the potential for one’s patients to have good outcomes. In addition, being vaccinated increases the chance that the worker will have immunity to the flu and be able to provide care in the event of a global pandemic. Thus, in virtually all instances, the duty to be vaccinated places an acceptable burden on the individual healthcare worker when weighed against the potential benefit to the population they have electively committed to serve.

—Tom Curran

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Bioethics in Brief is a newsletter of the Center for Bioethics and Humanities, committed to promoting clinical health care and health policy which is patient-centered, compassionate, and just. Opinions expressed in the newsletter are those of the authors and do not represent the position of the Center.

Bioethics in Brief