PHIL 386 Healthcare Ethics

A blog about ethical issues in healthcare from a philosophical perspective

“I Object!”: An Analysis of Conscientious Objection in Medicine

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On December 3, 2021

In Uncategorized

Introduction

Our modern world is riddled with ethical debates regarding the legislation of things like freedom of speech, reproductive rights and LGBTQ+ rights, to name a few. Religious convictions and other beliefs inform how many people respond to these subjects of debate, but more than that, strongly held beliefs can dictate how people will act in professional settings. In the medical profession, conscientious objectors are people who wish to be exempt from providing medical services that contradict their beliefs. Whether or not conscientious objectors in medicine have the right to refuse fulfilling the duties of a profession they have voluntarily joined remains an important topic of discussion in contemporary bioethical discourse. In this blog post I will explore Schuklenk and Smalling’s argument that medical professionals should not be able to use their conscience as a pretext for refusing to meet the requirements of their field. I will then analyse a case study to show why I agree with their point.

Background 

In order to fully grasp Schuklenk and Smalling’s argument, one must first have a knowledge of what they mean by conscience. They define conscience as “our conviction that we should act in accordance with our individual understanding of what morality demands of us” (192). Thus, the concept of a conscience seems to be closely related to the concept of autonomy. A conscience is a desire to act according individual beliefs and morality, whereas autonomy is the right to act in such a way. Furthermore, Schuklenk and Smalling note that “the rights to freedom of conscience and conscientious objection are argued to be constitutive of liberty and autonomy and to be necessary for the preservation of individual moral integrity” (457). It seems clear, then, that a person’s right to reject certain actions based on their conscience is important, however, Schuklenk and Smalling still contend that conscientious objection should not be permitted in the field of medicine. They make this argument for a number of reasons. First, they hold that there is no real way to determine the validity of conscience-based claims, or the sincerity of conscientious objectors when making these claims. They also argue that when restrictions are placed on the types of exemptions that doctors can receive, the result is that certain treatments may be arbitrarily denied to patients. The possibility of “arbitrary accommodation” for conscientious objectors in the medical profession could “have harmful real-world consequences” (195). Schuklenk and Smalling go on to offer further points for consideration, including how respect for conscience choices could reduce access to healthcare, result in unfair workloads for doctors, and lead to “unfair service delivery” (197). They offer a consequentialist point of view by asserting that permitting conscientious objection in healthcare will not lead to happiness and welfare for the greatest number of people.

Case Study

Vancouver Coastal Health (VHC) has been enforcing a mandatory vaccine policy since 2012. From this point on, all health care workers have been required to “get flu vaccine shots or wear a protective mask at all times […] if they want to keep their jobs” (471). There has been debate about the necessity of such a policy, as the research regarding the efficacy of flu vaccine shots seems to point in different directions (471). If there isn’t conclusive evidence about the the necessity of the vaccine, then shouldn’t healthcare workers be able to object to the mandatory policy? I argue no, for reasons similar to those presented in Schuklenk and Smalling’s article. In order to make my point, however, I will first have to make one critical assumption, which is that although some scientific research “does not prove that having all or a very high percentage of health care workers vaccinated against the flu actually results in fewer infections in patients,” there has been enough substantial research regarding the usefulness of the flu vaccine to cause the VCH to make it mandatory (471). I am working under the assumption that policy makers have reviewed a significant amount of research on the subject, and have thus determined that mandatory vaccination for all health care workers is in fact the best way to mitigate the risk of transmission in healthcare settings. Of course, one of the reasons that a person might become a conscientious objector is because they are skeptical of policy makers, and they do not believe that it is fair to trust the counsel of authorities in their profession. I would refer these people to another point in Schuklenk and Smalling’s article, where they highlight the fact that “choosing to join a profession is a voluntary activity undertaken by an autonomous adult” (212). Choosing to join the medical profession should not preclude you from questioning the decisions of those in leadership positions, however it seems peculiar to me that healthcare workers would refuse to be vaccinated when it is members of their own community who develop, research and advocate for vaccines. I can imagine that there are people with legitimate reasons for denying vaccination, such as an allergy to an ingredient in the vaccine, but for the majority of healthcare workers it seems fair to say that protecting yourself, if only to protect your patients, is a reasonable demand. Forcing vaccination upon everyone for the safety of the general population is a difficult thing to enforce, as we’ve seen with the COVID-19 pandemic, but it is the duty of healthcare workers to ensure the safety of their patients, as per the principle of nonmaleficence, which holds that doctors have a duty not to inflict harm. I would also note that the case study mentions that healthcare workers can wear protective clothing as an alternative to vaccination. With these two options available, I contend that it is reasonable to deny accommodation to healthcare workers who do not wish to be vaccinated for whatever reason.

Works Cited

Fisher, Johnna, et al., editors. Biomedical Ethics: A Canadian Focus. 3rd ed., Oxford University Press, 2018. 

 

A Conditional COVID-19 Vaccination Policy for Frontline Healthcare Workers: A Morally Viable Solution

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On December 1, 2021

In Uncategorized

The world’s battle with the SARS-CoV-2 virus is far from over. To date, over 5.22 million people have died from COVID-19 (Ritchie et al.), and this number just keeps climbing. The COVID-19 pandemic poses a serious public health threat, as measured by mortality rate, incidence and prevalence (Bradfield and Giubilini 1). It disproportionally affects older people and racial and ethnic minorities, in terms of frequency and severity of infection. The risks and impacts of COVID-19 in healthcare settings are substantial. Frontline health care workers, defined as healthcare staff who interact directly with patients, and include doctors, nurses, allied health clinicians, pathology staff, security, cleaners, and students (Bradfield and Giubilini 1), are at high risk of infection and death. These healthcare workers may become infected by the virus at work and then transmit the virus to their patients, colleagues, family, and the wider community. Thus, there is a large ethical debate surrounding whether COVID-19 vaccination of frontline healthcare workers should be mandatory. In this post, I shall explore the idea of a ’conditional’ vaccination policy proposed by Bradfield and Giubilini in their article “Spoonful of Honey or a Gallon of Vinegar? A Conditional COVID-19 Vaccination Policy for Front-Line Healthcare Workers.”

Bradfield and Giubilini (1) argue for a ‘conditional’ vaccination policy to be implemented for frontline healthcare workers who do not have a medical reason for refusing vaccination. They state that this represents a middle ground between an entirely voluntary and an entirely mandatory approach, thus this strikes the best balance between the various ethical principles at stake. In this conditional mandate, contact between unvaccinated frontline healthcare workers and vulnerable patients and colleagues could be restricted by redeploying the unvaccinated healthcare workers to non-clinical administrative duties or telehealth services, assuming their roles can be fulfilled by other vaccinated healthcare workers without significant costs to colleagues and the healthcare system. Bradfield and Giubilini (3) state this is less restrictive than excluding unvaccinated healthcare workers from full employment or professional activity, which would be the case in an entirely mandatory approach. If redeployment to other roles is not possible, then unvaccinated frontline healthcare workers would be asked to take either paid or unpaid leave. If after their period of leave, they still have not been vaccinated, then their employment or professional registration could be suspended or cancelled. Bradfield and Giubilini (3) recognize that this solution is not perfect, as it could impose significant financial costs on public health services and significant professional burdens on vaccinated healthcare workers who would be required to take over their unvaccinated colleagues’ clinical duties. However, they state that if the costs are not too high and effective healthcare delivery is not compromised, then these costs may be a reasonable price to pay in order to accommodate some of the frontline healthcare worker opposition to vaccines. However, they go on to state that it is important to bear in mind that the primary aim of healthcare is to provide adequate care to patients, and the personal freedom of healthcare professionals may and should be constrained accordingly.

Bradfield and Giubilini (4) defend their conditional vaccination policy by responding to the potential objection that frontline healthcare workers’ own judgments, moral integrity and personal freedom ought to be prioritized. They state that this objection, as applied to vaccine refusal among frontline healthcare workers, fails for a number of reasons, some of which include the following. They argue the right to exercise free choice is not absolute; “personal freedoms only extend so far as they do not infringe on the legitimate interests of others” (Bradfield and Giubilini 4). The European Convention on Human Rights recognizes that freedom of thought, conscience and religion may be limited by public safety concerns. They also argue that frontline healthcare workers have a professional and ethical obligation of non-maleficence (to not cause harm) toward their patients. Since vaccine refusal puts patients at risk of infection and death, and given the evidence that vaccination prevents disease transmission to vulnerable patients and helps to maintain the health of other healthcare workers, they argue that vaccination should be seen as a fundamental moral requirement for all frontline healthcare workers (4). They state that the duty not to infect patients must take priority over any right to vaccine refusal. When infection can be easily prevented, there is an unequivocal duty not to infect another person. Another argument they make is that promoting the autonomy (capacity to make your own decisions) of frontline healthcare workers should not confine the autonomy of patients (4). They go on to state that while healthcare workers can choose between vaccination and their job, patients cannot choose whether they get sick and cannot choose who cares for them when they are sick. They might have no alternative than to be cared for by an unvaccinated healthcare worker, and this is not just. The healthcare worker’s autonomous choice not to get vaccinated should not infringe on the autonomy of the patient that they do not wish to be cared for by someone who is unvaccinated. Bradfield and Giubilini offer many more arguments that defend their conditional vaccination policy, and ultimately conclude that this would be the least restrictive policy that would be the most likely to achieve adequate vaccination uptake and satisfy ethical and professional requirements.

Bradfield and Giubilini seem to take a very utilitarian approach in their article, because they wish to minimize risks all while maximizing patients’ and frontline healthcare workers’ welfare. Utilitarians believe that the ethically right acts to perform are those with the best overall consequences for everyone involved. Perhaps, I, myself, am a bit of a utilitarian then, because I found myself in utter agreement with everything Bradfield and Giubilini stated in their article. I believe Bradfield and Giubilini have proposed a very good solution, because although I do not agree with those who are skeptical of science and vaccines, I do not necessarily believe their employment should be terminated for refusing to be vaccinated. I do, however, strongly believe that those frontline healthcare workers who are not vaccinated should not be interacting directly with patients or other frontline staff. Thus, this policy provides a good middle ground. It is not too coercive, in that it first attempts to redeploy unvaccinated healthcare workers so that they can keep working, but not in areas where they are in direct contact with patients. The policy provides these workers with an opportunity to decide whether they value their job or their ‘personal freedom’ more, and if they choose personal freedom, they will likely not lose their job, but they may be suspended if redeployment opportunities are not found/feasible. Thus, I believe this policy grants healthcare workers the most autonomy the healthcare system can afford during a worldwide pandemic. At the end of the day, I truly believe that the patients are the ones who need to be prioritized, since the primary goal of healthcare systems is to provide adequate care to patients. I have little empathy for those frontline healthcare workers who claim that urging them to get vaccinated is a violation of their freedom. They are the ones who signed up to work in healthcare, and with that comes the moral duty of non-maleficence to patients. They do not have to work in healthcare, and they could easily go work somewhere else where the control of infection and disease is not such a big priority. It is not just to expose patients to a greater risk of infection just so certain healthcare workers can make their own (uninformed) choices.

The issue of mandatory vaccination for healthcare workers hits close to home for me, perhaps that is why I have such a strong opinion on the matter. My father was diagnosed with colon cancer shortly after Christmas 2020, and then a few weeks later he was diagnosed with thyroid cancer. This meant he was particularly susceptible to becoming infected with COVID-19, and he still is today. The consequences could be very grave if he were to become infected. Being diagnosed with cancer is terrifying, but being diagnosed with two types of cancer in the middle of a pandemic is far worse. My father had to have two different surgeries in the span of a few weeks, and this meant he spent several days in the hospital. Alberta Health Services’ vaccine mandate was not yet in effect then, this means he was likely cared for by unvaccinated healthcare workers. His stay in the hospital made me nervous, as the COVID-19 virus was lurking within the walls of that building. I cannot even imagine what may have happened if one of his nurses or doctors had accidentally transmitted the virus to him, he could have ended up dead. Thus, in my opinion, any policy that reduces the risk of already vulnerable and ill patients becoming infected with COVID-19 should be implemented. The freedom of choice of one individual is not worth more than the life of another. Like Bradfield and Giubilini (5) stated, patients are not able to choose who they receive as a healthcare worker when they are sick, but whoever they receive has the moral duty to protect them from further sickness, and thus has the moral duty to be vaccinated. Unless someone is immunocompromised, in which case they should be permitted an exemption, the risks associated with vaccination are much lower than the risks following infection with COVID-19 (Bradfield and Giubilini 4). Therefore, to me, the solution is simple, frontline healthcare workers should either get vaccinated or should not be permitted to work where there is a possibility they could infect vulnerable patients or other frontline healthcare workers. Frontline staff who are immunocompromised or have a different, valid medical reason for being unable to be vaccinated should receive an exemption, however, they should also be redeployed to positions where there is a significantly lower risk of them becoming infected. Having a policy in place like the conditional vaccination policy will significantly reduce the chances of infecting already vulnerable patients and frontline healthcare workers, and is a morally viable solution.

References

Bradfield, Owen M., and Alberto Giubilini. “Spoonful of Honey or a Gallon of Vinegar? A Conditional COVID-19 Vaccination Policy for Front-Line Healthcare Workers.” Journal of Medical Ethics, vol. 0, 2021, pp. 1-6. BMJ, https://doi.org/10.1136/medethics-2020-107175.

Ritchie, Hannah, et al. “Coronavirus Pandemic (COVID-19) – The Data.” Our World In Data, Global Change Data Lab, ourworldindata.org/coronavirus-data. Accessed 30 Nov. 2021.

Mandatory Vaccination as a Last Resort

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On December 1, 2021

In Uncategorized

Introduction

The COVID-19 Pandemic is obviously one of the biggest threats to our health at the current moment; as of December 2020, the virus had infected about 131 million people worldwide and caused approximately 2.8 million deaths (Bradfield and Giubilini, 2021). Given this severity, it is not surprising that when a vaccine was approved rather quickly by governments across the world, there was and still is huge controversy around the topic of making the COVID-19 vaccine (CV) mandatory. Vaccines are considered one of the best weapons against the virus because not only do they protect the receiver from adverse symptoms, but they also prevent people from potentially spreading the virus to others. Parker et al. present their views and reasoning behind these views surrounding the controversial topic of vaccines in their paper, Should covid vaccination be mandatory for health and care staff?. Parker holds the position that the CV should be made mandatory, while his co-authors Bedford, Ussher, and Stead argue for the opposite. In this blog post, I will explain both Parker’s and his co-authors’ positions, and then give my take on the controversy based on their arguments. 

 

Parker’s Viewpoint

Parker’s whole rationale for his defense of making the vaccine mandatory is based on the point that “patient safety is the ultimate responsibility of health and social institutions” (Parker et al. 2021). He then begins his justifications by boldly stating that when it comes to institutions that have a CV mandate in place, any new hires that would be in direct contact with patients should either not be offered the job, or should be placed in a non-patient setting if they refuse to be vaccinated. However, Parker acknowledges that when the attention turns to existing staff members, the situation becomes much more complicated because it is the duty of employers to ensure the well-being of their employees. Despite this, Parker still believes that employees should be willing to modify their practices/beliefs if they are interfering with getting the CV. An example he gives to highlight the practicality of mandating the vaccine for current staff is that if a chef fails to adapt to new hygiene procedures that would keep the food edible and ultimately protect the health of diners, the chef would undoubtedly face consequences or be forced to follow the procedures. Apart from reasons pertaining to staff, Parker also recognizes that although the CV is not 100% protective against COVID-19, scientific data (which he does not explain further) suggests that barring any existing risk of adverse reaction, the vaccine is pretty safe. In his ending statements, Parker states that before considering mandatory vaccinations, employers should make vaccines more accessible and actively promote getting vaccinated while also reducing the stigma around it. However, he also ends off by saying that if all other reasonable alternatives have been attempted without success, then the vaccine should be made mandatory for all healthcare workers without a serious medical condition that prevents them from getting one to ensure the safety of patients. 

 

Bedford, Ussher, and Stead’s Viewpoints

These 3 co-authors also begin their argument by making the bold statement that they consider making the CV mandatory to be “a blunt instrument to tackle a complex issue” (Parker et al. 2021). They then continue to say that although freedom of choice cannot be given higher priority than a patient’s safety, it definitely needs to be considered. This freedom of choice is expressed in the form of hesitancy and even reluctance to work by healthcare professionals, and the 3 authors convey that governments should work to decipher and address the reasons for their hesitancy rather than just make the vaccine mandatory. The 3 co-authors propose solutions such as providing and improving access to vaccines, making information about the vaccines more accessible in various formats, and hosting question and answer sessions regularly for concerned patients. These solutions not only would address the hesitancy of patients, but they would also create an active-listening environment that would instill feelings of trust in the government within healthcare workers; another risk that the 3 co-authors state can be a consequence of making the CV mandatory. Although these authors argue using the points above that a mandatory CV could be counterproductive, they also communicate that mandatory vaccination is acceptable as a last resort if other measures have failed in order to maximize the population of vaccinated healthcare workers. 

 

Analysis of Both Viewpoints

I think that although Parker et al. structured their paper as a clash of conflicting views, all of them are essentially arguing for the same end goal; that if all other measures are exhausted, then the CV should be made mandatory. The end of the former two paragraphs both highlight this similarity between the authors’ views. That is why I support the argument from both sides; because they stand on a sort of middle ground that proposes that all other feasible options be exhausted before making the CV mandatory. In terms of just Parker’s section, I specifically admire how he points out that the safety of vaccines should not be a point of hesitancy as their relatively risk-free nature is backed by scientific evidence. On the other hand, the other 3 co-authors do an excellent job of providing specific measures that can be enforced prior to the vaccine mandate so that healthcare workers are provided with a fair chance to obtain the vaccine of their own will. Additionally, I also agree with their point that if the CV is made mandatory without any effort to resolve healthcare workers’ reasons for being hesitant, then the only result will be counterproductiveness in the form of mistrust in the government by healthcare workers. In the end, I would once again like to highlight that I agree with both arguments made in the paper by Parker et al because they essentially support a middle ground that promotes exploiting all possible options prior to initiating a strict policy for the CV. 

 

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. JOURNAL OF MEDICAL ETHICS, 47(7), 467–472. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/medethics-2020-107175

Parker, M., Bedford, H., Ussher, M., & Stead, M. (2021). Should covid vaccination be mandatory for health and care staff? BMJ-BRITISH MEDICAL JOURNAL, 374, n1903. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/bmj.n1903

Objectively Objecting to Conscientious Objection

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On December 1, 2021

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An Introduction to Conscientious Objection

Let us begin this post by defining what it means for a healthcare professional to partake in conscientious objection. In their writing of Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodation, Schuklenk and Smalling explain that conscientious objection takes place when a healthcare professional such as a doctor or nurse refuses to provide specific services to patients based on their own personal beliefs such as religion and/or culture (2016). Usually, the most popular services to be refused in the name of conscientious objection are reproductive in nature, such as abortion and contraception use, or are involved with end-of-life care, as is assisted dying (193). It is also important to note that various members across the 2SGLBTQIA+ spectrum are disproportionately negatively affected when wishes to refuse service based on conscientious objection are appeased. For the remainder of this post we will be discussing the reasons for which I wholeheartedly agree with Schuklenk and Smalling (2016) in their argument against allowing professionals healthcare to rely on conscientious objection by walking through their perspectives in conjunction with applying their beliefs against the backdrop of mandatory vaccinations for medical professionals as outlined in Case Study 1: Healthcare Workers and Their Flu Shots (Fisher, et al., 2018). 

Why Conscientious Objection is Unacceptable in Healthcare

Most of the efforts put forward by Schuklenk and Smalling to explain the downfalls of accepting conscientious objection are based on the freewill of autonomous adults being able to choose a career in healthcare wherein they have been established as monopoly providers of specific services alongside the involuntary context of being denied those services from the professionals who voluntarily choose to deny it. The authors introduce us to the potential inequity involved with a healthcare professional’s right to exercise conscientious objection by outlining two hypothetical situations: a hypothetical Muslim, female doctor not wanting to see a male patient vs. a pharmacist of any gender refusing to provide contraceptives. The Muslim doctor would not be granted conscientious objection even though her hesitancy is religion-based whereas the pharmacist, who is also refusing service for religious reasons, could, in some regions, freely refuse contraceptive provision (194). This scenario excellently illustrates the inequity within the profession, an aspect that should be considered highly unacceptable amongst medical experts and their scope of practice. Furthermore, this specific form of inequity could lend itself to more insidious patterns of control if conscientious objection were to become commonplace. Legal scholar, Alta Charo, ingeniously captures these risks when she stated, “claiming an unfettered right to personal autonomy while holding monopolistic control over a public good constitutes an abuse of the public trust—all the worse if it is not, in fact, a personal act of conscience but, rather, an attempt at cultural conquest” (194). Now that we have established our agreement with Schuklenk and Smalling (2016), and Charo (2005), let us conclude by taking a look at how medical institutions can navigate conscientious objections to maximize beneficence amongst the masses.

Conclusion

Since 2012, Vancouver Coastal Health (VCH), which is the community health authority of Vancouver, British Columbia, has required that all healthcare professionals must be vaccinated against the flu or wear protective masks at all times while interacting with patients during the flu season, claiming that these policies are necessary to exercise their “moral responsibility to not harm their patients and clients” (Fisher, et al., 2018, p. 471). This policy was made as a means to combat the objection to getting vaccinated voiced by many healthcare workers in a realm of work that calls for “a special moral duty that healthcare workers have that is greater than the one ordinary people have not to harm others” (p. 471). The underpinning message of importance when drawing a parallel between the mandates called for by VCH and the personal conscientious objection of a singular doctor is that patients who access care are entitled to consistent care from healthcare providers that effectively minimizes harm to those who request such monopolized services. The denial of such services could lead to very real adverse outcomes for specific groups whilst being of no concern to others, specifically in the context of contraceptive use, abortion, and gender-affirming treatments.

Let us also not forget that entering into a career in healthcare is done so by an autonomous, willing adult. If a human is competent enough to find themselves placed in the incredibly prestigious world of medicine, they should also be competent enough to understand that there are systems of understanding and beliefs held by the masses, which they have committed themselves professionally to help, that will not adhere to their own personal set of beliefs and understandings. If such a notion is too overwhelming, Schuklenk and Smalling were just in recommending that the healthcare providers who find their own beliefs too overbearing to allow for the provision of specific services perhaps simply pursue an alternative career path to increase the potential for every single human accessing medical services being treated with equity and respect. 

References

Charo, R. (2005). The celestial fire of conscience—refusing to deliver medical care. New England Journal of Medicine, 352(247), 1-3. 

Fisher J., Russel J., Browne A., & Burkholder L. (2018). Case 1. Biomedical Ethics, A Canadian Focus. (3rd Ed.). Oxford University Press. 

Schuklenk, U., & Smalling, R. (2016). Why medical professionals have no moral claim to conscientious objection accommodation. Biomedical Ethics, A Canadian Focus. (3rd Ed.). p. 191-200. Oxford University Press.

Nuances of Conscientious Objections and the Need for Some Accommodations

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On December 1, 2021

In Uncategorized

“Do your homework.” “Clean your room.” “Get up and do some exercise.”

These were some of my most hated comments growing up. It was not that I did not see any value in what my parents were asking of me, it was simply that I did not want to be told what to do. Even if I had already intended to carry out a specific task, the idea of someone else potentially infringing on my delicate sense of autonomy would prevent me from moving forward with the task. Never mind that those who would remind me of my obligations had my best interests at heart and were doing so from a place of genuine love. As an adolescent beaming with confidence, no one should be allowed to inform my decisions. I know best what is beneficial for me…

Fortunately, life has since taught me the importance of heeding advice and has humbled me into accepting that I do not know as much as I think I know. Whereas we can all mostly agree that my younger self had very little practical backing behind their objections – surely an arbitrary refusal of what is ultimately good for someone should not come merely as a knee-jerk reaction to being told what to do – conscientious objections based on a deeply held moral or religious belief should be weighed more heavily. Conscientious objections in professional settings can be understood as objections to a particular legal role or responsibility of a profession based on one’s individual moral convictions and understandings [1],[2]. In the healthcare profession, for example, conscientious objection can take the form of a healthcare practitioner refusing to provide treatments that they deem to be unconscionable, such as abortions or euthanasia for consenting patients [1]. In Canada, the Supreme Court has ruled in favor of allowing autonomy as it pertains to conscientious objection for all citizens barring that in exercising this right there is no detriment to those who would oppose the moral or religious grounds for the objection [2].

However, many oppose this ruling in the context of conscientious objections to services provided in the healthcare profession. Udo Schuklenk and Ricardo Smalling argue for this very point in their article titled Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodations in Liberal Democracies [2]. They argue that the inability to ascertain the objective truth behind one’s beliefs along with an inability to truly determine one’s adherence to said beliefs provide a weak argument against fulfilling a crucial role of a profession, which in the context of the medical profession is to standardize the level of care for all patients [2]. This they believe results in suboptimal access to care for patients due to unpredictable and unfair service delivery as a consequence of healthcare practitioners touting conscientious objections to certain treatments and procedures [2]. In addition, they argue that conscientious objections create unfair workloads for practitioners willing to provide the services that their peers may object to due to moral or religious beliefs [2]. Thus, the authors conclude that conscientious objections have no place in medical practice and should not be entertained [2].

Unfortunately, in this posting, I will attempt to outline a number of flaws in the arguments dictated by Shuklenk and Smalling. In so doing, I wish to strengthen the arguments for conscientious objections and indicate their importance in medical practice. The goal is not to argue for absolute acceptance of conscientious objections but rather to highlight the nuance of the situation and why medical practitioners have some level of moral claim to conscientious objection accommodations.

My first objection to Shuklenk and Smalling’s article lies in the idea that individuals who autonomously choose to join a profession should not be exempt from any of the responsibilities of the profession, regardless of whether or not those responsibilities change over time [2]. An example of this would be an individual who autonomously chooses to enter the field of obstetrics and gynecology (OB-GYN) but refuses to carry out abortions on religious or moral grounds. Such individuals should note prior to joining the profession that abortions are a legal entitlement for patients within Canada and are an expected part of the job description [2]. Shuklenk and Smalling argue that for licensed providers holding a monopoly to consciously object to provide such a service – based on untestable claims of psychological burden by acting against one’s conscience – they bar access to this service resulting in lack of care and an inequitable workload for other OB-GYNs [2]. To further drive this point home, they outline how women in Prince Edward Island currently must leave the province in order to get an abortion due to healthcare providers not offering this service within the province [2]. This creates, as they mention, an unacceptable barrier for access to legal abortions [2].

While I agree that in most cases it would be unacceptable for an OB-GYN today who would have prior knowledge of the requirement for carrying out abortions to reject to provide this service, my main quarrel lies in the idea that healthcare providers should accept changing responsibilities for their role. The argument presented by Shuklenk and Smalling indicates that in joining the medical profession, one recognizes that societal expectations may change with time [2]. Thus, healthcare providers should understand the need to adapt and exercise flexibility. A failure to do so due to a possible conscientious objection to the changing expectation would therefore follow as a failure to act professionally and should serve as an indication of a lack of fit for the profession, per their argument [2]. However, I believe that a blanket disregard for conscientious objections to changing expectations would be greatly damaging to the medical profession at large. We simply do not know what we do not know. By perpetuating the idea that medical practitioners have no moral claim to conscientious objection accommodations we inadvertently stifle their voices and minimize any concerns they may have. This may result in a jaded environment where healthcare professionals feel invalidated and so shy away from discussions where their input is crucial.

The question I pose is this: who determines expectations for healthcare professionals and when they should change? Should not healthcare professionals themselves partake in the discussion that would impact their roles and responsibilities? If we accept that healthcare professionals should have a say in how their professional expectations shift over time, as I believe we should, one of the better ways to ensure beneficial evolution would be to consider the current conscientious objections along with proposed accommodations. By arguing that there is no moral claim to conscientious objection accommodations, we may prevent harm to patients by ensuring optimal access to services. However, at the same time, we abruptly end all discussions that could yield solutions that are of greater benefit not only to the patients but to the healthcare professionals who care for these patients. Ultimately, it is through conscientious objections and the request for accommodations that we develop an avenue by which to excite change and constant improvement in the healthcare profession. To further emphasize this point, let us look at the abortion example from a different lens:

Let us consider Bill TX SB8, legislation that took effect in Texas as of September 1st, 2021, and bans elective abortions for individuals if a fetal heartbeat can be detected by ultrasound [3]. In this example, I wish to highlight some of the conscientious objections noted by Danielle Jones, an OB-GYN practicing in Texas, who discusses the bill in her YouTube video titled ObGyn Explains Abortion Ban in Texas. Dr. Jones starts off by discussing how the prohibition of abortion once a fetal heartbeat can be detected by ultrasound is subject in its duration to factors such as the type of ultrasound conducted, the capabilities of the ultrasound machine used, and the individual conducting the ultrasound [4]. Thus, she argues that there is no standardized timeframe after which elective abortions become illegal, which subsequently constrains the amount of time that individuals have to request an abortion [4]. Additionally, she argues that with the only exception in Bill TX SB8 extended to mothers whose lives have become endangered, this bill results in the potential undue harm of a patient [4]. Life endangerment exists on a spectrum, she argues, and by threatening legal actions against a healthcare professional, it creates hesitancy regarding the determination of life endangerment which could delay treatment and result in negative consequences for the patient [4]. Finally, she argues that a lack of exceptions to others such as rape victims and mothers whose babies suffer from fetal abnormalities such as anencephaly (i.e., lack of proper brain development but brainstem exists to regulate heartbeat), directly harms the patient by limiting their choices and preventing them from carrying out an abortion when they might believe it to be the most merciful course of action for themselves or their babies [4]. It becomes impossible then to note these points and continue to argue that all conscientious objections serve to provide suboptimal access to care and thus harm the patient. In this case, Dr. Jones presents a compelling argument against Bill TX SB8 and can be seen to argue beneficently for accommodations that would better serve patients. Thus, we cannot look at this example and argue that medical professionals have no moral claim to conscientious objection accommodations since the objections in this very example are made in the best interests of patients and in the interest of creating better policies.

My second and final objections to Shuklenk and Smalling’s article are in regard to the acceptance of the burdens imposed on healthcare professionals by ignoring their conscientious objections and requiring that they partake in actions that would go against their conscience [2]. If we look back to the Prince Edward Island example regarding the lack of access to abortions in the province, conscientious objections to abortion should be allowed in this case. This does not go against my previous statement as I noted that in most instances, I would find such a stance unacceptable, not all. In this case, we need to consider the impacts of a healthcare practitioner carrying out an abortion in a province where such a practice is broadly considered unacceptable, as can be concluded from the lack of service availability. Thus, healthcare professionals in this instance are a reflection of the values and beliefs held by the broader community. We would therefore not only have to consider the psychological burden imposed on a healthcare practitioner who is mandated to carry out abortions in the province, but also the burdens that they would have to carry as a result of going against what is locally accepted. This additional societal burden could threaten to drive individuals from the profession and is why accommodations can be acceptable in this case but not necessarily others. Therefore, I conclude the opposite of what Shuklenk and Smalling concluded in that the burden to a healthcare system by making the State and not healthcare professionals a guarantor of access to legally entitled services such as abortions, is justified [2]. Finally, Shuklenk and Smalling fail to see the dangers in driving away qualified individuals from the medical profession. They argue that those individuals can be easily replaced as the number of applicants to the medical profession far exceed the spots available [2]. However, I would counter by stating that due to the lack of availability and heavy competition, the current system is designed to select the most worthy and competent candidates. Thus, it would ultimately be both harmful to the medical community and patients if our very best were driven away from the profession due to a lack of reasonable accommodation to their conscientious objections.

All in all, my goal through this post was to draw attention to the nuances of conscientious objections and the need for some accommodations. While I argue that healthcare practitioners have a moral claim to conscientious objection accommodations, I do not believe that all objections should be accommodated. Per the Supreme Court ruling, I agree that accommodations should be limited in that they should not come at a detriment to others who would exercise a different view.

References

[1]          Shanawani H. The Challenges of Conscientious Objection in Health care. J Relig Health. 2016 Apr;55(2):384-93. doi: 10.1007/s10943-016-0200-4. PMID: 26923838.

[2]          Fisher, Johnna, et al. Biomedical Ethics: A Canadian Focus, Oxford University Press, Don Mills, Ontario, Canada, 2018, pp. 191–201.

[3]          “Texas SB8: 2021-2022: 87th Legislature.” LegiScan, https://legiscan.com/TX/text/SB8/id/2395961.

[4]          Obgyn Explains Abortion Ban in Texas – Youtube. https://www.youtube.com/watch?v=zjB5Jakytyc.

 

  

The Compromise for Vaccinations

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On December 1, 2021

In Uncategorized

Introduction

There are numerous perspectives on the current COVID-19 vaccination situation, with many of them contradicting one another. COVID-19 is a severe worldwide pandemic that has been causing devastating effects on peoples’ lives. After reading the paper Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers, I can better understand why it is important for front-line healthcare workers to be vaccinated. However, I still believe there are some situational errors that I will address later. Front-line healthcare workers (FHCWs) are the employees who physically interact with patients, such as doctors, nurses, cleaners, students, allied health clinicians, pathology staff, and security (Bradfield & Giubilini 2021). Vaccines are being distributed, with FHCWs being a priority in receiving them; therefore, this raises the ethical question of whether vaccines should be mandatory for them (Bradfield & Giubilini, 2021). In this blog, I will discuss the benefits and drawbacks of the COVID-19 vaccination and the compromise the paper suggests for FHCWs.

 

Vaccination Benefits

COVID-19 is a serious threat to the public’s health, and the virus disproportionately affects ethnic and racial minorities in consideration of the severity and frequency (Bradfield & Giubilini, 2021). Therefore, especially in a healthcare setting, FHCWs, particularly the older ones and those who belong to racial and ethnic minorities, are at high risk of infection and death (Bradfield & Giubilini, 2021). Increasing vaccination rates among FHCWs is anticipated to reduce the amount of infection, morbidity, and mortality (Bradfield & Giubilini, 2021). Leading to the point that there is an urgent need to minimize the amount of COVID-19 transmission within healthcare facilities to ensure that patients and FHCWs, especially those at high risk, are less likely to be disproportionately affected by COVID-19 (Bradfield & Giubilini, 2021). I know people who refuse to enter unvaccinated people’s homes because they are afraid of the virus. This leads me to believe many people will not seek medical attention because they are concerned that their healthcare provider is not vaccinated. Therefore, it is understandable that the vaccination has a variety of positive impacts, explicitly focussing on those affected within a healthcare setting.

 

Vaccination Drawbacks

Although COVID-19 vaccinations are beneficial for people’s health, I still believe it is important to choose whether or not to be vaccinated. Vaccines are not 100% safe, and when a person receives a vaccine, there are risks of adverse vaccine reactions (Bradfield & Giubilini, 2021). By now, most people have heard stories about how the COVID-19 vaccine has caused some harm in different individuals’ lives, but these adverse reactions are usually minor. Although, there is still a risk of infrequent complications caused by the vaccine (Bradfield & Giubilini, 2021). For FHCWs, if a worker has a high likelihood of a severe adverse reaction to the vaccine, it is morally understandable to exempt this employee from a mandatory vaccination policy (Bradfield & Giubilini, 2021). A significant concern is if vaccines are mandated for FHCWs, there may be a significant understaffing issue if too many of these employees refuse to be vaccinated (Bradfield & Giubilini, 2021). An example from my life is at the nursing home where I work; we do not have enough staff, so many of us have been working overtime to compensate for how many staff members we lost due to them not getting the COVID-19 vaccine. Many of my coworkers are religious, so they left their job because you have to have the vaccine to work there, and they did not attempt exemptions for personal reasons. This real-life example has proven that understaffing due to a mandatory vaccine is becoming a serious problem.

 

Compromise & Conclusion

In the paper, a compromise is explained for FHCWs so that they have the option not to be vaccinated. A ‘conditional mandate’ is the solution to avoid forcing vaccinations and allows less severity of infection in healthcare facilities (Bradfield & Giubilini, 2021). The ‘conditional’ vaccination policy allows a balance between an entirely voluntary and mandatory method (Bradfield & Giubilini, 2021). Redeployment of unvaccinated FHCWs to telehealth services or non-clinical administrative duties is a way to keep these staff members employed, but if redeployment is not possible, then paid or unpaid leave may be the only other option for FHCWs that refuse the vaccine (Bradfield & Giubilini, 2021). After the period of leave is finished, and if the FHCW has not been vaccinated, their employment or professional registration may be canceled or suspended (Bradfield & Giubilini, 2021). This solution is not perfect, and many situational errors may occur, such as the previously mentioned understaffing and serious financial costs. In conclusion, mandating the COVID-19 vaccination for FHCWs will help protect patients’ health but will incur many costs. Therefore, I agree with the current solution of a compromise to attempt the best solution for everyone involved.

 

Reference

Bradfield, O., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal Of Medical Ethics, 1-6. doi: 10.1136/medethics-2020-107175

An Obligation to Care: Mandatory Vaccines for Healthcare Workers

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On December 1, 2021

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Introduction

The debate of whether or not vaccines should be mandatory, especially for Healthcare workers (HCWs), is a very hot topic right now mainly with regards to the available COVID-19 vaccines. Understandably, individuals have their own thoughts, morals and conscience but that should not mean that the risk of patients should increase as a result. In this posting, I will examine multiple arguments for and against mandatory vaccines for HCWs and explain why I believe the conclusion that can be drawn is clear: vaccines should be mandatory for HCWs. 

Non-Maleficence 

The concept of non-maleficence is a relatively easy concept to understand: do no harm to the patient (Bradfield & Giubilini, 2021). This may sound like common sense but when applied to different situations, it can become a gray area when personal values are thrown into the mix. When a HCW refuses to get a vaccine that has been shown to reduce transmission of infections and still chooses to treat patients (who are most likely vulnerable to such infections), they are putting the patient in a direct line of harm (Bradfield & Giubilini, 2021). The argument against getting the vaccine could come from a place of self-defence as it may seem permissible for an individual to expose others to risks to protect themselves (Bradfield & Giubilini, 2021). However, I believe that the chances of harming the patient by transmitting COVID-19 or another illness is higher than the chances of having serious life-altering side effects from the vaccine. 

Coercion/Preservation of Autonomy

Many people view the idea of mandatory vaccines for HCWs as a form of coercion and should only be used if all other measures fail (Parker et al., 2021). The fear people may feel from believing they have no other choice but to go against their wishes can be mitigated by using a type of “intervention ladder” (Bradfield & Giubilini, 2021). An intervention ladder can be explained as a concept where less intrusive methods, such as no intervention or simple persuasion, must be shown to be ineffective until more intrusive methods can be implemented, such as forced vaccination with physical or chemical restraint (Bradfield & Giubilini, 2021). Although I believe that vaccination should be mandatory for HCWs, I do not believe that physical restraint should be used where people are held against their will and essentially tortured into receiving the vaccine. I believe that HCWs should have the choice to get vaccinated or not but there should be serious consequences for those who refuse. Furthermore, the concept of autonomy, or the ability to make your own decisions, cannot be forgotten. Everyone has their own unique set of beliefs and values which dictate the course of action an individual takes, including their viewpoint on getting vaccinated. However, as a HCW, certain professional obligations were agreed upon when an individual became a HCW which I will analyze next.

Professional Obligations

As a HCW, there are certain codes of ethics and guidelines to abide by that outline how a HCW should behave (Bradfield & Giubilini, 2021). Non-maleficence, as mentioned above, is one of these professional obligations that a HCW must abide by. Consequences of not following these rules, with regards to choosing to be unvaccinated, could result in being temporarily redeployed, suspended or even having their license revoked if refusal persists (Bradfield & Giubilini, 2021). In a healthcare setting, the patient should always come first and most often, the patient does not get to choose when they are sick or who is taking care of them (Bradfield & Giubilini, 2021). As a result of this, a patient should not have to suffer if their designated HCW does not want to get vaccinated for reasons other than medical exemption; it is very clearly unfair and unjust towards the patient. 

Final Thoughts

It is no surprise that the current COVID-19 vaccines are not 100% effective in stopping the transmission of the illness but they have been shown to greatly reduce the risks associated with the illness (Bradfield & Giubilini, 2021). I believe that when an individual chooses to be a HCW, they are agreeing to a set of rules and obligations that allow them to provide the best care possible and are bound by a certain code of ethics that outlines how to do so. The reasons listed above, although there are many more, demonstrate that although implementing a mandate for mandatory vaccinations for HCW may seem like a form of coercion or an infringement of autonomy, HCWs should be the bigger person and remember that in their line of work, the patient’s well-being must be put first.

I believe that a large part of increasing vaccination rates would be to ensure that all HCW know where to get the vaccine, that everyone knows the risks/rewards associated with the vaccine and where to find support to voice any concerns they have regarding vaccination protocol (Royal College of Nursing, 2021). When all of these things occur, HCW with worries will feel less alienated, more heard and most likely more responsive to getting the vaccine. When given all of the proper tools and information to make a proper decision on getting the vaccine, it becomes less intimidating and more like a duty to protect patients, which is what every HCW should strive to do.

 

References

Parker, M., Bedford, H., Ussher, M., & Stead, M. (2021). Should covid vaccination be mandatory for health and care staff?. BMJ, 374.

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of medical ethics.

Royal College of Nursing. (2021). RCN position on mandating vaccination for health and social care staff. https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn
-position-on-mandating-vaccination-for-health-and-social-care-staff

Mandatory Vaccination Policies for Healthcare Workers are Justified

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On December 1, 2021

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Introduction

The COVID-19 vaccination is mandatory for healthcare workers in Alberta; in support of this policy, Dr. Verna Yiu, the Alberta Health Services President and CEO, states that “at the end of the day, it’s about protecting patients, continuing care residents…we have a responsibility to do that” (“Alberta extends mandatory COVID-19 immunization deadline”). However, not everyone is fully comfortable with such a policy. For example, the Royal College of Nursing points out that a mandatory vaccination policy will marginalize their vaccine hesitant staff (“RCN position on mandating vaccination for health and social care staff”). The purpose of this post is to present both sides of the vaccine debate, and to establish my own position that mandatory vaccinations for healthcare workers are justified, both because i) the benefits of vaccination seem to outweigh the relatively minor risks, and ii) the risks can generally be managed.

 

Those in Favour of Mandatory Vaccinations

Michael Parker argues that since vaccinations generally present minimal risks to the individual being vaccinated and greatly reduce the risks of harm of others by preventing the spread of infectious diseases, getting vaccinated is a “duty of easy rescue” that all healthcare workers are obligated to follow (Parker et al. 1). Furthermore, while Bradfield and Gibuilini acknowledge the potential negative consequences of mandatory vaccinations, they suggest that the benefits far outweigh the drawbacks (Bradfield and Giubilini 2). In fact, they even make the argument that one of the “drawbacks”—the restriction of one’s personal freedoms—does not carry much weight (Bradfield and Giubilini 4). To elaborate, Bradfield and Giubilini state that personal choices “extend only so far as they do not infringe on the legitimate interest of others.” Furthermore, one’s choice to not get vaccinated may result in their contraction of the virus and subsequent spreading of it to others, thus harming others’ legitimate interests. Therefore, they argue that not getting vaccinated should not be available as an open choice in the first place (like how we do not have the option to freely steal for our own personal gain) and thus conclude that making vaccinations mandatory is not contrary to one’s personal freedoms, but instead represents a boundary of one’s freedoms in order to protect the freedoms of others.

 

Those Against Mandatory Vaccinations

On the other hand, Bedford, Ussher, and Stead argue that mandatory vaccinations can be counterproductive, because they may increase the vaccine skepticism amongst the public and foster distrust towards the governmental and medical institutions; furthermore, they argue that such a policy would damage the morale amongst the healthcare team, who are already overburdened (Parker et al. 2). Instead, they favour an educational approach to improve vaccine acceptance. The Royal College of Nurses shares this hesitancy towards mandatory vaccination policies, as they fear that it will both marginalize those who do not wish to be vaccinated and could lead to unemployment issues for such staff (“RCN position on mandating vaccination for health and social care staff”).

 

Which Side to Take?

Now that we have seen both sides of the debate, I will present my own perspective on this issue. While I agree that there are some risks associated with a mandatory vaccination policy, I will argue that i) the benefits of such a policy will outweigh such risks, and that ii) the risks can be effectively managed.

As of today, there are 5.2 million deaths worldwide, and 262 million cases of COVID-19 (“COVID-19 Coronavirus Pandemic”). In healthcare settings where patients’ health is already compromised, the consequences of a patient’s contraction of COVID-19 are particularly severe (“COVID-19”). Vaccination of healthcare professionals greatly reduces the risks that the professionals themselves will be infected with COVID-19 and will subsequently reduce the potential that patients will be exposed to COVID-19. The risks of getting vaccinated, by contrast, are generally far less—a little poke in the arm and a few side effects; therefore, it seems obvious that the physiological benefits far outweigh the physiological risks to the individual being vaccinated.

However, there are a few other more substantial risks that we must consider, such as the development of distrust and unemployment of healthcare professionals. While such risks are concerning, I believe that they can be mitigated. To elaborate, the development of vaccine hesitancy and distrust towards the government/healthcare institutions may occur following a mandatory vaccination policy, but if such a policy were accompanied by extensive vaccine education, such distrust should decline sufficiently. Furthermore, while the unvaccinated healthcare professionals may become unemployed from their regular jobs, they can apply to work as virtually accessible doctors, such as through the Cleveland Clinic (“On-Demand Virtual Care”). Therefore, while the mandatory vaccination may have some drawbacks, the huge benefit to vaccination (i.e., protecting many lives) and the ability to manage these concerns well enough seems to be reason enough to favour a mandatory vaccination policy for healthcare workers.

 

Works Cited

“Alberta extends mandatory COVID-19 immunization deadline.” Alberta Health Services, 29 Nov. 2021, https://www.albertahealthservices.ca/news/Page16253.aspx

Bradfield, Owen M., and Alberto Giubilini. “Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers.” Journal of Medical Ethics, vol. 47, no. 7, 2021, pp. 467-472. BMJ, https://doi.org/10.1136/medethics-2020-107175.

“COVID-19.” Centers for Disease Control and Prevention, 29. Nov. 2021, https://www.cdc.gov/coronavirus/2019-nCoV/index.html

“COVID-19 Coronavirus Pandemic.” Worldometer, 29. Nov. 2021, https://www.worldometers.info/coronavirus/

“RCN position on mandating vaccination for health and social care staff.” Royal College of Nursing, 29 Nov. 2021. https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-mandating-vaccination-for-health-and-social-care-staff

“On-Demand Virtual Care. » Cleveland Clinic Canada, 29 Nov. 2021, https://my.clevelandclinic.org/canada/resources/express-care-online?utm_source=google_ppc&utm_medium=cpc&utm_campaign=Canada%20-%20Virtual%20Care%20%20-%20General%20-%20Region%20Canada%20BC%20Alberta&utm_term=virtual%20doctor&gclid=Cj0KCQiAkZKNBhDiARIsAPsk0WiJ9waFLrymmNllsofG5U6JHb_lupAE7cxmyJhsilvqcAHW5ZrRfmMaAtbXEALw_wcB/.

Parker, Michael et al. “Should covid vaccination be mandatory for health and care staff?” The BMJ, vol. 374, no. 1903, 2021, pp. 1-3. BMJ, https://doi.org/10.1136/bmj.n1903

 

 

Healthcare workers and their duty to be vaccinated

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On December 1, 2021

In Uncategorized

As the global phenomenon of the COVID-19 pandemic continues to linger, more and more counterbalances have been put in place in order to limit the spread of the highly contagious disease as well as to reduce mortality rates due to the disease. One of these countermeasures created for the purpose of stopping the spread of COVID-19 is vaccination. Although research has shown that there is a directly proportional correlation between an increase in vaccination rates and a reduction in COVID-19 related deaths (and cases in general), the issuing of mandatory vaccination has been widely criticized for centuries. Front-line healthcare workers (FHCWs), which include any staff who directly interact with patients in their work, are arguably most at risk of contracting COVID-19 (Bradfield & Giubilini, 2021). An issue resides in if these same frontline healthcare workers choose to remain unvaccinated, they also risk the spread of COVID-19 to vulnerable patients they are in direct contact with. In this blog post, I will evaluate arguments made in Bradfield & Giubilini’s proposed mandate using principles from a Utilitarian perspective and by assessing whether the conditional vaccine mandate aligns with a healthcare professional’s duty to provide care.

 

Coercive vaccination policies and the conditional vaccination mandate proposed by Bradfield & Giubilini

Coercion is defined as the practice in which persuasion is made with the threat of a penalty if individuals fail to comply (Bradfield & Giubilini, 2021). In Bradfield & Giubilini’s article, they describe an “intervention ladder,” a ladder that ranks public health policies regarding mandatory vaccination for FHCW from least to most intrusive. The term intrusive will refer to the extent that each policy impedes an individual’s autonomy (the ability for individuals to make their own decisions regarding their healthcare). At the bottom of the intervention ladder, there is the policy of no intervention, which undoubtedly fulfills the role of allowing FHCWs free choice and autonomous decision-making. A rung up the ladder is persuasion, where educational campaigns and such in favor of vaccination are offered, although not mandated, to FCHWs. Next, the policy of nudging through opt-out policies (policies where FHCWs must sign a declination statement to explain their refusal to vaccinate) is another rung up the ladder of intervention. Higher up would be incentives, privileges that may be used to encourage FCHWs to vaccinate like allowing additional paid leave, and disincentives, factors used to discourage FCHWs from being unvaccinated like not having access to tea rooms or health clubs. The highest rungs of the ladder would consist of penalties for unvaccinated FCHWs like fines or imprisonment and forced vaccination with severe consequences upon infringement. In their article, Bradfield & Giubilini argues in favor of the use of a conditional mandate for vaccination which would preserve the liberty to refuse vaccination at the first instance through redeployment to other roles. However, if redeployment becomes impossible, unvaccinated FCHWs would be asked to take a paid or unpaid leave and if during the leave the FCHW remains unvaccinated, their professional registration may be revoked (Bradfield & Giubilini, 2021).

 

Utilitarianism and Mandatory Vaccination

Utilitarianism is the ethical theory that places emphasis on preserving the consequences which ensure the maximization of the greatest net happiness, or, the greatest satisfaction of preferences (Welchman, 2021). From a utilitarian perspective, the argument made by Bradfield & Giubilini to reinforce a conditional vaccination mandate is an acceptable example of maximizing net happiness. This is done firstly through the harm principle, a principle which states that no individual should have a right to harm another, proposed by John Stuart Mill as a rule that maximizes preference satisfaction if followed generally (Welchman, 2021). Therefore, the harm principle in the case of the conditional vaccine mandate justifies the use of slightly intrusive policies on the basis that unvaccinated FCHWs will cause harm by spreading COVID-19 to patients they are in direct contact with since they are more susceptible to the virus as well. Moreover, utilitarianism is also emphasized through Singer’s duty of easy rescue which is the duty to act to ensure the greatest net happiness in a situation where an individual may do so while sacrificing something of comparably less value (Welchman, 2021). According to the duty of easy rescue, one should be prepared to sacrifice something small, such as getting vaccinated like encouraged in the conditional vaccine mandate, in order to prevent something detrimental of greater value from occurring, such as spreading COVID-19 to patients and putting them at risk. The risk that unvaccinated FHCWs impose on their patients (which would not maximize the greatest net happiness) is outweighed by their right to exercise free choice, and so the policies proposed in the conditional vaccine mandate would follow Utilitarian ethics.

 

The duty to care and the obligation of non-maleficence

Healthcare professionals including but not limited to FHCWs must also abide by their duty to care, especially so in the presence of a global pandemic. A healthcare professional’s duty to care is defined as an obligation to tend to their patients’ well-being and to hold their patients’ well-being as being a primary priority (BC Ministry of Health [BCMH], 2021). The importance of this duty to care is that it explains the reasoning behind a healthcare professional’s obligations to their patient and occupation. This is because, as touched on in the previous section, FHCWs must always obey their ethical and professional obligation of non-maleficence towards their patients. This aspect is encompassed in any healthcare professional’s duty to provide care since, in order to provide safe, competent, compassionate, equitable, and ethical care for their patients, FHCWs should take necessary measures not to do harm to their patients (BCMH, 2021). In the case of vaccination, because many studies have proven the effectiveness of vaccines in reducing the spread of COVID-19 which puts patients at risk, it should be considered a part of an FHCW’s duty and moral obligation to be vaccinated (Bradfield & Giubilini, 2021).

 

Reflection

Personally, I believe that the conditional vaccination mandate proposed by Bradfield & Giubilini is very reasonable and in accordance with both Utilitarianism and a healthcare professional’s duty to provide care. One thing that I would like to mention however is that the conditional vaccination mandate cannot be regarded as a social contract; rules that individuals must obey in order to receive protection and cooperation in return (Cox, 2020). This is due to the fact that FHCWs who get vaccinated through the implementation of the conditional vaccination mandate do not get direct reciprocal benefits from society for vaccinating themselves. Put in other words, the newly-vaccinated FHCWs are forced to bear the nonreciprocal burden of vaccinating themselves simply for the “greater good” like instilled in the values of utilitarianism (Welchman, 2021). Contractarianism, an ethical theory which states that free and rational individuals should accept to abide by a social contract to live cooperatively, would not justify the conditional vaccination mandate under these circumstances (Shafer-Landau, 2012). Thus, I believe that in order to also appeal to Contractarianism, the conditional vaccination mandate should offer some form of compensation (for example, in the form of incentives) for abiding by its policies. Although I overall would consider the proposed conditional vaccine mandate to be extremely reasonable given the circumstances surrounding the pandemic, I think that adding reciprocal benefits (such as in the form of incentives) for FHCWs who are hesitant to get vaccinated would definitely motivate more unvaccinated FHCWs to get vaccinated.

 

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics, 47(7), 467–472. https://doi.org/10.1136/medethics-2020-107175.

British Columbia Ministry of Health. (2021). COVID-19 Ethics Analysis: What is the Ethical Duty of Healthcare Workers to Provide Care During the COVID-19 Pandemic? Retrieved from the British Columbia Government Official Website: https://www2.gov.bc.ca/gov/content/home.

Cox, C. L. (2020). ‘Healthcare heroes’: Problems with media focus on heroism from healthcare workers during the COVID-19 pandemic. Journal of Medical Ethics, 46(8), 510–513. https://doi.org/10.1136/medethics-2020-106398

Shafer-Landau, Russ. The Social Contract Tradition, in The Fundamentals of Ethics,2nd Ed. (2012), pp. 187-200.

Welchman, J. (2021, November 28). Week 14 Part A [Video]. Youtube. https://www.youtube.com/watch?v=ucjSApulACA.

Vaccine Mandates for Healthcare Workers

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On December 1, 2021

In Uncategorized

Introduction

In our current health care climate, there are a lot of debates surrounding whether individuals should be vaccinated or not. This debate is also prevalent for health care workers, especially in regard to the COVID-19 vaccine. In Alberta, it is required for health care workers to get the COVID-19 immunization, or they will be put on unpaid leave (Alberta Health Services, 2021).

The majority of healthcare workers are vaccinated at about 90% as of October 22, 2021 (Alberta Health Services, 2021). However, this leaves about 10% of health care workers in Alberta who are unvaccinated for a various of reasons; religious and medical being a few that are recognized by Alberta Health Services (AHS), but some health care workers simply refuse to be vaccinated for non-religious and non-medical reasons.

While I understand personal autonomy (deciding what is best for yourself) is a factor in the decision to not receive the COVID-19 vaccine, I believe that health care workers should not be putting patients at risk by deciding to not receive the vaccine. In other words, I believe that vaccines should be mandatory for health care workers unless there are “legitimate medical or religious reasons” (Alberta Health Services, 2021).

To better understand my position, let us look into some arguments for and against mandatory vaccinations.

Professional Responsibilities

“Health care workers have an ethical and professional responsibility to protect others. Vaccination is a tool to assist in meeting this standard.” (Alberta Health Services, 2021).

Mandating the requirement of the COVID-19 vaccine for health care workers falls right into the professional code of conduct and ethics of health care workers (Bradfield and Giubilini, 2021).

What exactly are these professional responsibilities?

Non-maleficence meaning do no harm (Bradfield and Giubilini, 2021) is one of them. Non-maleficence ties into beneficence, acting with the consideration of what is best for others. These two responsibilities; non-maleficence and beneficence tie into vaccine mandates because if a health care worker gets the vaccine, then they are helping to prevent the transmission of COVID-19 to vulnerable patients (Bradfield and Giubilini, 2021). Health care workers are also aiding in maintaining their own health and the health of their coworkers, in turn helping each other’s families too.

If a health care worker refuses to get the COVID-19 vaccine then they are ethically doing harm to patients (Bradfield and Giubilini, 2021) through the lack of taking preventative care. “The duty not to infect patients must take priority over any right to vaccine refusal” (Bradfield and Giublini, 2021) as it is a “fundamental moral requirement” (Bradfield and Giublini, 2021) of all health care workers to do no harm which aids in guaranteeing patient access to healthcare (Bradfield and Giublini, 2021).

Freedom of Choice

An argument against vaccine mandates that I can find from our readings is that having mandatory vaccines infringe on our ethical freedom of choice (Parker et al, 2021). Bedford, Ussher, and Stead argue that mandatory COVID-19 vaccines are “not necessary, acceptable or the most effective way to achieve high uptake”, they also say that they consider the vaccine mandate to be “a blunt instrument to tackle a complex issue”.

While Bedford, Ussher and Stead acknowledge that freedom of choice is not considered greater than the protection of patients but say that “mandatory vaccination could be counterproductive”. They bring up that while many individuals do partake in getting the COVID-19 vaccine (this is uptake), there are populations that do not and have lower uptake. They mention that there is a population of health care workers that are hesitant towards receiving the COVID-19 vaccine, which can stem from concerns and misinformation.

To counter vaccine mandates, Bedford, Ussher, and Stead suggest looking into the reasons that health care workers are hesitant towards getting the vaccine. They suggest that addressing these reasons are important, such as educating health care workers on the basics of vaccines, improving availability of vaccine appointments, and creating open safe spaces for health care workers to discuss their concerns and hesitancies towards the vaccine. After this is implemented, they say that an “active listening” approach is created which builds trust. This way health care workers can decide for themselves whether they would like to go forward with the COVID-19 vaccine or not, and not feel forced to get it.

Thoughts

Looking at the perspectives of Bedford, Ussher, and Stead; I both understand and appreciate their argument against mandatory COVID-19 vaccinations. I do agree that freedom of choice is important, especially in regard to what happens with our bodies. In a general sense I do agree with them. However, in the case of health care workers I still strongly believe that they should be vaccinated as per their professional responsibilities of non-maleficence, but I know that this can be difficult to achieve.

Current News

My health care worker friends this morning discussed the changes that the AHS to the vaccine policy for health care workers in Alberta. Today was the deadline for health care workers to get their COVID-19 vaccines or they would be put on unpaid leave. However, some facilities in Alberta would be short staffed if they lose these employees. Because of this they are implementing that these health care workers submit 48-hour negative covid tests to be able to come to work.

“I want to be clear, the testing option is temporary and will be limited in scope. Only clinical work locations deemed to be at significant risk of service disruptions due to staffing shortages resulting from unvaccinated staff will be part of the testing program” (CTV News) is what Dr. Verna Yiu (president of AHS) said about this. The vaccine deadline has also been extended to December 13, 2021, and if they remain unvaccinated then they will be placed on unpaid leave.

My friends bring up the issue of what if Alberta Health Services just keeps extending the deadline to get vaccinations. This is of great concern about which issues will be deemed more urgent and it appears that the issue of having workers for patients in the most important.

 

References

Alberta Health Services. (October 22, 2021).  AHS extends mandatory COVID-19 immunization deadline. https://www.albertahealthservices.ca/news/Page16253.aspx

Bradfield, O.M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics.

CTV News. (November 30, 2021). AHS to accept negative COVID-19 tests from unvaccinated workers at sites facing staff shortages. CTV News Edmonton.

Parker, M., Bedford, H., Ussher, M., & Stead, M. (2021). Should covid vaccination be mandatory for health and care staff? British Medical Journal.

Vaccinations: Should They Be Mandated?

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On December 1, 2021

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Introduction

The COVID-19 pandemic has negatively impacted our society greatly, having infected over 131 million people and caused over 2.8 million deaths in the time span of a year (Bradfield & Giubilini, 2021). Aside from the general population, this pandemic has impacted entire systems such as the job force, healthcare system, etc. To aid with this burden, seven different vaccines have been mass distributed globally and over 649 million doses have been administered (Bradfield & Giubilini, 2021). However, the vaccine has also stirred some controversy and many people are hesitant to take it. Therefore, a question that must be asked is should the COVID-19 vaccine be mandatory amongst certain groups of people, starting with healthcare workers?

In this blog post, I will explore the concept of vaccine mandates regarding healthcare workers specifically. I will first explain the two sides- those for a vaccine mandate and those who are against the mandate. Then, I will explore the reasons for why I believe that having a vaccine mandate is the better approach for society.

Having a Vaccine Mandate

In a paper by Parker et al. (2021), Michael Parker puts forth various reasons as to why he believes a vaccine mandate should be present. All his arguments revolve around the central idea that healthcare institutions are ultimately responsible for the safety of the patients (Parker et al., 2021). Firstly, he talks about the “duty of easy rescue.” This means that, based on various studies, the vaccine is associated with a low risk of adverse effects occurring to the individual and it has a great impact on the safety of the patients that are being treated by the healthcare worker. Therefore, he believes that establishing this duty makes sense morally. Additionally, Parker mentions that although employers have a duty to ensure the well-being of their employees is upheld, the employees also have a duty to care for their patients and be willing to modify their beliefs and/or practices if they go against getting a vaccine that ultimately benefits patient safety. For example, Parker et al. (2021) talks about a possible scenario that could arise with a hospital chef.  If these chefs fail to comply with new food safety guidance that are put in place, they are faced with consequences such as losing their jobs. This is because their choice to refuse puts patient safety at risk and these practices are put in place based on scientific evidence to ensure the safest measure is being taken. Furthermore, Bradfield and Giubilini (2021) argue that healthcare workers are the individuals that are at the highest risk of infection/death. Therefore, aside from the detrimental effects on their personal health, these individuals have the greatest risk of transmission to their patients, families, etc. This poses to be an issue in the hospital setting especially because patients are already sick and then if they were to contract the virus, they are in an even greater risk of developing serious complications or even death (Bradfield & Giubilini, 2021).

Not Having a Vaccine Mandate

In the paper by Parker et al. (2021), Helen Bedford, Michael Ussher, and Martine Stead put forth their reasons as to why they believe a vaccine mandate should not be present. All their arguments revolve around the central idea that vaccine mandates are a “blunt instrument to tackle a complex issue” (Parker et al., 2021). These mandates may risk increasing vaccine resistance because the forced aspect of it could damage the trust people have in the government/other organisations (Parker et al., 2021). They believe that although patient safety is of upmost importance, the freedom of choice is also important. Therefore, to maintain freedom of choice but also eliminate vaccine hesitancy, they believe that instead of having a vaccine mandate, hospitals should put forth various sessions that target the main points of hesitancy. These initiatives could be in the form of Q&A sessions, online webinars, etc. that create an active listening environment that develops trust (Parker et al., 2021). Additionally, Bradfield and Giubilini (2021) mention that an overly coercive regulation, such as a vaccine mandate, will foster negative emotions such as resentment, opposition, and mistrust in the healthcare workers towards their employers too. These workers are already faced with PTSD, anxiety, etc. from fighting the pandemic so being cognisant of this is important and enforcing a mandate would add to their stresses and deter them from their jobs (Bradfield & Giubilini, 2021).

Conclusion

In conclusion, I agree with the argument that making vaccines mandatory may be counterintuitive as it may further resentment and develop mistrust between healthcare workers and the government/employers. I also agree with Bradfield and Giubilini (2021) in the sense that healthcare workers should not be forced to face serious risks for the sake of others’ safety. However, I think what is of upmost importance is the collective benefit of society. Therefore, since scientific evidence has shown that vaccines promote greater safety among individuals while limiting the individual risks, I think some form of a mandate should be present. As Bradfield and Giubilini (2021) mention, a conditional mandate would be the best approach as it allows healthcare workers to make the decision for themselves if they wanted to get vaccinated or not. However, if they choose not to, they will be redeployed to other duties that do not involve face to face interactions between them and vulnerable patients/colleagues (Bradfield & Giubilini, 2021). In my opinion, this system is the best for both sides as it encourages job security (redeployment instead of termination), but it also promotes the safety of the greater population.

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics, 47(7), 467–472. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/medethics-2020-107175

Parker, M., Bedford, H., Ussher, M., & Stead, M. (2021). Should covid vaccination be mandatory for health and care staff? British Medical Journal, 374, 1-3. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/bmj.n1903

Mandating COIVD-19 Vaccines

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On December 1, 2021

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The COIVD-19 virus has affected all of our lives for over two years. The recent omicron variant only insights more controversial debates on vaccine mandates that are starting to be implemented across the world. The crux of the discussion surrounds topics of collective benefits towards health & safety and the cost to personal autonomy. Bradfield and Giubilini’s (2021) paper titled Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers delves into this topic and argues favouring an approach that encourages frontline healthcare workers (FHCW) to get vaccinated. In this post, I will begin with normative ethical theories, then I will use those to highlight Bradfield and Giubilin’s argument and their vaccine policy suggestion for FHCW. 

Normative Ethical Theories

Two main normative ethical theories conflict concerning the topic of vaccine mandates: Utilitarianism and Deontology. A Utilitarian would argue that vaccine mandates are necessary as vaccines are proven to be highly effective in protecting people from the harmful effects of contracting the virus, and this benefit far outweighs any personal costs. To a Utilitarian, even a person with a medical condition that drastically increases their odds of adverse side effects should get vaccinated because vaccines’ collective benefit exceeds the risks incurred by a small few. 

In response, Deontologists would argue that a person’s autonomy, or right to make their own decisions, should be upheld to the highest standards. Thus, any policy that undermines a person’s autonomy would not be ethical. Their rebuttal would suggest that each person holds inherent dignity, and every life is just as important as the next; sacrificing even one life for anyone else’s is unjust and unethical. 

In healthcare, both perspectives are valued, and the system strives to balance protecting a person’s right to autonomy and collective benefits to society. 

Conditional COVID-19 vaccination policy

Bradfield and Giubilini (2021) wanted to balance collective benefits without overly compromising a person’s autonomy. Therefore, they proposed that an intervention ladder must be built that ranks each policy by the amount that it suppresses a person’s autonomy. The policy should be implemented from the bottom up, increasing intervention as necessary. At the bottom is a default position where no intervention is taken, and a person’s autonomy is unaffected, whereas, at the top is a vaccine mandate that if refused results in the termination from their position, which is highly coercive and leaves nearly no options other than to “get the jab” (Bradfield & Giubilini, 2021). In between the extremes of the ladder, Bradfield and Giubilini (2021) suggest a conditional vaccination policy. In this policy, if an employee refuses to get the vaccine (and does not have sufficient medical exemption), they would be redeployed to non-clinical administrative duties and/or moved to another location. If redeployment were not possible, then the member may be put on either paid or unpaid leave. 

This system does seem to be appropriate for implementing vaccine policies as the measures only become more restrictive if the previous “ladder rung” fails to improve vaccinations. 

There are still problems with this policy. Bradfield and Giubilini (2021) directly address the possibility of labour shortages when a large number of FHCW refuse the vaccine. In this case, the conditional vaccine policy might be reconsidered as the benefit of a fully vaccinated staff may not outweigh the risks of severe understaffing in hospitals. Thus far, we have not seen concerningly high rates of understaffing during previous mandates, such as influenza vaccine mandates; therefore, we should not expect this from a COVID vaccination mandate (Bradfield & Giubilini, 2021). An additional problem with Bradfield and Giubilini’s proposed policy is their suggestion of paid leave for vaccine refusal. Offering paid leave may not act as a deterrent but as an incentive for “time-off” with pay. I would argue that to mitigate abuse, a FHCW refusing vaccination must be placed on unpaid leave if they cannot be redeployed. 

Moreover, many individuals argue that a person’s autonomy is undermined even in a conditional vaccination policy. Bradfield and Giubilini respond directly to this argument by referencing a famous philosopher and political economist, John Stuart Mill. John Stuart Mill is famous for the quote, “your rights end at my nose.” In this quotation, he references the rights of a person, stating a person maintains their right until they infringe upon the rights of another person; my right to punch you in the face ends at your nose, where your right to not be stuck in the face, begins. This argument is directly applied in Bradfield and Giubilini’s paper, stating that a person maintains their autonomy up until a point where it infringes upon the autonomy of another person (Bradfield & Giubilini, 2021). A person may insist upon their right to uphold their autonomy and refuse the vaccine; however, in the case of FHCWs, their choices affect the patients they treat, who often cannot choose who treats them. In this sense, a patient’s autonomy is directly undermined by the healthcare professional’s choice to remain unvaccinated. Bradfield and Giubilini argue that healthcare professionals are obligated to put the patient before themselves, including the patient’s autonomy. 

Another rationale supporting conditional vaccine policies lies in the responsibilities of healthcare workers. As outlined by the CMA code of ethics, healthcare professionals first have a duty to “do no harm,” and choosing to remain unvaccinated may directly violate this oath. In fact, early in the pandemic, I had an uncle who was admitted to the hospital for non-COVID-related issues. He contracted COVID-19 and subsequently passed away due to COVID-related complications. Although the source of infection was not revealed, the possibility of spread from an FHCW was possible and could have contributed to his passing. This anecdote exemplifies the high stakes of remaining unvaccinated in hospitals where many patients are immunocompromised and more at risk of ill effects. 

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics, 1–6. https://doi.org/10.1136/medethics-2020-107175 

Conscientious Objection in Healthcare: Necessary or Detrimental?

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On December 1, 2021

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Introduction

Physicians play an extremely important role in our societies. As professionals that are essentially granted a monopoly on the provision of healthcare services, they have a duty to serve the public to the best of their abilities. However, the refusal of physicians to perform procedures that they are morally opposed to, an action referred to as conscientious objection, seriously challenges this viewpoint as it exposes the complexities that occur when the duty to serve conflicts with the freedom of the physician as an individual(Global News, 2021). The following paragraphs will explain and analyse the position that conscientious objection has no place in medicine which was put forth by Schuklenk and Smalling. While their position may seem extreme to some, I believe that they succeed in exposing the many weaknesses and detriments of the conscientious objection process.

The Arbitrariness of Conscientious Objection

Throughout their article, the primary problem that Schuklenk and Smalling propose regarding our current acceptance of conscientious objection in healthcare is the incredibly arbitrary nature of the entire process. Since claims of conscientious objection are largely utilised on religious grounds, the actual content of the claim cannot be tested since it is impossible to prove or disprove religious beliefs(Schuklenk & Smalling, 2016). Also, the writers rightly point out that it is practically impossible to prove whether an individual actually holds these beliefs. Therefore, how could we prove that such refusals aren’t simply tactics utilised to avoid the provision of certain demanding or uncomfortable medical services?

The arbitrary nature of conscientious objection is also observed when analysing the list of conscience-based objections that are protected(Schuklenk & Smalling, 2016). After all, one cannot refuse to treat homosexual patients due to one’s religious opposition to homosexuality, and yet a refusal to perform an abortion due to religious reasons is allowed. Therefore, the argument that conscience-based objections are necessary to act against the potential of a “Nazi-style government” forcing physicians to commit grievous acts is simply misguided. If certain conscience-based objections are already disregarded based on the views of society and the government, why would a totalitarian government not also disregard refusals?

Conscientious Objection and the Social Contract

The writers frequently mention the responsibility of physicians to provide predictable and guaranteed services to the public since they have been entrusted with the right of having a monopoly over healthcare provisions by society(Schuklenk & Smalling, 2016). By allowing conscientious objection, the ability of the medical profession to provide guaranteed service to the public is compromised. Since we have proven that verifying both the validity and existence of beliefs in conscientious objection is impossible, how can the public maintain trust in their physicians when they can essentially refuse to provide certain services?

Physicians have been granted a monopoly by society as part of a social contract in which they must fulfill their end of the bargain. Therefore, as legal scholar Alta Charo states, “claiming an unfettered right to personal autonomy while holding monopolistic control over a public good constitutes an abuse of the public trust”(Schuklenk & Smalling, 2016). Physicians that utilise conscientious objections are essentially violating their end of the social contract.

Possible Counterpoints

Supporters of conscientious objection could state that the problems listed by the writers are quite theoretical and would not occur in reality. They may state that while widespread conscientious objection could hypothetically lead to distrust in physicians, such a phenomenon has not been observed. However, I believe this is demonstrably false. The negative aspects of conscientious objection have been observed in Canada and across the world. For example, due to the refusal of doctors in PEI to perform abortions, residents have had to leave the island in order to procure the operation(Schuklenk & Smalling, 2016). Many patients in remote rural areas are forced to travel long distances for effective care if their local physician refuses to perform an operation based on conscientious objections. Therefore, conscientious objection’s harmful impacts on healthcare are not theoretical. They are being observed in reality as well.

Others may argue that terminating conscientious objection would lead to difficulties in acquiring individuals that wish to become physicians. I find this difficult to believe considering that very little data indicates that such an abandonment of the profession would occur. Also, Canada currently has much lower rates of acceptance into medical institutions than other advanced countries like the United States.(AFMC, 2019). This is not due to the inferiority of Canadian students, but due to the small number of seats available which leads to many deserving candidates being left out. Therefore, even if certain individuals refuse to enter the profession, there is no shortage of competent would-be physicians that will be willing to replace them. Medicine is ultimately a voluntary profession that individuals choose to enter. If they find that they cannot enter a profession that will potentially ask them to perform tasks that are against their beliefs, they do not need to do so.

Conclusion

Ultimately, the arguments put forth by Schuklenk and Smalling reveal the arbitrariness of conscientious objection in both analysis and enforcement, along with the costs incurred by adopting such a system, especially to those in remote and under served areas. These results directly violate the social contract that has granted physicians a monopoly in health care provisions under the condition of efficient and predictable healthcare . Since the potential negative consequences that could occur from terminating conscientious objection also do not appear likely, I believe that conscientious objection has no place in Canadian healthcare.

References

Lao, D. (2021, August 20). What is ‘conscientious objection’? Here’s why major parties are talking about it – national. Global News. Retrieved November 30, 2021, from https://globalnews.ca/news/8125975/conscientious-objection-federal-election/.

Schuklenk U, Smalling R. 2016. Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodation. In: Biomedical Ethics, A Canadian Focus. 3rd Ed. (2018). p. 192-199.

The Association of Faculties of Medicine of Canada. (2019). Canadian Medical Education Statistics. Retrieved November 30, 2021, from https://www.afmc.ca/web/sites/default/files/pdf/CMES/CMES2019-Complete_EN.pdf.

An Analysis of an Absolute Rejection of Conscientious Objection Accommodation in Liberal Democracies

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On December 1, 2021

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Introduction

Conscientious objection accommodation is generally protected in liberal democracies under freedom of conscience and religion. Conscientious objection is the refusal to carry out a legally required role of one’s profession based on personal beliefs or values, which is generally accepted as a corollary to the freedom of respect for persons. In the medical profession, physicians have cited conscientious objection as a means to not carry out certain procedures, such as abortion, which may restrict access to health care. The degree to which conscientious objection should be protected in liberal democracies is examined in Udo Schuklenk’s and Ricardo Smalling’s article Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodation in Liberal Democracies. In this blog post, I will outline the argument put forth by these authors, followed by their description of the practical ramifications of conscientious objection, and I will conclude with my thoughts on their argument.

Schuklenk’s and Smalling’s Argument

Schuklenk and Smalling begin their absolute rejection of conscientious objection accommodation by outlining theoretical reasons against these claims. They argue that the types of claims made to invoke objection are often outdated, as they are typically a recourse to tradition, the Hippocratic Oath, or religion. These, in the authors’ opinion, have no bearing on the practice of 21st century medicine (Schuklenk and Smalling, 2016). The other concern the authors raise is that medical professionals simply have to claim that the beliefs are deeply held for them to be respected, which is an unverifiable claim. Even the US Supreme Court has ruled that courts must not determine the place of a particular belief or the plausibility of a religious claim (Schuklenk and Smalling, 2016). Indeed, establishing whether or not the beliefs claimed under conscientious objection are actually deeply held is not possible. This premise allows the authors to also reject a fettered model of conscientious objection, which would only recognize objection claims in certain cases. The authors argue that limiting conscientious objection to defensible claims simply will not be possible until we can test the legitimacy of the depth to which individuals claim their objection affects their beliefs (Schuklenk and Smalling, 2016). The authors also point out that medical professionals making objections voluntarily joined the profession in an autonomous decision, and their attempt to allow private beliefs to impact their professional obligations is indefensible (Schuklenk and Smalling, 2016). To this point, Canada guarantees freedom of conscience and religion in the Charter, but the Supreme Court of Canada has also ruled that while the state protects these rights, it may not promote the participation of believers or nonbelievers in public life to the detriment of others (Schuklenk and Smalling, 2016). Indeed, for medical professionals to use religion or other beliefs to refuse patient care, especially when they provide a monopoly service, poses a danger to Canadians, which is explored in the next section.

The Practical Ramifications of Conscientious Objection Accommodation

After outlining their argument, the authors provide practical examples of how conscientious objection in a liberal democracy poses problems, which can be explored through their example on abortion. They describe the Canadian Medical Association’s (CMA’s) decision to not oblige doctors to perform abortion, or to even refer patients to doctors who can provide abortion services. They challenge this decision because women in Canada are legally entitled to access abortions, it is typically fully funded by government healthcare, and yet women must ultimately depend on physicians to not have moral objections to abortion, despite them being the only practitioners licensed to perform this procedure (Schuklenk and Smalling, 2016). They also describe how decisions such as that of the CMA’s will result in suboptimal healthcare due to patients being uncertain whether their family doctor can provide them with any given service, or even offer a referral, which will limit access (Schuklenk and Smalling, 2016). In the case of the abortion, the authors reference a study out of Italy citing that about 70% of Italian gynaecologists object to performing abortions, likely contributing to Italy’s high backstreet abortion rates (Minerva, 2015). Moreover, physicians refusing certain services will shift the workload onto physicians not conscientiously objecting to that service, which will force them to bear a large and inequitable amount of work (Schuklenk and Smalling, 2016).

My Perspective on Schuklenk’s and Smalling’s Argument

Overall, I largely agree with the arguments set forth by Schuklenk and Smalling, however, I think that there should be room for conscientious objection in certain cases. I agree with their arguments that freedom of conscience and religion should not cause interference in the practice of medicine, that physicians voluntarily joined the profession and should not generally allow private concerns to affect their practice, and that conscientious objections may reduce access to care. However, the intrinsic challenge here is that conscientious objections are almost by nature unverifiable, and yet the authors argue objections should not be accepted until they are verifiable. This is simply not feasible. And while I do think in a profession as competitive as medicine, ideally medical schools would accept qualified individuals who would have no moral conflicts with practicing care, they must ultimately accept the individuals they see fit to be the most qualified. If these individuals should have objections later down the line, that is acceptable because they were ultimately entrusted by a medical school to practice health care as best as possible. Also, it is unrealistic to reject medical school applicants based on potential future conscientious objections; I think this indeed leads into murky territory and is not a suitable screening question in determining who the best future physicians will be. A rejection of conscientious objections ultimately wouldn’t be practical because either a denial of medical school applicants, or the firing of practicing physicians, on grounds of a conscientious objection, raises more serious concerns over restriction of freedom of conscience and religion. Indeed, forcing physicians to carry out procedures counter to their religion, or otherwise firing them, may be regarded as more ethically dubious than a patient needing to consult with other physicians to receive a particular service.

Conclusion

In sum, Schuklenk and Smalling put forth an intriguing argument on an absolute rejection of conscientious objections in liberal democracies. While I agree that such objections pose risks to health care access, and thus ideally would be fettered to some extent, these claims are inherently unverifiable and cannot be expected to be verified. Ultimately, medical schools must accept applicants they feel are most qualified for the profession, and should they pose objections to certain services as future physicians, that must be accepted as a part of entrusting the profession to these individuals. Denying the practice of medicine based on a desire to accommodate religious beliefs may represent more of an ethical minefield than simply having patients seek the help of another physician.

References

Minerva, P. (2015). Conscientious objection in Italy. Journal of Medical Ethics, 41, 170-173.

Schuklenk, U., Smalling, R. (2016). Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodation in Liberal Democracies. In Fisher (3rd Ed.), Biomedical Ethics, a Canadian Focus (pp. 191-201). Oxford University Press.

Mandatory Vaccination of Health Care Workers is Necessary

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On December 1, 2021

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Introduction:

The Covid-19 epidemic has been going on for two years. In this epidemic, medical workers have been under tremendous pressure. At present, vaccination is the most effective way to prevent epidemics (RCN, 2021). In order to protect the lives of medical workers and patients, mandatory vaccination of medical workers seems reasonable. But the proposal remains controversial. This blog compares the views of both sides and concludes that mandatory vaccinations for health workers are necessary.

Views of the proponents:

Vaccination is an effective preventive measure, and the risk of vaccination is minimal (Parker et all, 2021). Health care providers should be encouraged to vaccinate, and if they are unable to do so, they should be transferred to positions that do not pose a threat to the patient’ s health (Parker et all, 2021). If none of this is feasible, then mandatory vaccinations for health care workers are necessary. Since health care workers are at low risk of being vaccinated against Covid-19, while health care workers who refuse to be vaccinated put patients at significant risk (Parker et all, 2021). Then, it is the moral obligation of health care workers to receive the Covid-19 vaccine if they do not have special physiological conditions that prevent them from receiving it.

Opponents’ view:

Opponents of mandatory vaccinations argue that the government’ s imposition of new vaccines would undermine health-care workers’ right to free choice (Bedford et all, 2021). Health care workers may resign in order not to be vaccinated, exacerbating the problem of understaffing (Bedford et. all, 2021). Moreover, mandatory vaccinations can lead to distrust of Governments by minority groups (Bedford et. all, 2021). To sum up, rather than mandatory vaccination of health care workers, health care workers should be encouraged to vaccinate themselves voluntarily. So far, the UK has implemented a very successful vaccine program without the use of coercion.

Compulsory vaccination is necessary:

Dr. Bradfield gives a very good rebuttal to the argument that forcing health care workers to be vaccinated jeopardizes their right to free choice (Bradfield et all, 2021). Bradfield’s doctor believes that health care workers may choose not to be vaccinated and lose their jobs, while patients have difficulty choosing their own health care providers. As a result, if health care workers are not vaccinated, patients will have to be treated by unvaccinated health care workers, and patients will have to take significant risks. This is a great detriment to patient autonomy.

It is doubtful that forcing health care workers to be vaccinated will make ethnic minorities more distrustful of the government. Bradfield’s doctor believes that if health care workers refuse to be vaccinated, it may increase distrust of the vaccine. Conversely, if health care workers lead by example, it can boost people’ s willingness to be vaccinated.

In terms of the concerns about the lack of medical personnel. There is evidence that mandatory vaccinations do not lead to a large number of resignations (Bradfield et all, 2021). In fact, surveys show that in large health service organizations, no more than eight employees have been recorded as suspended or terminated (Bradfield et all, 2021). With the majority of health care workers receiving the vaccine, even if a small number of health care workers resign because they do not want to be vaccinated, the impact on the health care system will not be significant.

Conclusion:

Patients are among the most vulnerable in the Covid-19 outbreak, and even a small number of unvaccinated health care workers could pose a significant threat. Although most health care workers can be vaccinated through incentives, a small percentage may reject the vaccine. Stronger measures are needed. Mandatory vaccination of health care workers is necessary.

Reference:

Should covid vaccination be mandatory for health and care staff? BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1903

RCN position on mandating vaccination for health and social care staff.https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-mandating-vaccination-for-health-and-social-care-staff

Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers, Owen M Bradfield &Alberto Giubilini, 2021https://eclass.srv.ualberta.ca/pluginfile.php/7473814/mod_resource/content/1/Spoonful%20of%20honey%20or%20a%20gallon%20of%20vinegar_%20A%20conditional%20COVID-19%20vaccination%20policy%20for%20front-line%20healthcare%20workers.pdf

How a Vaccine Mandate Affect Understaffing

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On December 1, 2021

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Introduction: The Dire Situation of Understaffing

Even before COVID-19, there was a shortage of staff especially in critical care nurses (Weikle). However, this issue is exacerbated with the pandemic since there are more patients in critical care (Favaro et al.). “ICU patients need one-on-one nursing” (Weikle). As a result, the workload of nurses has greatly increased (Weikle). It is not just higher workloads that worsen this problem, but also that the difficult working conditions have prompted some nurses to leave the profession (Weikle). With the high number of Covid patients requiring critical care, Ontario’s biggest challenge was not the number of ICU beds available but the number of staff who were able to staff them (Ward). The Canadian Medical Association has expressed their disappointment in “Quebec and Ontario governments to not require mandatory COVID-19 vaccination of healthcare workers” (Canadian Medical Association). However, this decision was made in light of the concern of further decrease of healthcare workers.

In this blog post, I will explore the possible ways that a vaccine mandate could affect the issue of understaffing. Is the government decision to not require COVID-19 vaccinations from health care workers justified? First, I will discuss what a vaccine mandate is. Second, I will discuss the ways that a vaccine mandate actually helps with understaffing. Then finally, I will discuss the predicted number of patients who would leave due to a vaccine mandate.

What Does a Vaccine Mandate Look Like?

A vaccine mandate would make it mandatory for healthcare professionals to receive a vaccination (Bradfield and Giubilini). I will not be going into detail evaluating the different forms of mandatory vaccinations, as discussed in Bradfield and Giubilini paper.

For this blog post, I will make a couple assumptions of what a vaccine mandate looks like. First, it will not require healthcare workers who have a higher risk to the Covid-19 vaccine to get a vaccination. If possible it allows those workers to assume a position where they will interact less with patients in-person. For those who are eligible to receive a vaccine and refuse to receive one, they will go on unpaid leave.

Justifying Vaccine Mandates

A vaccine mandate can benefit the issue of staff shortage in two ways: decreasing the number of sick leaves and decreasing the number of patients infected with COVID-19.

Out of the total COVID-19 cases in Canada, 6.8% are of health care workers (Canadian Institute for Health Information). Between April 10th and June 15th, 567 personal support workers, 317 nurses, and 170 physicians tested positive for Covid-19 (Canadian Institute for Health Information).  One issue that contributes to understaffing is front line health care workers getting sick. Adults over 18 are legally required to isolate if they present with cold-like symptoms in Alberta (which includes sickness other than COVID-19) (Government of Alberta). If they are sick, they legally cannot go to work for at least 10 days (Government of Alberta). However, the time that they are unable to attend patients could be longer (Government of Alberta).

COVID-19 contributes to understaffing as less staff are available to work, temporarily, due to sick leaves. With an increased vaccination rate in COVID-19, there will be an overall decrease in healthcare workers with cold-like symptoms. If the number of sick leaves decrease, then there will be less stress burden on healthcare workers. This is because more healthcare workers would be more available at a given time.

The second way a vaccination mandate would benefit the issue of understaffing is by decreasing COVID-19 transmission from healthcare worker to patient OR to coworkers. As discussed in statistics related to the number of COVID-19 cases in Canada between April 10th and June 15th, healthcare workers are not immune to getting sick. If healthcare professionals can contract COVID-19 even when they wearing PPE, what makes us think that they cannot transmit it to their patients? And what if an overly tired, stressed, and burnt-out nurse applies her PPE incorrectly? These further stresses the importance of COVID-19 vaccinations. Especially since sick, elderly, and immunocompromised individuals are more susceptible to severe symptoms (Mayo Clinic). And these individuals, make up a significant number of patients. We also need to consider that there are healthcare workers who are older and may have medical conditions.

Michael Parker describes COVID-19 vaccinations as the “duty of easy rescue.” The essentially refers to the fact that the COVID-19 vaccine has a low risk of adverse effects but provides benefit in terms of protecting patient health (Parker et al.). But how is the “duty of easy rescue” related to the issue with understaffing? If Covid-19 is transmitted to a sick or elderly individual, they have a higher likelihood of developing severe symptoms. This means that they may need an ICU bed (Mayo Clinic). We also need to consider the possibility that sick patients can infect each other. This increases the number of patients needing an ICU bed. Critical care requires more staffing, as it requires nurses to provide one-on-one patient care. But since there is already an issue of understaffing, what happens is that nurses have to overwork themselves in order to provide healthcare.

To summarize, the benefits of increased vaccinations would allow more staff to be available and decreases the demand for critical care. Lessening the burden of understaffing will (1) allow more staff to be available to patients in need and (2) improve the environment of healthcare workers and (3) decrease the number of critical care nurses leaving due to stress.

Suspension or Termination of Frontline Healthcare Workers

How many frontline healthcare workers would leave if a vaccine mandate was enforced? According to previous observations of vaccine mandates related to influenza, “large health service organisations of between 5000 and 40000 staff that adopt mandatory influenza vaccination policies have reported suspending or terminating the employment of no more than eight FHCWs” (Bradfield and Giubilini). This would rather be an insignificant cost, considering the benefits. However, just because this statistic is observed in one community towards one vaccine, does not mean that it will necessarily be the same for each scenario.

Conclusion

Overall, I am supportive of a vaccination mandate as it could alleviate the issues with understaffing. However, the population that the vaccine mandate should be considered as to better assess how many health care professionals will leave the professional. In addition, we have to consider where exactly these health care professionals located. Are they providing healthcare in rural communities? This will influence whether we implement a vaccine mandate in each province.

 

Cited Works

Bradfield, Owen M., and Giubilini, Alberto. “Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers.”J Med Ethics, vol. 0, pp.1-6. doi:10.1136/medethics-2020-107175. Accessed 30 November 2021.

Canadian Institute for Health Information. “Covid-19 Cases and Deaths in Health Care Workers in Canada – Infographic.” CIHI, https://www.cihi.ca/en/covid-19-cases-and-deaths-in-health-care-workers-in-canada-infographic. Accessed 30 November 2021.

Canadian Medical Health Association. “CMA Reacts to Decisions by Quebec and Ontario to Not Require Mandatory Vaccine Requirements for Health Workers.” Canadian Medical Association, https://www.cma.ca/news-releases-and-statements/cma-reacts-decisions-quebec-and-ontario-not-require-mandatory-vaccine.

Favaro, Avis, et al. “Stress, Staffing Shortages Brought on by Covid-19 Causing Nurses to Leave the Front Lines.” CTV News, https://www.ctvnews.ca/health/coronavirus/stress-staffing-shortages-brought-on-by-covid-19-causing-nurses-to-leave-the-front-lines-1.5582781. Accessed 30 November 2021.

Government of Alberta. “Isolation and Quarantine Requirements.” Alberta.ca, https://www.alberta.ca/isolation.aspx#requirements. Accessed 30 November 2021.

Mayo Clinic. “Covid-19: Who’s at Higher Risk of Serious Symptoms?” Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-who-is-at-risk/art-20483301. Accessed 30 November 2021.

Parker, Michael et al. “Should covid vaccination be mandatory for health and care staff?” BMJ, vol. 374, no. 1903, pp. 1-3, https://doi.org/10.1136/bmj.n1903. Accessed 30 November 2021.

Ward, Katherine. “Doctors Say Staff Shortages in Ontario Icus Continue as Covid-19 Admissions Climb.” Global News, https://globalnews.ca/news/7750776/covid-19-ontario-icu-staff-shortages/. Accessed 30 November 2021.

Weikle, Brandie. “Canada Was Already Desperately Short of Nurses before COVID-19. Now Nurses Say They’re Hanging on by a Thread | CBC Radio.” CBCnews, https://www.cbc.ca/radio/whitecoat/canada-nursing-shortage-covid-pandemic-1.6174048. Accessed 30 November 2021.

Should Vaccination be Mandatory?

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On December 1, 2021

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Introduction 

 

Amidst the current COVID-19 pandemic, frontline health care workers (FHCWs) are forced to walk the fine line between life-and-death in their medical setting. However, as the pandemic has progressed, companies have developed potential vaccines in an attempt to prevent the spread of the virus and preserve life. Due to this, there is an ongoing debate on the need for the vaccination, and whether it should be mandatory or not. In this blogpost, I will outline the benefits and costs of mandatory vaccination as illustrated in Bradfield and Giubilini’s paper, as well as identify their proposed policy for vaccination. Furthermore, I will also discuss a case regarding mandatory vaccination in Vancouver, and finally illustrate both Bradfield and Giubilini’s opinion in conjunction with mine on the case. 

 

Benefits of Mandatory Vaccination

 

In their paper, Bradfield and Giubilini identify the potential benefits of mandatory vaccination within the medical work setting. An analogous situation which concerns influenza vaccinations. Studies have shown that influenza related illnesses and deaths among elderly inpatients can be significantly reduced when just half of the FHCWs are vaccinated against influenza. Therefore, given that COVID-19 poses a greater threat compared to influenza, a mandatory vaccination policy could result in substantial benefits with regards to the reduction of the illness. Prior to vaccination, hand hygiene, personal protective equipment (PPE), physical distancing, regular surveillance testing and quarantining were our optimal strategies for infection control (Bradfield and Giubilini, 2021). Even though vaccinations can be more burdensome than basic measures such as hand sanitization, it is significantly less burdensome compared to other techniques such as wearing PPE for extensive periods of time. Prolonged use of PPE can result in physical problems, including breathing difficulties, pain, discomfort, and dermatological reactions, and these problems can be mitigated via vaccination (Bradfield and Giubilini, 2021). 

 

Costs of Mandatory Vaccination

 

In addition to the benefits of mandatory vaccination, Bradfield and Giubilini also recognized potential drawbacks. They acknowledged that no vaccine is 100% safe, and that different individuals have different reactions to the vaccine. For instance, the UK government advised individuals with a history of allergic reactions to abstain from the Pfizer-BioNTech vaccine due to two prior FHCWs reporting adverse effects (Bradfield and Giubilini, 2021). Furthermore, mandatory vaccination also undermines the relationship between FHCWs and their employers. An obligatory mandate intended to force employees to get vaccinated could result in resentment, opposition, and mistrust. In addition, the mandate would also deprive FHCWs of free choice and autonomy. After recognizing the potential costs of mandatory vaccination, Bradfield and Giubilini argue for a compromise, and propose a policy aimed to represent a middle ground between an entirely voluntary and entirely involuntary approach (2021). The policy centered around temporary redeployment of employees against obtaining the vaccine. The FHCWs who refuse to get the vaccine could be restricted by being redeployed to non-clinical administrative duties or tele-health services. If redeployment is not feasible, they can be asked to take a paid or unpaid leave for a period of time, and afterwards, if they are still not vaccinated, their employment can be terminated (Bradfield and Giubilini, 2021). This method targets the need for vaccinations in a somewhat more lenient way. 

 

Case 1 

 

Vancouver Coastal Health (VCH), a local health authority for Vancouver, employs thousands of health care workers (HCWs). These employees see hundreds of thousands of patients with many distinct health conditions every year (Case 1, 2018). Since 2012, the VCH has required all of their HCWs to get flu vaccine shots or wear a protective mask at all times when in contact with patients and clients during winter flu seasons. They claim that HCWs have a moral responsibility not to harm their patients and clients. If a HCW had the flu, they could easily infect a patient; this could harm the patient, and in some cases even lead to death (Case 1, 2018). Therefore, VCH believes the best way to combat this issue is for HCWs to get a preventative flu vaccination, or wear a protective mask. However, their efforts to persuade the workforce resulted in failure. Not everyone was happy about the policy. Furthermore, the BC Nurses Union presented evidence that shows nurses and other HCWs should choose to be vaccinated because this stops infections and so prevents harm to patients. However, they also believe that HCWs should not be obligated to obtain the flu vaccine or wear a mask because this requirement violates an individual’s autonomy (Case 1, 2018).  

 

Conclusion

 

With regards to the VCH case, I believe that Bradfield and Giubilini would side with the VCH to a certain extent. They believe that vaccinations give rise to numerous benefits which often outweigh the small risks of harm. However, they do not believe in breaching free choice and autonomy in order to enforce vaccinations on HCWs. Therefore, they would also side with the BC Nurses Union, and aim to develop a compromise to allow individuals their choice in the matter. Bradfield and Giubilini would look to redeploy the workers who are against vaccination, and allow them to contemplate whether or not getting the vaccination is the best decision for them or not. In the process, the health of many other HCWs and patients would not be compromised. However, I choose to take a different view on this case. I believe that all HCWs should either be vaccinated or provide a valid reason (such as allergic reaction) to be exempt from being vaccinated. The health and safety of patients should be the number one priority for HCWs, as this is essentially what their job entails. However, by refusing the vaccine, they could potentially be the source of the harm endured by the patients. COVID-19 poses a serious threat to mankind, and vaccinations are currently the most optimal method to combat this threat. Overall, I understand Bradfield and Giubilini approach in an attempt to preserve HCWs’ autonomy, but I believe that autonomy of HCWs should be forfeited in this situation as it is concerned with patient health and safety. 

 

References

 

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. JOURNAL OF MEDICAL ETHICS, 47(7), 467–472. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/medethics-2020-107175

 

Case 1. (2018). Health Care Workers and Flu Shots. In Fisher, J., Russell, J. S., Browne, A., & Burkholder, L, Biomedical ethics : a Canadian focus (Third edition.) (pp. 413). Oxford University Press.

Pros and Cons to Mandating the Covid-19 Vaccine

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On December 1, 2021

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Choosing whether or not the Covid-19 vaccine should be mandatory for healthcare workers is an ongoing debate. For the most part, individuals are on one of 2 sides; getting vaccinated is not mandatory for the job or that it is mandatory with those refusing without a medical reason being redeployed and if “refusal persists after redeployment period” then the individual should be suspended (1). In my opinion, the vaccine should be mandated in healthcare as it is the best way to protect vulnerable groups and frontline workers under FHCW (doctors, nurses, clinicians, cleaners, etc.). 

In the article “Spoonful of honey or a gallon of vinegar? A conditional Covid-19 vaccination policy for front-line healthcare workers”, Owen Bradfield and Alberto Giubilini discuss how we can balance personal preferences with professional ones. On the bright side, mandatory vaccinations would protect FHCW’s that are at high risk of contracting infections and death and will slow the transition of the virus to others as there is close contact in healthcare facilities and between staff and patients. “People avoid attending healthcare services for fear of contracting Covid-19” which can give them a greater chance of dying from other medical conditions that they might be suffering from (1). Making vaccinations mandatory would make patients feel more comfortable visiting hospitals, medical clinics and seeking other forms of medical aid. There are alternatives to the vaccine being personal protective equipment to keep contact to a minimum and protect healthcare workers. But this can have negative effects when there is long term wear like “physical problems including breathing difficulties, pain, discomfort and dermatology reactions” (2). These issues as well as only the staff being mandated to wear the PPE and patients are only required to wear a mask. If healthcare workers are told to wear such layers for protection, should the patients visiting also be required to wear PPE to protect oneself and the staff further? Vaccines would eliminate the need for such intense protective clothing, that while trying to protect the staff, it can actually cause more problems. 

Bradfield & Giubilini also point out that there are negative drawbacks to mandating the Covid-19 vaccine. One drawback would be that some FCHW may be at risk of getting a reaction to the vaccine which is why “it is permissible for individuals to expose others to risks of harm if need to defend oneself” (3). The mandate could also undermine the goodwill between FHCW and their employers , as well as the need to address cultural differences and “informational needs of diverse racial groups” (2). The vaccine must also be accessible, offered at little to no cost and have vaccine injury compensation. Bradfield & Giubilini also state that while the maximization of the vaccinated can reduce Covid-19 transmission, it also “deprives individuals from free choice and autonomy” (4).   

There are alternative ways to help slow the spread of Covid-19. For those refusing to get the vaccine, we could consider conditional mandates that minimize the contact between the unvaccianted and vulnerable patients. But this can cause more strain and stress on those healthcare workers who are vaccinated and may not be possible in some clinics resulting in paid/unpaid leave or a suspension. Incentives can also be given to make individuals want to get vaccinated, but this can be unfair to those who voluntarily got the vaccine with no “prize” of doing so. 

The RCN’s, Royal College of Nursing”, position on mandating the Covid-19 vaccine is similar to that expressed in Bradfield & Giubilini article. While the mandate can “marginalise those already hesitant and put pressure on the workforce by forcing some out of employment”, not creating the mandate can also put pressure on the employers as they must provide PPE, ventilated environments and increased number of breaks (RCN, 2021). Those working in RCN nursing homes are mandating to get vaccinated as they are around elderly, vulnerable individuals. 

When thinking about mandatory influenza vaccines that already exist, I wonder why the Covid-19 vaccine is not yet mandatory. We can already see how the influenza shots have helped reduce the spread and protect the staff and patients, so wouldn’t we assume that this would also be achieved through the Covid-19 vaccine? I agree with the utilitarian perspective on this issue as “mandatory vaccination appears morally justifiable” as it minimizes the risk and maximizes the welfare of society (2). After volunteering over the summer in healthcare clinics, the use of PPE can become exhausting after even a couple of hours. The alternative of getting vaccinated and hopefully reducing the amount of PPE needed seems like a more justified option. I do agree with how Bradfield and Giubilini also pointed out that there should have been more planning and communication between the staff and employers and how individuals should get notice of consequences for not getting vaccinated. There should also be more of an emphasis and awareness of ethnic minority groups that have a higher risk associated with getting vaccinated. 

I do believe that some exceptions should be given to healthcare providers who refuse getting the vaccine due to medical reasons. If this is the case, they are at a higher risk of contracting Covid-19 so it would be in their best interest, and the patients, to have conditional mandates. They will still be able to work in their field and keep their jobs but doing so in a safe and low risk environment. In some cases, not all healthcare facilities can provide for alternative roles as they might already be understaffed and already have nurses overworked in Covid units or working with vulnerable patients. At this point, I don’t think that individuals medically unable to get the vaccine or refusing to should continue to work in healthcare as it may be increasing the risk of Covid-19 transmission rather than helping prevent it. 

 

References:

Bradfield & Giubilini. “Spoonful of honey or a gallon of vinegar? A conditional Covid-19 vaccination policy for front-line healthcare workers”. (March 30, 2021)

“RCN position on mandating vaccination for health and social care staff”. Royal College of Nursing. https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-mandating-vaccination-for-health-and-social-care-staff (September 22, 2021) 

Vaccination and Healthcare Workers: Non-maleficence or Autonomy

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On December 1, 2021

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Introduction

Much ethical debate exists surrounding mandating vaccination because of the argument that it infringes the autonomy (ability to make decisions for oneself) of the individual to make that decision. However, frontline healthcare workers have a duty to care and this extends to non-maleficence (to prevent harm). These two ideals oppose one another in the ethical debate of mandating vaccination to healthcare workers. This conversation is especially crucial now due to the current COVID-19 pandemic. In order to restore the way of life before the pandemic and prevent further spread and harm, vaccination for COVID-19 is seen to be the solution.  

Healthcare workers hold special duties and responsibilities due to their profession, unlike an average individual. In this blog post, I will explore the duties of healthcare workers and the perspectives of upholding nonmaleficence and autonomy.

Duty to Ensure Non-Maleficence

Nonmaleficence is defined as preventing harm, and in this situation, nonmaleficence is achieved when healthcare workers take measures to lower the chances of inflicting harm on their patients. “First Do No Harm” is one of the foundational principles of healthcare ethics that healthcare providers must follow. If they fail to follow this by refusing vaccination, they are putting their patients at risk which is ethically flawed and the healthcare worker has failed to follow their obligation (Bradfield & Giubilini, 2021). Nonmaleficence can be achieved by being vaccinated as it is a thoroughly studied medical practice that results in preventing individuals from contracting a disease and preventing its spread (“RCN position on mandating vaccination for health and social care staff”). Therefore, many health authorities take the position that healthcare workers do indeed hold an obligation and duty to get vaccinations to prevent harm to their patients. For instance, Vancouver Coast Health mandated flu vaccination and wearing masks for healthcare workers to decrease the likelihood of transmission to their patients in 2012. They believe it is the moral responsibility of healthcare workers to ensure nonmaleficence to their patients by preventing transmission to their patients. The mandate is the last resort that many authorities employ to ensure vaccination in their healthcare workers as previous efforts such as encouragement did not (Fisher et al., “Case 1,” 2018). Furthermore, the Royal College of Nursing states that all nurses should be vaccinated to stop the spread of COVID-19 and that it is the ethically right thing for a person in this profession to do. Instead of arguing for obligating vaccination, the RCN advocates for other measures to increase vaccination rates in healthcare workers by easy access to vaccination and to accurate information so individuals can make an informed decision to get vaccinated. They also advocate that if employers require employees to be vaccinated, it should be explicitly stated in the contract so that they make an informed decision and acknowledge that it is their duty as a healthcare worker. The RCN states that efforts should be made to make the healthcare worker accept vaccination and if not, relocate the individual to lower their risk of spread/contraction before having to dismiss them (“RCN position on mandating vaccination for health and social care staff”). Although mandating vaccination is easiest for employers, there are other methods to still uphold the autonomy of healthcare workers. Healthcare workers being required to be vaccinated can be ethically justified by Utilitarianism, which is the ethical theory that is consequentialist in nature and justifies actions taken to maximize net happiness (Welchman, “Utilitarianism,” 2021). Bradfield & Giubilini also state that the collective benefits of the mandate on vaccination are greater than the risks of vaccination, which can be justified by Utilitarianism as it results in the greatest net happiness for most people (2020). By the healthcare workers getting vaccinated, it promotes the greatest non-maleficence and beneficence in the patients and society as it decreases transmission.

Challenges in Autonomy 

Although the vaccination of healthcare workers is greatly beneficial to prevent diseases from spreading and prevent harm to vulnerable individuals, the autonomy of the healthcare worker should not be overlooked. Autonomy is defined as the ability of individuals to make their decisions. Mandating vaccination violates the individual’s right to autonomy as they are forced to do something they did not decide for themselves. The autonomy of healthcare workers is challenged when vaccination is required in their workplace as individuals could have many reasons preventing them from doing so like their religious beliefs, concerns to their health due to vaccination, the privacy of medical information, misinformation, and needle-phobia. Furthermore, when individuals are coerced into being vaccinated (such as when there is a penalty for not being vaccinated), their autonomy is breached as there is no other viable option for individuals if they don’t wish to face disciplinary actions. However, one must keep in mind that there are limits to one’s autonomy, such as if it infringes another individual as explained by John Stuart Mill. The autonomy of healthcare workers may infringe on the autonomy of patients as healthcare workers have the choice to choose between vaccine refusal or keeping their job but patients do not necessarily get the choice of being sick and choosing their healthcare provider that is vaccinated or not. Therefore, as the autonomy of the healthcare worker impedes the autonomy of the patient, it should be limited (Bradfield & Giubilini, 2021). 

Conclusion

Personally, I believe that it is the duty of healthcare workers to be vaccinated. Mandating vaccination is ethically justifiable because of the duties that healthcare workers hold as explained by Utilitarianism. Another argument I have that highlights the ethical justification of mandating vaccination to healthcare workers can be explained by Kantianism. The Kantian theory is a consequentialist theory that follows the “categorical imperative” as its goal is that individuals act rationally and preserve the autonomy of others to deliberately make a decision (Fisher et al., “Kantian Ethics,” 2018). The categorical imperative is a test in which ethical maxims are tested for universality, and if it does not respect the autonomy of others in all situations, it cannot be ethically justified (Welchman, “Kant Slides” 2021). It can be concluded that healthcare workers hold a duty to be vaccinated as it is a “promise” in their duties as healthcare workers to ensure non-maleficence due to the categorical imperative (Welchman, “Professional Obligations, Vaccination, and Ethical Evaluation” 2021). The autonomy of the patient is not respected (as mentioned previously) when the healthcare worker breaks their obligations as they are left with no alternatives. Healthcare workers already agreed to their obligations before choosing their profession, therefore if they have already agreed to this but then do not fulfill their promises, this act is ethically wrong as explained by Kantian ethics. Because there is no clear answer to make sure every ethical element is taken into consideration, it should then be concluded that the right course of action is one that encompasses most of the elements or that results in the greatest benefit. Since the mandate on vaccination can be explained using Utilitarianism and Kantianism theories, I believe it is ethically justifiable to mandate vaccination on healthcare workers since they have a duty to nonmaleficence and must keep the obligations they agreed to. 

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics, 47(7), 467–472. https://doi.org/10.1136/medethics-2020-107175.

Fisher, J., Russell, J.S., Browne, A. & Burkholder, L. (Eds.) Case 1: Health Care Worker and Flu Shots, in Biomedical Ethics, A Canadian Focus, 3rd Ed. (2018), pp. 471.

Fisher, J., Russell, J.S., Browne, A. & Burkholder, L. (Eds.) Kantian Ethics, in Biomedical Ethics, A Canadian Focus, 3rd Ed. (2018), pp. 10.

“RCN position on mandating vaccination for health and social care staff.” Royal College of Nursing, 22 Sept. 2012, https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-mandating-vaccination-for-health-and-social-care-staff, Accessed 20 Nov., 2021

Welchman, J. (2021). Professional Obligations, Vaccination, and Ethical Evaluation [PDF Slides]. eClass. https://eclass.srv.ualberta.ca/ 

Welchman, J. (2021). Kant Slides [PDF Slides]. eClass. https://eclass.srv.ualberta.ca/ 

Welchman, J. (2021). Utilitarianism Slides [PDF Slides]. eClass. https://eclass.srv.ualberta.ca/ 

Diversity, Equality of Quality Care, and Conscientious Objection in Healthcare

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On December 1, 2021

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Would denying conscientious objections by healthcare providers result in more equitable access to quality healthcare for patients? Schuklenk and Smalling argue that in liberal democracies medical professionals have no legitimate moral claim to accommodations on the grounds of conscientious objection. Schuklenk and Smalling note that while the debate currently focuses on issues like abortion and assitance in dying, they argue due to the arbitrary nature of conscientious objections means they could theoretically be applied to any medical pratice (Schuklenk and Smalling, 195). I will argue that we do need to accommodate conscientious objections, largely on the grounds that doing otherwise would exclude entire segments of the society who deserve to have healthcare providers who share similar backgrounds, identities and beliefs as them. However, I do not believe that accommodation for objections should be unlimited and I will explain why the line must be drawn on the grounds of providers’ objecting to referring a patient to another provider who will provide the service. 

 

Schuklenk and Smalling’s basic argument is that it is impossible to evaluate the legitimacy of one’s conscientious objections and thus allowing accommodations for medical duties and the ability to deny some services on the grounds of conscientiousness is nothing more than a blank check for people to choose what aspects of health care they wish to provide (Schuklenk and Smalling,194). They note that declaring some conscientious objections justified over others is just as arbitrary a process of determining if conscientious objections are deeply held (Schuklenk and Smalling,194). Thus the governing rules over what services healthcare providers must provide should be consistent and universal without exception. To further support this argument they note that conscientious objections create unequal access to services for patients, especially rural communities who may have to travel long distances to find another medical provider (Schuklenk and Smalling, 196). Therefore, they argue, it is unjust to provide suboptimal access to healthcare on the morally arbitrary grounds of conscientious objections (Schuklenk and Smalling, 196). 

 

While I agree with the authors on the arbitrary nature of conscientious objections, I think not allowing them would actually result in worse quality healthcare which is one of their main concerns. Equal access to quality medical services is important, but I believe there is a missing aspect of that discussion, that of equality and quality of care which requires diversity in providers of healthcare. Positive health outcomes require diversity in healthcare workers. It is well understood and empirically proven that healthcare and health outcomes improve when the background of providers matches those of their patients. This is due to a variety of factors including more accurate diagnosis and better treatment resulting from less bias, mutual respect, and trust between healthcare providers and patients. A policy that would not grant any conscientious objections would cut out entire religious and ethnic communities who hold strong beliefs about the permissibility of particular healthcare services and thus would be unable to serve in specific specialties in medicine. 

 

Schuklenk and Smalling note that medical professionals not only choose their profession, but also have a fair degree of autonomy over which sub-disciplines they specialize in (Schuklenk and Smalling, 197). Thus it follows that if one does not want to provide abortions then one should not specialize in the areas that may require one to do so. However, this means that entire ethnic and religious groups would effectively be banned from some occupations specifically where diversity matters the most. Cultural sensitivity is perhaps most important in communicating with marginalized groups during pregnancy and on the deathbed. The beginning and end of life is often where religious and cultural differences have the most impact on patients being respected and having quality care.  

 

With all that said, the unwillingness of providers to refer patients to another provider who can provide them with the services they object does pose a real threat to access as it is unreasonable for patients to be forced to navigate the complex healthcare system themselves. 

This, I argue, would actually result in the drop in quality and equality that Schuklenk and Smalling fear because instead of being unable to get a service in one normal location by one’s normal physician one is required to find a new provider with very little support. The barriers of travel and time are unfortunately inherent to rural life and, while they can be minimized, can never be fully equalized. However, the literal inability to get sound advice and knowledge on options available and where to obtain them would mean that patients with providers who object to referral receive a fundamentally different level of healthcare. As long as providers are willing to make referrals, then I believe that healthcare is on net more equal and accessible with some accommodation of healthcare providers. 

 

Now one can argue, as Schuklenk and Smalling do, that referrals are not always possible in a timely manner, specifically in rural communities (Schuklenk and Smalling, 196). I believe a solution to this is traveling medical professionals who specialize in commonly-objected-to practices. When healthcare providers take up a position in a rural community they can indicate what procedures they object to and arrangements can be made to have a travelling professional on call if the need arises. In the instance where having traveling professionals is not possible, I think it is not too large of an infringement to deny particular healthcare providers the ability to work in some rural areas, unlike outright bans from having specialists of some identities which would result from an outright ban on conscientious objection.  Unfortunately under no system will healthcare ever be truly equal on travel terms but I believe this comes the closest to balancing competing claims to equal access without stopping entire segments of a population from seeking specialists with a shared identity to them. As I have shown, the identity of one’s provider affects their equal access to the same quality of care. In conclusion, on the grounds of equal access to quality healthcare, conscientious objections should be permitted as long as providers are willing to refer patients to another provider.

How much coercion is needed when attempting to get healthcare workers vaccinated?

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On December 1, 2021

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Health care workers (HCW) are an important part of the safety of people’s lives. HCW’s must not only think about themselves but also those that they work to save. With the vaccine for COVID-19 being widely released some HCW’s have not been vaccinated. People in authoritative positions are left to look for ways to increase the number of HCW’s being vaccinated. Bradfield and Giubilini (2021) bring up an intervention ladder with different ways healthcare workers are being coerced into receiving the vaccine. This blog post will briefly look over why HCW’s should be vaccinated as well as the methods being used to get more of them vaccinated and which I think would be the best way to increase vaccination rates in HCW’s.

Why vaccinate Healthcare workers:

Brandfield and Giubilini (2021) talk about a few different reasons as to why HCW’s should be vaccinated, these are as follows. Hospital patients are generally in a weaker state and more susceptible to serious outcomes if they contract COVID-19. Some studies show that deaths and illnesses in elderly inpatients can be significantly lowered when just half of the HCW’s are vaccinated. Finally, data suggests that high vaccination rates among HCW’s provides a safe working environment even in a high presence of COVID-19. With just these three reasons it is clear that having high vaccination rates among HCW’s is important for the healthcare industry to remain safe.

Methods to increase vaccination:

Now I will look at the table and go from least to most coercive. At the very bottom is no intervention. If a HCW doesn’t get the vaccine there will be nothing done in an attempt to make them change their mind. This is doing nothing to increase vaccination rates in HCW’s which would result in overall less safe working environments. Above this is one of the most widely used methods for not just HCW’s, it is persuasion. This involves education campaigns or other non-mandatory activities that attempt to persuade HCW’s. This is one of the best methods in general as it does not infringe on anyone’s right to choose and instead tells them the benefits if they choose to get vaccinated. Next is Nudging/Libertarian paternalism. Paternalism is a policy or practice made by people in positions of authority that is supposed to be in the worker’s best interest. Libertarian paternalism is to do this without coercion and only have the goal of influencing choices. Brandfield and Giubilini (2021) give examples such as having HWC’s sign an explanation as to why they are refusing, or by reporting vaccination rates in other sectors. This is similar to persuasion but instead, they are mandatory which marks the biggest difference between the two methods. After this is a loss of incentives. This is where they lose privileges to certain things that don’t affect their ability to work but create many minor inconveniences that add up in hopes of getting the HWC’s to choose to just get vaccinated. This step is where we get very close to infringing on the rights of the HCW’s while these incentives are not part of their job, they are things the HCW expected to receive when they worked. Next on the list is redeployment. Redeployment is having HWC’s moved to do different duties or to work from home. This does not infringe on their rights as they are still able to work and it stops unvaccinated HCW’s from doing direct clinical work with the elderly and vulnerable patients. As previously said, studies show that deaths and illnesses in elderly inpatients can be significantly lowered when just half of the HCW’s are vaccinated, when all those in contact with elderly inpatients are vaccinated this will only be further increased (Brandfield & Giubilini, 2021). As we get up into the three more coercive methods we start with professional restrictions/conditions. This can be suspension of employment, forced leave, conditions for being able to register professionally as well as others. From here on all the methods go against the HWC’s rights. In this situation, the HWC’s are unable to work and they can not get paid unless they get vaccinated which infringes on their freedom of opinion and expression. The HWC’s opinion is that they do not want the vaccine and they express that by remaining unvaccinated. As we nearly reach the top we have compulsion/penalties. This can be fine or even imprisonment with their employment and professional registration being terminated. This once again does not respect the HCW’s right to remain unvaccinated. Finally, the most coercive method is forced vaccination. Brandfield and Giubilini (2021) define this as forced vaccination that can use chemical or physical restraint. Not only does this go against the HCW’s right to remain unvaccinated, but forced vaccination through physical restraint would also be inhumane and go against a person’s human rights.

The best method:

Persuasion and using things such as advertisements to educate the general public on why getting vaccinated is important works well but for the healthcare industry, high vaccination rates are even more important. To raise the vaccination rates in HCW’s a more coercive method would be needed. I think that a hybrid of redeployment and nudging/libertarian paternalism would be the best way to increase vaccination rates without infringing on HCW’s rights. With redeployment, HCW’s who are not vaccinated should not be involved in direct clinical work with the elderly and immunocompromised patients as they are at the highest risk of dying if they contract COVID-19. The nudging and libertarian paternalism making things mandatory would be a stronger version of persuasion used for the general public. By having mandatory policies the hope will be to have a more noticeable increase in the vaccination rates of HCW’s than those seen in the general public. Using redeployment to keep at-risk patients safe and nudging/libertarian paternalism to influence more HCW’s to get vaccinated is the best method without infringing on anyone’s rights.

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics, 47(7), 467–472. https://doi.org/10.1136/medethics-2020-107175

Conscientious Objection & COVID-19 Vaccine Mandates

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On December 1, 2021

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To live in a pluralistic society means to accept the diversity of beliefs that exist and to respect their freedom of expression. Such an idealistic view of tolerance is the foundation of Canada’s democracy, yet there are many circumstances in which  conflicting beliefs seem to demand an impossible compromise. In the case of conscientious objection in the medical profession, deeply held personal beliefs of the healthcare provider influence which medical services they are willing to provide. Concerns about whether the conscientious objection of medical professionals may adversely affect the goals of the profession has been a widely debated subject, and in this blog I will start by exploring two main reasons as to why conscientious objection should not be accepted in the medical field. Afterwards, I will examine the policy of mandatory COVID-19 vaccination, using the arguments provided above to support why conscientious objection is an insufficient basis for forgoing vaccine mandates.

 

Conscientious Objection

The concept of conscientious objection is based upon an individual’s perceived obligation to act in accordance with their fundamental moral beliefs (Schuklenk & Smalling, 2016). By making a conscientious objection, one refuses to behave in a way that goes against their own definition of morality. The ability to make these objections is the most basic expression of autonomy, which holds that individuals are able to make decisions based upon their personal moral convictions. Protection of this autonomy may be called into question when the well-being of others is directly affected by the results of conscientious objection.

Schuklenk and Smalling address this problem of conflicting interests, arguing that conscientious objection has no place in the practice of medicine. Although they give many reasons in support of their view, I will be limiting my focus to just two reasons, which can be utilized in arguments about vaccination mandates. The first reason why conscientious objection should not play a role in medical practice, is that the decision to join the medical profession means voluntarily entering into a social contract with the public. The public has given medical professionals a monopoly over providing treatment, therefore it is expected that they act in a way that attends to the changing healthcare demands of the public. This means that those who voluntarily enter into the contract and accept the monopoly are willing to provide the services deemed essential by the public. If all medical professionals decided to conscientiously object to a service that was required by the public such as contraceptive prescription, it is unlikely that the medical professions would receive government funding, or maintain their monopoly. 

The choice to join the profession is similarly not made uninformed-the obligations that come along with being a healthcare professional are not in any way hidden to those who wish to join the field of medicine. This leads into the second reason that conscientious objection should not be allowed within medical practice- the objection may directly impact the adherence to professional obligations. Such obligations may include fundamental principles and goals of medical care, like nonmaleficence or beneficence. Although a physician has a right to their own autonomy, it should never interfere with their professional obligations to their patients. This can be viewed not as an unjust limiting of a healthcare professional’s autonomy, but as an obligation that was understood upon choosing to be a part of the profession. Since entering into the profession is voluntary, anyone who would not consent to overriding their own moral convictions to promote patient beneficence should think carefully before joining the medical field.

 

Conscientious Objection of COVID 19 Vaccines?

Conscientious objection has perhaps never been so widely discussed in the past few decades as it has been now, with the rise of mandatory COVID-19 vaccine policies for healthcare workers. Although studies have proven that mandatory influenza vaccinations are the most clinical and cost-effective method for mitigating the harm caused by infections, some healthcare providers have made a conscientious objection to getting the COVID-19 vaccine. This is especially worrying, as those who work in medical settings tend to interact with vulnerable populations, for whom a COVID-19 infection could be fatal.

With regards to the social-contract relationship between healthcare providers and the public, it seems reasonable to expect that those who have been given a monopoly over medical practice should be held to a standard which protects the reputation and aligns with the goals of the profession. For example, an unwillingness amongst healthcare workers to be vaccinated may be interpreted by the public as a message that vaccines are not safe, or that the healthcare providers do not truly value the well-being of their patients. All of this can endanger the reputation of the medical profession and the relationship it has with the public, leading to distrust in situations where trust is essential to beneficence.

With regards to the ethical obligations of the medical professions, there exists a duty to nonmaleficence. If a healthcare worker refuses to get a COVID-19 vaccine and then goes on to spread the infection, there has been a clear violation of nonmaleficence. Since vaccination has been proven as effective at stopping the spread of similar infections, it seems that even the risk of exposing patients to the virus by choosing to not get vaccinated may violate the principle of nonmaleficence (Bradfield & Giubilini, 2021).

Overall, when it comes to those who have voluntarily taken on the obligations of the medical professions, conscientious objection should not be tolerated in circumstances like the mandating of vaccines.

 

References

Schuklenk, U., & Smalling, R. (2016). Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. Journal Of Medical Ethics, 43(4), 234-240. doi: 10.1136/medethics-2016-103560

Bradfield, O., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal Of Medical Ethics, 47(7), 467-472. doi: 10.1136/medethics-2020-107175

Vaccines – A Debate

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On December 1, 2021

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As we continue to live through a global pandemic, the whole notion of getting vaccinated has been in the hot seat for the past year and a half. Some are completely in support of the idea of vaccines while others simply struggle to understand the benefits of getting vaccinated as a form of defense from viral diseases. For the past year and a half, COVID-19 has ravaged our world on many different levels and has compromised the lives of millions of people. Being a novel virus, little was known about its effects and how deadly it could be. During the first year of the pandemic, no one knew how to cure the virus or slow the spread apart from the obvious frequent hand washing, social distancing and mask wearing measures. Once experts were able to build their knowledge on how to fight the spread of the virus and develop a vaccine that could protect not only ourselves but those around us, mandatory vaccination policies started to come into place. 

 

In Canada,  many provinces began implementing mandatory vaccination policies in work settings and other public spaces. For example, Alberta Health Services was one of the many organizations that strictly wanted its members to be fully vaccinated prior to returning to work. Although many cooperated for the most part, there were still a few who were not comfortable with the policy for varying reasons. In fact, in an article published by the Royal College of Nursing, they point out this idea of implementing mandatory vaccination policies as a way of marginalizing employees who are hesitant on getting the vaccine. Although, the main focus of the article is to present the thoughts and opinions of those in support of vaccinations and compare them to those hesitant of getting vaccinated. 

 

To begin, the article published by the Royal College of Nursing makes the claim that implementing mandatory vaccination policies does more harm than good in the health sector. Precisely, they believe that apart from the exclusion of certain members from working, the implementation of such policy will only cause strain on the healthcare system as they’ll face more staffing shortages and unemployment issues due to the prevention of vaccine-hesitant staff from working. 

 

To contrast, in an article written by Julian Savulescu, they make the claim that vaccines generally offer more protection than harm when it comes to viral and infectious diseases. Throughout their paper they explain how vaccines are “one of the greatest medical accomplishments” when it comes to public health (Savulescu, 2021). They argue that vaccines simply aren’t deemed effective unless they “undergo rigorous testing” and approval (Savulescu, 2021).. Hence why, they are deemed to be the best prevention measure out there.

 

If I were to take a stance in this debate, I personally would agree the most with Savulecu for a couple of reasons. First and foremost, I truly believe that vaccines are one of the best sources of protection from infectious diseases considering the benefits primarily outweigh the costs. Although, I do understand why some may be hesitant about getting vaccinated. Take the COVID-19 vaccine for example, many of those who are hesitant to get the shot argue that the vaccine was created too quickly and therefore lacks evidence when it comes to proving its effectiveness in minimizing the risks associated with COVID-19. But if one were to think about it, vaccines undergo a lot of rigorous testing prior to their release and approval by the Health and Safety authorities along with the Centres for Disease Control and Prevention. Therefore, if vaccines weren’t deemed to be safe and effective, would they still be put out on the market and made available to the public?

 

References

 

“COVID-19 Vaccine Immunization Policy Posters”. Alberta Health Services. https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-vaccine-immunization-policy-poster-8-11.pdf.

“RCN Position on Mandating Vaccination for Health and Social Care Staff.” Royal College of Nursing. https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-mandating-vaccination-for-health-and-social-care-staff

Savulescu, J. (2021, February 1). Good Reasons to Vaccinate: Mandatory or Payment for Risk? Journal of Medical Ethics. from https://jme.bmj.com/content/47/2/78.citation-tools.

Conditional Mandatory vaccination: best healthcare approach to COVID-19

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On December 1, 2021

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With the onset of the COVID-19 pandemic, measures to control its spread have received much controversy, specifically on the impingement of autonomy. Among those measures is the issue around mandatory vaccination for “front-line healthcare workers (FHCWs)”, which include “doctors”, “nurses”, “security, cleaners and students” (Bradfield & Giubilini, 2021, p. 467). Bradfield & Giubilini tackles the concerns of community health and FHCWs autonomy around mandatory vaccination, by proposing a “conditional vaccination” which somewhat compromises the two issues. I will begin by explaining how they lead to this idea, first by how they justify the need for mandatory vaccination, then how they explain and defend conditional vaccination, after which is followed by my input.

Justification of Mandatory Vaccine

Bradfield & Giubilini initially express the importance of having mandatory vaccination for health care workers, since they are one of the at-risk groups of contracting COVID-19, and because in hospitals most patients are bodily vulnerable, increased risk of transmission. Mandatory vaccination, according to, Bradfield & Giubilini, also prevents others from suffering from a disease or medical condition simply because of fear of obtaining COVID-19 from the hospital. Additionally, they argue that alternatives to vaccines, such as “hand hygiene, “physical distancing and “quarantining” are “inferior” measures to control the infection spread (Bradfield & Giubilini, 2021, p. 467). To morally justify mandatory vaccination, Bradfield & Giubilini compared the current case with influenza vaccination, since more needs to be learned about the effect of the COVID-19 vaccine. They identified a study in elderly patients where “Influenza related illnesses and deaths” substantially decreased by vaccinating half of the healthcare workers and noted that this may also be true for COVID-19, which is an even “greater threat” of contagiousness and death (Bradfield & Giubilini, 2021, p. 468). These all suggest that mandatory vaccination is morally justified from a utilitarian perspective, in that it protects both the patients and FHCWs.

However, Bradfield & Giubilini conveys the need for a balance between benefits and risks of mandatory COVID-19 vaccination to healthcare workers. Among those risks is for very rare, adverse effects to health workers. An example they provided is after two physicians reacted to the vaccine due to allergy, the UK government deferred vaccines for FHCWs who have had adverse allergic reactions in the past (Bradfield & Giubilini, 2021, p. 468) Another risk of mandatory vaccination is that it may ruin the relationship between healthcare workers and their employers, in which Bradfield & Giubilini highlights the importance of implementing vaccination respectfully. They elaborate this respectful implementation by ideas such as the need to “address cultural and informational needs” of minority groups since they and their healthcare workers are “disproportionately impacted by COVID-19. Another important risk that Bradfield & Giubilini tackles is healthcare workers with medical conditions. They draw on Flanigan’s “right to ‘self-defense’’ ” in exchange for risking others’ harm, as “not absolute”, and thus exemption from vaccination should be allowed but will depend on how serious the risk is for the healthcare worker.

Conditional Vaccination

Nevertheless, even considering the need for mandatory vaccination, Bradfield & Giubilini adopts Wertheimer’s definition of coercion: in which the “treat of penalty” for nonconformity violates an individual’s autonomy by giving them seemingly no room to choose otherwise (p. 467). And this according to Bradfield & Giubilini, means that “ ‘mandatory’ vaccination policy is considered coercive” so much so that the “choice to vaccinate is… practically unavailable” because of the penalties (namely unemployment or license revoked) (p. 467). But they also note that since healthcare is aimed at patient care, FHCWs’ “personal freedom…should be constrained accordingly” (Bradfield & Giubilini, 2021, p. 470). As such they propose a conditional vaccination, which will promote public health by extending the liberties of FHCWs with a less restrictive measure. The extend an “‘intervention ladder’” of how intrusive COVID-19 measures need be, to FHCWs, where at the bottom is no restrictive measure, the top as complete mandatory vaccination with little to no individual choice, and the middle as conditional vaccination. They note that further up the ladder, there is the debate between “incentives and disincentives”, as the degree of each of these may step into the line of coercion. Namely, with increasing disincentives, there is also an increase in coercion. Bradfield & Giubilini show that such measures of “persuasion and nudging” (likely the lower-middle of the ladder), may not work to increase vaccination rates to the desired amount. They explained the result of low influenza vaccination rates when given the choice to refuse, to show that this may be the case. Thus, they explain that using a conditional vaccination could maximize vaccination for the public good, but at the same time balance the autonomy of FHCWs. A conditional vaccination mandate involves restricting unvaccinated FHCWs from contact with patients by temporarily relocating them to “non-clinical…duties”, so long as other vaccinated FHCWs will not be overly burdened by their absence (Bradfield & Giubilini, 2021, p. 469). When Bradfield & Giubilini compared influenza vaccination rates, they deemed it unlikely that a conditional vaccination will result in a significant amount of the workforce refusing vaccination. As such, the penalty is not immediately such a great disincentive as unemployment or suspension/cancellation of professional license.

Now in regard to concerns regarding the autonomy of FHCWs, such as skepticism of the vaccine, Bradfield & Giubilini relates the issue to conscientious objection in healthcare. While they do not dwell on the debates regarding conscientious objection, they explain that the arguments that use it to justify refusing vaccinations do not work. They provide 6 reasons to detach conscientious objection arguments for vaccine refusal, firstly by drawing on John Stuart Mill, that “personal freedoms extend only so far” so as not to infringe on others’ personal freedoms (Bradfield & Giubilini, 2021, p. 470). Another of the 6 reasons include an FHCWs’ ethical and professional duty of non-maleficence leads one to prioritize protecting patients from risk rather than own right to refuse vaccines. Another reason is the autonomy of FHCWs should not compromise patient’s lack of autonomy to choose if one who treats them is vaccinated or not, that requiring vaccination follows “professional codes of conduct” in that it has been approved by infectious agencies, and finally that vaccination of all healthcare workers will serve as an example for the general public who do not trust vaccines.

Opinions

Firstly, I agree that healthcare workers must be vaccinated. As Bradfield & Giubilini pointed out, and as will current cases occurring worldwide, COVID-19 is very infectious especially in hospital settings where people are most vulnerable, and the best protection a healthcare worker can have for oneself, and others is a vaccine. As such, weighing in the risks of illness and death and taking on somewhat of a utilitarian perspective, I believe an infringement of autonomy, in this case, is necessary for the public good and for non-maleficence. I agree with Bradfield & Giubilini’s on John Stuart Mill’s boundaries of one’s personal freedom, in that conscientious objection cannot be used to justify the right to refuse vaccines. However, I do not deny the importance of FHCWs’ autonomy, especially those who only defer the vaccine due to skepticism, or those who refuse the vaccine for high risk of adverse medical effects. In those latter cases, I agree with Bradfield & Giubilini for allowing their exemption for medical reasons. But all else who refuse to be vaccinated, I believed that it seemed somewhat unethical to simply fire healthcare workers or to take away their licence so readily- it is as suggested by Bradfield & Giubilini: unemployment is too disincentive, more coercive, and thus a greater impingement on autonomy. Since I stated earlier that I am in favor of that, and yet still value autonomy, I agree with Bradfield & Giubilini’s conditional vaccination, which somewhat loosens the noose around FHCWs’ autonomy. I agree that more liberty should be taken to give healthcare workers time/space to learn and consider vaccination, especially to consider that it is inevitably the interest of healthcare to promote patient care, and that refusing to get vaccinated for other reasons not based on medical risks or the like, is risking that very goal, and thus why it would be reasonable to revoke their licence if they still refuse.

References

Bradfield, O. M., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. JOURNAL OF MEDICAL ETHICS, 47(7), 467–472. https://doi-org.login.ezproxy.library.ualberta.ca/10.1136/medethics-2020-107175

Mandatory Vaccination Against COVID-19

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On December 1, 2021

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Right now, the vaccine is something that has been around, and accessible to just about everyone in North America for over half a year. The first bunch of health care workers received their first doses almost a year ago in December 2020. The effectiveness of these vaccines cannot be understated. The biggest impact they have is that they decrease the chance of having a severe reaction to COVID-19. In the past 120 days in Alberta, only 2.6% of people in the hospital due to COVID-19 are fully vaccinated and don’t have a pre-existing condition (AHS, 2021). On top of that, in the same time frame, only 1.1% of ICU patients due to COVID-19 are fully vaccinated and have no pre-existing conditions. This is such a substantial difference when compared to the 84.9% of ICU, COVID-19 patients who are fully unvaccinated (AHS, 2021). Not only do they severely decrease the likelihood of serious symptoms, but they also decrease how contagious the infected person is (Syal, 2021).

Let’s continue off the premise that being vaccinated is the best form of protection from COVID-19, except for constantly physically distancing, and that for the average person, the benefits both personally, and for society substantially outweigh the

I will argue that I believe being vaccinated is a crucial part of being a health care worker, however, I don’t think that mandating it is the best way to ensure maximum vaccination percentages. I think mandating vaccines will cause more harm than good, and there are more effective ways that don’t create hostile environments.

First off, front line health care workers (for simplicity I will use the abbreviation FHCW, as is done in Bradfield and Giubilini), are constantly in a state of exposure due to their place of work. Whether they are working in a hospital, in a clinic, or are travelling for work they are in the direct crossfire of disease. This puts them at a higher risk to get infected, and then once they are infected, gives them lots of opportunities to pass the infection on to vulnerable populations who may not recover from the disease as easily. About 95.7% of the deaths in Alberta had at least 1 or more pre-existing condition. This shows how much more vulnerable this immunocompromised population is to severe outcomes, and how important it is to do everything possible in order to protect them. This includes having the people interacting with them as protected as possible, meaning all FHCW should be vaccinated, have full personal protective equipment (PPE), and physically distance when possible. Obviously, with hands on care physically distancing is often never a reality, which means that the other protective measures are that much more important.

All that being said, I think that mandating vaccines should be the last resort to ensuring a maximized vaccinated population in FHCW. Let’s make a blanket statement that all FHCW are educated to some level, saying that paramedics are probably the least formally educated with a 2 year diploma program in Alberta. I think that almost all FHCW that do not want to be vaccinated probably have a reason that they believe to be logical behind that decision. Enforcing a mandatory vaccination policy would disregard these reasons and would probably leave the FHCW feeling neglected and unheard (Bradfield and Giubilini, 2021). This could lead to disconnect in the workplace, and may lead to a decline in job performance, in a field where mistakes could have extremely serious consequences. Because of this, I think that education is the solution to upping vaccine percentages. Listening to the FHCW’s concerns and addressing them with fact based information to convince them of the decision on their own I believe is a much more effective way than forcing them to pick between getting vaccinated and keeping their job. As we’ve seen in the past few months, for example in New York, when the mandate is imposed many FHCW’s will not change their mind and instead will protest the mandate. Educating instead of forcing is definitely more work and time that needs to be invested by the employer but I think that the long term benefits severely outweigh the cost. Especially when mandating the vaccine could cost the employers to loose many FHCW’s when FHCW’s are already scarce.

I think that the method of education over mandate is especially important in places like senior care homes where the nurses may not be as educated as in a hospital, and there may be many immigrant workers who either don’t have access, or aren’t sure where to find reliable information. The vaccine should be made readily available, with paid leave to recover for these workers in order to make it as accessible as possible. I think that after thorough education if the person still does not believe that the vaccine is important for both their own and others’ safety then they should face the ultimatum of their job security or taking the vaccine, but only as a last resort.

There is also the issue of those who could have serious reactions to the vaccine and I think those should be handled on a case to case basis by a committee.

In conclusion, I think that education over mandating is a more effective way to increase vaccine rates in FHCW’s.

I would just like to note that I severely dislike that in Bradfield and Giubilini they repeatedly state that ethical minorities are especially prone to the virus but don’t give any further justification for that. I would just like to clarify that the reason that is, is because these minorities live disproportionally in the “lower class”. Meaning that more of the population would probably live in somewhere with close contact to lots of individuals like an apartment building, or might not have the luxury of their own car so have to take public transit to commute, all these are added exposures that would increase the risk of infection. This was seen at the beginning of the pandemic when the meat plant in Southern Alberta had a massive outbreak, so many of those workers were minority populations. So the reason that the virus disproportionally has affected minorities is due to their increased exposure.

Alberta Health Services. Table 7 and Table 10. COVID-19 Alberta Statistics. Alberta Government. Updated November 29, 2021. https://www.alberta.ca/stats/covid-19-alberta-statistics.htm#vaccine-outcomes.

Akshay Syal. Vaccinated People are Less Likely to Spread Covid, New Research Finds. NBC News. October 1, 2021. https://www.nbcnews.com/health/health-news/vaccinated-people-are-less-likely-spread-covid-new-research-finds-n1280583.

Owen M Bradfield and Alberto Giubilini. Spoonfull of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front line healthcare workers. Medical Ethics 2021.

Alberta Health Services. Table 18. COVID-19 Alberta Statistics. Government of Alberta. Updated November 29, 2021. https://www.alberta.ca/stats/covid-19-alberta-statistics.htm#pre-existing-conditions.

Vaccinated Healthcare Workers

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On December 1, 2021

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In light of the ongoing COVID-19 pandemic, there have been many intense debates surrounding the topic of vaccines. In this subject, one of the most important questions related to healthcare is whether or not covid vaccination should be mandatory for health and care staff. Parker et al. (2021) writes on this issue and presents arguments for and against the mandating of vaccines for healthcare staff.

The ultimate argument for mandatory vaccination of healthcare workers is the responsibility for patient health, and healthcare workers’ obligation to not cause harm to patients. Because COVID-19 is highly infectious, if healthcare workers are not vaccinated against it, they pose a serious threat to themselves and others (including patients). In this regard, Parker et al. (2021) states that healthcare staff “should…be willing to modify their practice in the interest of patient safety” (p. 1). Parker et al. (2021) furthers his argument by stating that this obligation to accept vaccination in order to protect patients is grounded in the notion of personal morality. However, he rightly points out that grounds of personal morality may not be sufficient for practicality. Accordingly, he discusses the involvement of employers to promote vaccination to their employees by establishing expectations, improving access and awareness for vaccinations. If all else fails, he proposes that employers should then mandate vaccination for all frontline staff in order to hold up their obligations to patients. For those who are not able to receive the vaccine due to other medical concerns, he proposes a great suggestion that they should be relocated to alternative roles to minimize exposure and risk.

I think Parker provides logical and suitable ways to increase the number of healthcare workers getting vaccinated. Utilizing the concept of personal morality in this debate is certainly effective. However, in this case, I think vaccination of healthcare staff should be viewed as a work requirement, much like how first aid training is required for paramedics. This is because being vaccinated against infectious diseases, such as COVID-19, allows a healthcare professional to be able to do their job most effectively. It reduces concerns of contracting diseases and infections in a hospital setting, and at the same time allows for a safer environment for incoming patients.

Mandating vaccination for healthcare staff means that those who fail to comply are at a risk of losing their job. Parker et al. (2021) claims that this complicates the situation because now if employers remove a worker based on their vaccination status it is considered discriminatory. Here again, if we view vaccination as a work requirement, the complexity decreases. If being vaccinated against COVID-19 (and other infectious diseases) is established as a work requirement, then not employing unvaccinated workers will not be viewed as discrimination. Revisiting the example about paramedics: if an individual applies for a paramedic position without having the necessary requirements (e.g., first-aid training), it is completely valid for the employer to not hire them solely on the grounds of having incomplete requirements.

The opposition, presented by Bedford, Ussher & Stead, claims that Parker’s suggestion of mandating vaccination is a rather “blunt instrument” (p. 2) in this complex debate. I agree with them that “as with the general population, exploring the reasons for vaccine hesitance among these workers is fundamental to informing interventions to improve uptake” (p.2). Hesitations against being vaccinated arise from doubts regarding the effectiveness and safety of the vaccine. However, I think we must establish here that it is very important for healthcare workers to not be hesitant, and believe in the medicine. Vaccines that are approved for the general public go through tremendous amounts of research and testing before being used in clinical practice. I am not saying that we should blindly accept the medications that are out there, but those within the healthcare profession should have sufficient training that provides them with awareness and understanding so that they can have faith in medicine. Having confidence in the medicine that a healthcare worker is providing is necessary to ensure that patients are receiving the best care.

Bedford, Ussher, & Stead mention successful initiatives that address hesitations regarding vaccines and improve staff vaccine uptake. These initiatives provide support in the forms of increasing access to vaccines, providing “evidence-based information” (p. 2) about vaccines, and hosting sessions to answer any concerns and provide clarifications in a non-judgemental manner. Bedford, Ussher, & Stead claim that such an ‘active listening’ approach is extremely effective in improving confidence in vaccines, and vaccine uptake by building trust. I think such initiatives should be a critical component of the training that healthcare professionals receive through educational institutions. Additionally, these initiatives and programs can also be implemented as part of employee training in healthcare facilities.

While this paper presents measures we can take as a reaction towards unvaccinated healthcare workers, I am arguing for a more proactive approach. I believe this will ensure that all healthcare employees are vaccinated (exceptions granted), and thereby well-equipped to provide the best care for patients. At the end of it all, healthcare workers should always keep patient safety in mind when making these kinds of choices that undoubtedly affect patient care.

 

Reference:

Parker, M., Bedford, H., Ussher, M., & Stead, M. (2021). Should Covid vaccination be mandatory for health and care staff? BMJ. https://doi.org/10.1136/bmj.n1903

Are vaccine mandates the right course of action?

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On December 1, 2021

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Introduction

The COVID-19 pandemic is something that most people are familiar with and have to live alongside. It has greatly impacted the health of many individuals, as well as entire systems which operate in our society. One of the systems impacted by the pandemic is the healthcare system. Novel vaccines have been produced and distributed to ease some of the burdens of the COVID-19 virus. However, not everyone is convinced to be injected with such a vaccine, especially some front-line healthcare workers (FHCWs). Therefore a question must be asked whether there should be a COVID-19 vaccine mandate for FHCWs. A vaccine mandate simply means that in order to continue working at one’s job, one must be vaccinated for a specified virus (Ratini, 2021). This blog post will explore the reasons that a vaccine mandate would not be a good idea and the reasons that a vaccine mandate would be a good idea. Finally, the blog post will conclude with personal remarks. 

 

No vaccine mandate

There are several reasons why a vaccine mandate would not be the right course of action for FHCW. First of all, a mandate can be seen as coercive because there can be penalties for non-compliance such as dismissal from work, which leaves FHCW with no alternatives (Bradfield & Giubilini, 2021). When many employees are dismissed from work, this can cause a shortage of staff (Bradfield & Giubilini, 2021). The mandate can be an infringement on a worker’s individual autonomy (Bradfield & Giubilini, 2021). Autonomy is the quality of self-governing and self-directing freedom (Autonomy definition & meaning, n.d.). Furthermore, certain individuals may have a negative reaction to a COVID-19 vaccine, such as allergies to certain ingredients, or an existing medical condition that will be worsened by a vaccine (Bradfield & Giubilini, 2021). Certain individuals are highly skeptical of the effectiveness and safety of novel COVID-19 vaccines (Bradfield & Giubilini, 2021). Coercive vaccine mandates may cause mistrust and resentment between FHCW and their employers (Bradfield & Giubilini, 2021). Another big problem with vaccine mandates is that culturally diverse ethnic minorities are overrepresented in FHCWs, and would be most affected by the mandate. These groups need to be provided with information about vaccines that is culturally sensitive, accurate, and comprehensible to them (Bradfield & Giubilini, 2021). Incentives such as free meals, bonuses, or parking might not be enough to persuade individuals who have religious or moral reasons not to be vaccinated (Bradfield & Giubilini, 2021). These are just some reasons that a vaccine mandate might be a questionable course of action for healthcare workers.

 

Vaccine mandate

There are many reasons to have a vaccine mandate rather than not have one. First of all, if patients know FHCWs are not vaccinated they might lose trust in the healthcare system (Bradfield & Giubilini, 2021). Patients might avoid hospitals because of the fear that they might become infected while in the hospital, and if the healthcare workers are not vaccinated the fear is only stronger. Avoiding healthcare might mean that more individuals are not treated properly for their illness and might suffer complications at home. While FHCWs have the option to choose to be vaccinated or choose to lose their job, patients cannot choose to be sick or choose whether their doctor or nurse practitioner is vaccinated (Bradfield & Giubilini, 2021). There might be a scenario where a patient must be treated by an unvaccinated FHCW, which is a great disadvantage for the patient and might even put them at higher risk of infection of COVID-19. Furthermore, FHCW themselves are at higher risk of infection and death because they are constantly in contact with sick patients. In a similar case where influenza illnesses were rampant, studies demonstrated that if only half of FHCW were vaccinated against influenza, the rates of influenza illnesses and deaths were significantly lower (Bradfield & Giubilini, 2021). I believe that if studies from other pandemics show that vaccine mandates seem to be effective, then it should be adapted to this current pandemic as well. Vaccination is costless and easy to obtain for a FHCW, and provides tremendous benefits to patients (Bradfield & Giubilini, 2021). Lastly, vaccination is less strenuous on FHCW than already established infection control practices such as intense personal protective equipment that may cause shortness of breath, skin irritation, and physical pain as well as frequent testing for bloodborne infections (Bradfield & Giubilini, 2021). After considering the points demonstrated in this paragraph, I believe that vaccine mandates are the best way to ensure high rates of vaccination among FHCWs. Not only do vaccines protect the healthcare workers from potential infection from sick patients, it provides comfort and trust in patients seeking medical treatment. Vaccinations also protect patients from being infected from FHCW and other patients. I would not want to seek medical treatment from a doctor that is not vaccinated against COVID-19.

 

Conclusion

I personally advocate for vaccine mandates for FHCW. To make a comparison, in Alberta all university students must be vaccinated for COVID-19 to be allowed to participate in activities on campus. In the University of Alberta, students and staff must submit their proof of vaccination online and have a vaccination pass ready to show at any time. Universities are crowded spaces, with lecture halls and hallways packed with students. Hospitals can be compared to a university campus with crowded halls and patient rooms. However the people present in a hospital are sick and are even more prone to infection than young adults that would be on a university campus. In British Columbia as of October 26, 2021 over 4000 healthcare workers are not vaccinated (Dickson, 2021). So why then do all students and staff on a university campus have to be vaccinated but some healthcare workers in hospitals are not? I am a strong supporter of vaccine mandates for FHCW for the reasons described.

 

References

Autonomy definition & meaning. (n.d.). Merriam-Webster. https://www.merriam-webster.com/dictionary/autonomy.

Bradfield, OM., & Giubilini, A. (2021). Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers. Journal of Medical Ethics. 47, 467-472.

Dickson, C. (2021, October 26). More than 4,000 health-care workers remain unvaccinated, says Province’s health minister. CBCnews. https://www.cbc.ca/news/canada/british-columbia/vaccine-mandate-health-care-workers-1.6225527.

Ratini, M. (2021, November 9). Vaccine mandate: What to know. WebMD. https://www.webmd.com/vaccines/covid-19-vaccine/vaccine-mandates#1.

Mandating the shot for Healthcare Providers

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On December 1, 2021

In Uncategorized

In the current anxious environment surrounding the pandemic, there is an incessant need for knowledge to fill in the gaps which is often fulfilled by the rampant spread of misinformation. This puts not just the healthcare workers on backfoot but even large masses of people end up believing claims not scientifically sound. Therefore, vaccinations only seem to be the viable solution in the current situation but making it mandatory for healthcare workers (which would largely reduce risk to patients) does not come without some backlash and associated hesitant/unvaccinated healthcare providers.

The article by the Royal College of Nurses (RCN), RCN position on mandating vaccination for health and social care staff, highlights the stance of the College to mandatory vaccinations for the staff. The article begins by giving a background and details on this situation and policy which is followed by the proposed steps by the RCN (which are discussed below). The article clearly states “The fundamental position of the RCN is that all members of the nursing team should have any vaccine deemed necessary to help protect themselves, patients, colleagues, family members, and the wider community” (RCN position on mandating vaccination for health and social care staff 2021). Part of the policy also entails the responsibility of the employers which consist of “ensuring staff have easy access to the vaccines they need within the working day, providing staff with access to clear information about the risks and how to overcome or manage those risks, as well as information about the value and benefits of vaccination and providing confidential support to staff who have any vaccine related concerns” (RCN position on mandating vaccination for health and social care staff 2021). It is encouraging to see how England aims to tackle the current dilemma within the healthcare where HCP’s may not want to get vaccinated without any underlying conditions. The logic behind the new proposed policy follows sound rationale i.e. to accommodate for such individuals where possible, inculcate mandatory vaccination in hiring new staff etc. However, if this is not possible, the policy authorizes to reprimand nurses by firing them. It sets a standard (some may say barrier) for hiring new workers, but creates a slippery slope for those who currently are employed. While conditions may change with progress of the pandemic, it is fascinating to see that this policy doesn’t have its door shut, rather allows for future review whenever necessary to make amendments to accommodate for the condition then. Despite this being viewed as a fool-proof policy, it will be interesting to see the policy’s ramifications and consequences in the real world.

Much as a response to the policy, the article from The British Medical Journal (Should covid vaccination be mandatory for health and care staff?) begins by highlighting the reasons for HCP vaccination and the employer dilemma. This BMJ article describes the necessity of HCPs to be vaccinated as it is a part of their responsibility to protect the patient. HCPs not vaccinated put the patient at a much greater risk. Unfortunately, this brings out the dilemma of employers who have a responsibility to the patients and their employees. It becomes difficult to protect one as this may inadvertently harm the other. Also, according to the article, steps must also be taken to relocate Healthcare Professionals who are unvaccinated (and/or have a medical contraindication) to roles that pose a lower risk to the patients; all the while, vaccinations should be encouraged in the staff by the employers. Thus, as an obligation to the patients, the healthcare workers must be vaccinated to reduce risk to patients (esp. for the most vulnerable individuals of the population) (Parker et al. 2021). However, making vaccination mandatory creates an issue of distrust. The article further describes, that amidst the chaos and the spread of misinformation during the pandemic, making vaccinations mandatory will reduce the trust of people to the government and the NHS. It is highlighted that even HCPs are not immune to misinformation. In order to tackle so, there must increased provision of evidence-based information and non-judgemental forums where one can raise their concerns and discuss their position (Parker et al. 2021). Therefore, I do agree with that certain people will simply not get vaccinated simply for the sake of refuting and opposing authorities therefore we must be careful when considering actions. I too am supportive of the alternate measures proposed to debunk misinformation. However, I do disagree with the statement that mandatory vaccination is “a blunt instrument to tackle a complex issue” (Parker et al. 2021). While covid-19 is a “complex issue” (Parker et al. 2021), vaccinations are the sole most effective solution (as of now) to keep the virus from spreading. We must not stop at this junction simply because vaccination rates are high enough. Yes, taking such an action will reduce trust with the healthcare system, however, reducing mortality trumps reduced trust in the current situation.

 

 

Works Cited

Parker M, Bedford H, Ussher M, Stead M. Should covid vaccination be mandatory for health and care staff? BMJ  2021;  374 :n1903 doi:10.1136/bmj.n1903

RCN position on mandating vaccination for health and social care staff. (2021). https://www.rcn.org.uk/about-us/our-influencing-work/position-statements/rcn-position-on-mandating-vaccination-for-health-and-social-care-staff

Mandatory Vaccination for Healthcare Workers

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On November 30, 2021

In Uncategorized

    The Covid-19 pandemic is continuing to affect the lives of everyone all over the world. Many people have varying opinions on the idea of vaccination. Some people have decided to receive their vaccination and others are completely against the idea for a number of different reasons. However, the question remains; should healthcare workers be obligated to receive their Covid-19 vaccine? According to the article by Owen Bradfield and Alberto Giubilini(2021), they believe in a “mildly coercive ‘conditional’ vaccination policy for FHCWs that represents a middle ground between an entirely voluntary and entirely mandatory approach”. In the next few chapters I will further explain Bradfield and Giubilini views on mandatory healthcare worker vaccination, as well as express my own opinions on the topic. 

    Front line health care workers are not only at a greater risk of obtaining Covid-19 or other illnesses, but they are also at a greater risk of passing these contagious diseases to their patients. Some individuals are even avoiding going to the hospital all together in fear of obtaining Covid (Bradfield, 2021). Some sort of policy that would increase the rates of vaccination among healthcare workers would decrease the amount of patients getting sick, while also decreasing the chance of the healthcare workers getting sick (Bradfield, 2021). This is important since many hospitals are understaffed at the moment due to the large influx of people with Covid-19 symptoms being admitted into the hospitals. It is proven, through the statistics of other illnesses aside from Covid, that the death rate of the elderly patients is significantly minimized when only a portion of the healthcare workers are vaccinated (Bradfield, 2021). Therefore, it is evident that the hospitals would greatly benefit from having their staff vaccinated. This would decrease the mortality rates in the hospitals while also potentially decreasing the amount of time one has to stay in the hospital by reducing the chance of them obtaining any other illness that would prolong their stay. This in turn could help with the issue of having too many patients and not enough hospital beds to serve these patients. 

    Although having a mandatory vaccine policy for the healthcare workers would be beneficial for the patients, we also have to weigh how this would affect the staff themselves. It is evident that a vaccine is never 100% safe or effective, there are always going to be underlying risks that may affect a very small portion of the total population who receive this vaccine (Bradfield,2021). There is also the risk of having some sort of allergic reaction to the vaccine. Another reason as to why mandatory vaccination may not be the best decision is that it could potentially cause some tension between the healthcare workers and their employers. Healthcare workers “already experience higher rates of depression, anxiety, insomnia, post-traumatic stress disorder and burn-out from dealing with the tragic reality of this pandemic” (Bradfield,2021). Causing the healthcare workers to distrust their employers on top of all the mental stresses they face each day could potentially cause an increase in the number of healthcare workers wanting to find employment elsewhere.

    Creating a policy that would allow those who have underlying health problems that prevent them from obtaining vaccination, those who have been allergic to different vaccines in the past, and those whose cultural or religious beliefs go against the idea of vaccination should have the option to not receive their vaccination. However, for those who are able, I believe it would be the best decision to receive their Covid-19 vaccination. It is my personal belief that all healthcare workers should receive their vaccinations unless there’s some serious reason as to why they cannot. However, I do not think that your own personal beliefs on vaccination, such as the government is trying to track or control us, is a justifiable reason to not receive the Covid-19 vaccination. By increasing the number of healthcare workers who are vaccinated, this in turn can decrease the cases of Covid-19 by helping to reduce the spread of this highly infectious disease.          

 

References

 

Bradfield. O. M, Giubilini. A. (2021). Spoonful of honey or a gallon of vinegar? A conditional Covid-19 vaccination policy for front-line healthcare workers. J Med Ethics Epub. 

Honey, Vinegar, and the Next Pandemic

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On November 30, 2021

In Uncategorized

The COVID-19 pandemic has either created or shown a divide in society. The great debate has ultimately been the debate over individual autonomy and collective benefits, and this has been an equally important matter in the healthcare system. Owen M. Bradfield and Alberto Giubilini write in A Spoonful of Honey or a Gallon of Vinegar? A Conditional COVID-19 Vaccination Policy for Front-Line Healthcare Workers their arguments for why healthcare workers need to be vaccinated, and how this can be achieved.

Many people have decided to refuse to be vaccinated against COVID-19, and the authors admits that this option is available to them as autonomous beings – but when it comes to healthcare practitioners, they must be vaccinated to continue working. Bradfield et al. write that “Vaccine refusal puts patients at risk of infection and death. Given the evidence that vacci- nation prevents disease transmission to vulnerable patients and maintains the health of FHCWs (Front-Line Healthcare Workers), vaccination should be seen as a fundamental moral requirement for all FHCWs. The duty not to infect patients must take priority over any right to vaccine refusal.” The author explains that this viewpoint is based on the utilitarian perspective, “because it minimises risks and maximises patients’ and FHCW’s welfare.” However, the article is not here exclusively to draw a line in the sand; instead, Bradfield seeks a way for healthcare workers to be vaccinated by their own accord. The authors explain that a ‘Intervention Ladder’ should be used, in which interventions should be put in place from least to most coercive. This ranges from no intervention upon refusal to vaccination, to a loss of employee privileges (such as no additional paid leave), to stronger measures such as imprisonment, termination of employment, and even forcible vaccination via chemical or physical restraint. This ‘Intervention Ladder’ seeks to reduce the loss of autonomy of these individuals until healthcare workers comply with vaccination requests, which ultimately prioritizes the collective good.

There is another harm to the collective which has often been ignored by the vaccine refusal by healthcare workers. If a healthcare worker refuses to be vaccinated against COVID-19, what message does this send to others that see this? How does this impact groups who have been historically mistreated by (and who lack trust in) the healthcare system, seeing their healthcare professionals refuse to be vaccinated while there is still campaigns to vaccinate these groups? At the least this is a concern. Whether someone judges COVID-19 to be of little risk and decides not to get vaccinated likely only puts future pandemics at higher fatalities due to the belief that certain vaccines are not necessary. To combat vaccine hesitancy, healthcare practitioners should be required to put on a united front: showing that the healthcare system supports what the healthcare system is saying. But when nurses, doctors, and others in the healthcare system are refusing to be vaccinated, they are saying that they do not believe in the system, and lending credence to the idea that maybe the system should not be trusted. Our society relies on experts telling society what is best, and when the trust between the experts and society is at risk, it is extremely difficult to repair.

Bibliography

Bradfield, Owen M., and Alberto Giubilini. Spoonful of Honey or a Gallon of Vinegar? A Conditional COVID-19 Vaccination Policy for Front-Line Healthcare Workers. Journal of Medical Ethics 2021; 47:467-472.

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