Healthcare Obligations: Personal vs. Institutional

In a typical year in the United States, the public is urged to get flu shots as a means of protection against influenza. A report published by an influenza expert at the British Columbia Centre for Disease Control found that the 2014-2015 rate of effectiveness for flu shots was 23% in the U.S., and that the shots offered no significant protection in Canada. A related finding published by researchers at the National Institutes of Health documented that, although the percentage of seniors who received flu shots in recent decades rose from 15% to 65%, the deaths caused by influenza among the elderly continued to climb during this period. These researchers concluded “either the vaccine failed to protect the elderly against mortality… and/or the vaccination efforts did not adequately target the frailest elderly.”

More recent research has tried to develop a method to assess in advance whether a given flu vaccine would have any protection benefit. A report published in 2016 in the journal Nature Immunology used a blood assay and identified a correlation between persons with a certain pattern of gene expression and the likelihood that such persons would experience adverse events after receiving a flu vaccine. If this assay could be made economical, and included in blood tests typically done in annual physicals, it could reduce the number of suits filed with the federal Vaccine Injury Compensation Program. With these reports in mind, consider the following case:

Dr. Jones works in a hospital and she recently became aware of all the above reports. She belongs to the American Medical Association (AMA), which strongly recommends that everyone receive flu shots each year. Moreover, her hospital recently informed her that she herself must take annual flu shots or risk termination of her hospital privileges or employment. Dr. Jones, however, is aware of the AMA Code of Ethics, which states that patients have a right of self-decision regarding their health care, and that this right can only be effectively exercised “if the patient possesses enough information to enable an informed choice.” She feels a moral obligation to inform her senior patients that she has reservations about the efficacy of flu shots for their age group and why.

Since the AMA and the Centers for Disease Control and Prevention are strong proponents of annual flu shots, if Dr. Jones gives contrary advice to her patients, this could jeopardize her standing with the AMA, in addition to her employment at her hospital. Furthermore, her hospital administrator and other health officials are concerned that if doctors advise patients about the relative ineffectiveness of, and potential injury from, flu vaccines, this could feed public doubts about the efficacy or safety of other vaccines. Such doubts could increase public opposition to new state laws that aim to promote “herd immunity” by mandating certain vaccinations.

While the case of Dr. Jones is based on the actual experiences of a medical doctor, her name and identifying details have been changed. This case study reflects the key ethical dilemmas the doctor faced.

Discussion Questions

1. Do you think Dr. Jones should discuss her reservations about flu vaccines with her senior patients? Why or why not?

2. Do you think Dr. Jones has a greater moral obligation to her family to protect her job security or to the recommendations of the AMA Code of Ethics, which encourage physicians to help patients exercise their “right of self-decision” by providing them with enough information to enable an informed choice? Explain your reasoning.

3. Even if flu shots provide protection less than one fourth of the time, is it ethically permissible for Dr. Jones to decide that protection for some patients is better than none? And, on that basis, decide not to discuss the potential benefits and harms of flu shots with her patients? Explain.

4. Do you think the AMA should promote open discussions about the efficacy of flu vaccines and support the development of blood tests that could predict that efficacy? Why or why not? What are the potential outcomes?

5. Both the AMA Code of Ethics and the World Health Organization endorse the primary “right of self-decision” of all patients regarding their health care. However, to foster “herd immunity,” the bill SB 277 was recently passed in the state of California, mandating multiple doses of vaccinations for all students entering kindergarten. Do you think there is a way to reconcile these two opposing ethical goals? Explain.

Bibliography

Mandated Influenza Vaccines and Health Care Workers’ Autonomy
http://journalofethics.ama-assn.org/2010/09/ccas2-1009.html

Impact of Influenza Vaccination on Seasonal Mortality in the US Elderly Population
http://www.worldcat.org/title/impact-of-influenza-vaccination-on-seasonal-mortality-in-the-us-elderly-population/oclc/110760362

Adjuvanted influenza-H1N1 vaccination reveals lymphoid signatures of age-dependent early responses and of clinical adverse events
http://www.nature.com/ni/journal/v17/n2/full/ni.3328.html

H1N1 viral proteome peptide microarray predicts individuals at risk for H1N1 infection and segregates infection versus Pandemrix vaccination
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479535/pdf/imm0145-0357.pdf

Vaccines for preventing influenza in healthy children
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004879.pub4/abstract

Vaccines to prevent influenza in healthy adults
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001269.pub5/abstract

AMA Code of Medical Ethics
https://www.ama-assn.org/about-us/code-medical-ethics

National Vaccine Injury Compensation Program
http://www.hrsa.gov/vaccinecompensation/index.html

California Vaccination Bill SB 277 Signed By Governor, Becomes Law
http://www.forbes.com/sites/tarahaelle/2015/06/30/california-vaccination-bill-sb-277-signed-by-governor-becomes-law/

How cognitive biases contribute to people refusing the flu vaccine
http://arstechnica.com/science/2016/05/how-cognitive-biases-contribute-to-people-refusing-the-flu-vaccine/

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