Physician vaccination a top priority and a duty

Physicians are among those refusing to get vaccinations. With the variety of institutional policies and legal decisions in force around the country, it's a serious matter. The American Medical Association Council on Ethical and Judicial Affairs has written an opinion on the ethics of physician vaccination, urging that it be viewed as a priority and a duty, with very few exceptions. A member of the council provides a brief history of vaccination and explains the rationale for the opinion.

Reply: In the spring of 1721, an epidemic of smallpox threatened several communities in the American Colonies with mass mortalities. In Boston, the Rev. Cotton Mather, a highly regarded spiritual and community leader, was aware of preliminary reports published in the Philosophical Transactions of the Royal Society of London about the use of inoculating a healthy individual's skin with pus from a smallpox victim's skin sores. Following an illness milder than traditional smallpox, patients were protected from the more lethal disease of community-acquired (respiratory) smallpox.

Mather lobbied Boston's physicians to try the approach in response to the pending epidemic, but his proposal was dismissed as too dangerous and unproven. Eventually he persuaded one local physician, Dr. Zabdiel Boylston, to try the approach. The immediate community response was condemnation of the effort. The outrage caused by the bold attempt to fight the disease manifested in many forms, including public protests. Indeed, in describing one such event, Mather's diary records the Boston people acting "like ideots but also like franticks."

Eventually, when the disease had run its course in Boston, it became apparent that the smallpox inoculation championed by Mather had a very positive effect on the death rate for those who received it. The death rate among those inoculated was 1 in 40 compared with a death rate of 1 in 6 for those who were not inoculated.

Fast-forward 290 years and, surprisingly, we are still engaged in the process of convincing skeptics that the now-advanced science of vaccination in appropriate contexts significantly reduces the likelihood of death and morbidity from epidemics of highly contagious illnesses, including the 2009 threat of an H1N1 pandemic.

Our understanding of epidemic viral illness has significantly improved during the almost three centuries since the 1721 events in Boston, and it is understood that during a contagious epidemic, infected individuals (particularly physicians) who are in close contact with sick and vulnerable patients, are a health risk. It has been demonstrated that for vaccine-preventable diseases, the most effective way to reduce transmission from health care workers to patients is immunization of the health care workers. Peer-reviewed studies demonstrate that, in acute and long-term care facilities, infected workers increase the risk of death and morbidity due to contagious viral illness.

Since the discovery of vaccines, a large volume of empiric data has accumulated supporting the claim that vaccination -- in the context of an epidemic caused by a highly transmissible virus for which there is a safe, effective and available vaccine -- has a positive impact on lowering disease transmission and improving survival. Policies that support vaccination of health care professionals in the context of a vaccine-preventable epidemic disease have been promulgated by national accrediting and professional organizations.

Physicians who refuse vaccination in the context of an epidemic of a highly transmissible virulent illness for which there is a safe, effective and available vaccine expose vulnerable patients to an increased risk of infection and deplete critical health care personnel resources. Exposure of physicians and other health care workers to potentially preventable epidemic infections may render them unable to serve the patients and communities in which they practice during the very times that are likely to require all available medical expertise.

Furthermore, by being vaccinated, physicians and other health professionals set an example concerning the importance of immunization. Arguably, in entering the profession of medicine, physicians accept certain constraints on their behavior and decisions as individuals in exchange for the privileges of professional status.

As promulgated in the AMA's Code of Medical Ethics principles and opinions, physicians must set their behavior standards by placing the interests of the patients and communities they serve before their own self-interest (Principle VII; Opinion 2.25, The Use of Quarantine and Isolation as Public Health Interventions; Opinion 9.067, Physician Obligation in Disaster Preparedness and Response). Thus, when a vaccine is deemed safe and effective in preventing an illness that is threatening to become epidemic among our patients, no sustainable argument can favor both forgoing the vaccine and continuing to treat patients, unless extenuating circumstances exist.

The strongest argument practicing physicians advance in favor of avoiding vaccination in such a context is that they, their immediate family or a unique patient population whom they serve may be at increased risk due to their receiving such a vaccine. Secondary arguments, including religious objection and other claims based in individual autonomy are generally difficult to support. The influence of such secondary arguments may vary depending on the specifics of the situation, including, but not limited to, the virulence of the disease, the efficacy of the vaccine, the role the physician plays in caring for ill patients and the available alternatives to vaccination.

In some communities, especially small, often rural settings, options for addressing physicians who are unwilling or unable to receive vaccination must be evaluated together with the proportional harm that eliminating such physicians and their services from the community may entail. In testimony at a June 2010 open forum hosted by the AMA Council on Ethical and Judicial Affairs, many physicians expressed the opinion that, in such situations, it was imperative to preserve local control over restrictions on patient care for unvaccinated physicians in the setting of epidemics.

With careful consideration of the issues involved in mandatory physician vaccination in the context of a virulent, highly transmissible epidemic infection for which there is a safe, effective and available vaccine, the Committee on Ethical and Judicial Affairs of the AMA has recommended, and the AMA House of Delegates has affirmed, that the following opinion be added to the Professional Code of Medical Ethics:

As professionals committed to promoting the welfare of individual patients and the health of the public and to safeguarding their own and their colleagues' well-being, physicians have an ethical responsibility to take appropriate measures to prevent the spread of infectious disease in health care settings. Conscientious participation in routine infection control practices such as hand-washing and respiratory precautions is a basic expectation of the profession. In some situations, however, routine infection control is not sufficient to protect the interests of patients, the public and fellow health care workers.

In the context of a highly transmissible disease that poses significant medical risk for vulnerable patients or colleagues or threatens the availability of the health care work force, particularly a disease that has potential to become epidemic or pandemic, and for which there is an available, safe and effective vaccine, physicians have an obligation to:

• Accept immunization unless there is a recognized medical, religious or philosophic reason to not be immunized.
• Accept a decision of the medical staff leadership or health care institution, or other appropriate authority, to adjust practice activities if not immunized (e.g., wear masks or refrain from direct patient care). It may be appropriate in some circumstances to inform patients about immunization status.

Patrick W. McCormick, MD, member, AMA Council on Ethical and Judicial Affairs; neurosurgeon, partner, Neurosurgical Network Inc., Toledo, Ohio; section head of neurosurgery, St. Luke's Hospital; clinical assistant professor, Dept. of Surgery-Division of Neurosurgery, Medical College of Ohio School of Medicine