Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma in patient care, you vote, and then we present an expert's judgment.
Last week, you voted on the ethics of allocating COVID-19 vaccines in a community. Here are the results from more than 1,600 votes:
Should the chief physician vaccinate all hospital staff first, then provide the remaining doses to high-risk individuals in the community?
Yes: 79.62%
No: 20.38%
Would you give the vaccine to yourself first?
Yes: 60.08%
No: 39.92%
Would you mandate healthcare staff to get the vaccine?
Yes: 67.88%
No: 32.12%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
Vaccination is unquestionably one of the great public health successes of the modern era. Many of the most dreaded scourges of the pre-inoculation age have either been eradicated (like smallpox) or vastly curtailed (like measles). While one can certainly debate the morality of compulsory vaccination and the role of both corporations and the state in the design and marketing of vaccines, the efficacy of childhood vaccines for certain diseases is empirically clear. For instance: In the 1920s, an estimated 13,000 to 15,000 Americans died each year of diphtheria; last year, that number dropped to one.
However, the history of vaccination is not without its tragedies as well. In 1955, mistakes in the manufacture of the early polio vaccine by Cutter Laboratories caused 40,000 cases of polio and killed ten children. More recently, a vaccine for dengue was discovered to increase danger to seronegative recipients after a mass vaccination campaign in the Philippines. So one of the key questions in this scenario is how to balance the unknown potential risks of a novel vaccine against its promised benefits.
Obviously, the vaccine should only be made available to anyone if the risk-reward calculus favors doing so. On the surface, such an approach favors giving the vaccine first to vulnerable populations because they are both at greater risk of dying from the disease and have a greater potential to benefit. In contrast, the risk of the disease to the providers is relatively low and the unknown risks of the vaccine might even run higher.
Of course, ensuring the health of the clinical workforce is crucial to providing care for others. However, there are likely ways of doing so short of vaccination, such as the use of PPE and social distancing. While this approach will certainly not prevent all providers from contracting COVID-19, and maybe some (as horrific as it is) from dying, from a utilitarian standpoint, alternative measures should prevent enough of them from doing so that a healthcare workforce can be maintained.
Needless to say, this is not ideal for morale. (I say this not merely as a bioethicist, but as a physician who has worked 12 of the last 18 nights in a New York City psychiatric emergency room.) However, optics also matter in healthcare. The perception that medical workers are receiving favorable treatment in COVID-19 care, as has been proposed as desirable in several ventilator rationing schemes, poses a grave threat to social solidarity. It is crucial that people believe "We are all in this together" to ensure compliance with prophylactic public health measures.
Voluntary acceptance of vaccination protocols is ideal and sometimes proves sufficient to protect the public. We often allow religious dissenters to avoid certain vaccines because we can rely upon herd immunity. We permit clinicians opposed to flu shots to wear masks and continue to provide hospital-based care. However, in the context of a pandemic, the state may be justified in forcing vaccination upon front-line medical workers if there is convincing evidence that doing so will save patient lives. A far more challenging question is whether, should this pandemic continue without a viable vaccine for COVID-19, the government could temporarily mandate flu shots to return to work or school for laypeople so as to mitigate the possible stresses on the healthcare system -- as CDC Director Robert Redfield has predicted may transpire should the COVID-19 pandemic and a flu epidemic occur simultaneously.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College. Appel is the author of the recent book, .
And check out some of our past Ethics Consult cases: Walk Out Over Mask Reuse?, Take Elderly COVID-19 Patient Off Ventilator?, and Hiding Dx From Elderly Cancer Patient? MD/JD Bangs the Gavel.