Ethical approaches to mandatory vaccination and quarantine in pandemic influenza response

¶ … ethical principles that should be applied to situations regarding pandemic influenza response. The situations are based on the following expected issues where ethical considerations may need to be considered. The major issues are mandatory vaccinations and quarantining, with consideration of controlling media representations in order to prevent panic, fear and hysteria from spreading also being a significant issue. The ethical approaches utilized seek a balance between utilitarian and libertarian principles, with one or the other or sometimes both being applied. The proper approach is dependent upon the situation and the proposed solutions to each issue.

Influenza Pandemic: Ethical Solutions to Practical Problems

Introduction

One of the most important ethical questions regarding preparation for a pandemic influenza outbreak is whether or not to incorporate mandatory vaccinations as a precautionary measure. Vaccinations are a controversial subject and elicit extremely different responses, often at odds with one another, across the public spectrum. Self-identity issues (such as personal, religious or work-related beliefs) have been cited as reasons for procuring exemptions from influenza vaccinations among health care personnel (Trafimow, 2013, p. 44). Trafimow (2013) argues that even though personnel may feel strongly or "sincerely" about their reasons for refusing vaccinations, the sake of the greater good is more important than the individual personal beliefs: what is at risk, Trafimow asserts, is the public health and safety of others, especially patients -- "My opinion is that patients' interest should be the overriding concern" (Trafimow, 2013, p. 44). At issue, however, are two points: first, what ethical approach should one take in this matter of to issue mandatory vaccinations or not; and, second, what do researchers say about the efficacy vs. risk of vaccinations (i.e., are they effective in stymieing the spread of outbreaks or are they participants in such outbreaks?). This latter point (born of suspicion) is one of the main causes for personal reasons against receiving vaccinations. Education or direct legal action can be possible factors in overcoming such resistance. The other point, however -- the ethical approach -- is essentially the main determining factor in how to proceed.

The Right Approach

Ethical approaches vary in today's modern world. There is the utilitarian approach (which is the pragmatic or practical approach that puts the "common good" above all else). The utilitarian approach is a consequence-based method of addressing such sensitive issues. A second approach is the categorical imperative approach, which places a universalist perspective on the issue -- as in what is right for one is what is right for all others. A justice as fairness approach would place the legitimate right of individuals as the ultimate factor in discerning what is just. A Confucian approach (or Golden Rule approach) would assert that one should treat others as he or she would like to be treated -- which in this case is perhaps too impractical to consider. Then there is the altruistic approach, which is rooted in helping others by placing their needs first (but this approach, too, may be impractical as it is unclear exactly how we are to help primarily because the problem of how to approach the ethical framework for this issue has yet to be resolved; thus, this approach may also be too impractical). Essentially, what is at stake here is whether it is justified to act authoritatively in this matter (assuming vaccinations are the safest course and making them mandatory for the public), or whether a libertarian type of approach (rights-based, in which the will of individuals is given priority over government wishes) is more ethical.

As Sandel (2009) notes, "The idea that justice means respecting freedom and individual rights is at least as familiar in contemporary politics as the utilitarian idea of maximizing welfare" (p. 20). But here the utilitarian concept is complicated by two conflicting ideologies: on the one hand, there is the appeal to freedom as the way towards the "common good" or happiness for the greatest number of people (Halbert, Ingulli, 1999, p. 15). And on the other hand there is the appeal to social welfare as the way. The two are exclusive: one cannot have absolute freedom and yet still be dependent upon the state. Either one is cut loose or one is chained (by dependency). A utilitarian or pragmatic happiness is only as endurable as the society's ability to control the environment which produces that pragmatic happiness. Thus, before proceeding to arrive at an approach, it is necessary to know that the environment can be controlled via vaccination. Many researchers support vaccination as helpful in deterring the spread of diseases and outbreaks (Ota, Idoko, Ogundare, Afolabi, 2013; Adams, Suresh, Lahey, 2016). Theodoridou (2014) goes so far as to argue that "voluntary vaccination programs have not achieved acceptable rates" and that "legally mandated vaccination is required" (p. 4866). In short, the majority of the medical community supports mass vaccination for the sake of "herd immunity" (Amin, Parra, Kim-Farley, Fielding, 2012) and some, such as Theodoridou, support mandatory vaccination as a preventative measure.

To Vaccinate or Not to Vaccinate

While a small number of dissenters disagree with vaccination policies, if one is to hold that the safest course of action is in following the majority, the utilitarian approach suggests that the common good lies in adopting a policy of mandatory vaccination in order to prepare for and help to prevent any pandemic influenza outbreak. The main solution to addressing the ethical issues related to this policy is already made when the appropriate ethical approach is discerned. The secondary solution consists of educating the public as to the reason this approach and policy is most efficacious and most effective in protecting the common good.

On the other hand, the voice of researchers who provide evidence that vaccinations may actually cause flu strains to become more resistant over time could pose a legitimate pause for concern. The study by Ohmit, Thompson, Petrie et al. (2014) shows that while "vaccine effectiveness in the 2011-2012 season was modest overall, with lower effectiveness against the predominant A (H3N2) virus," the main cause for this lower effectiveness "may be related to antigenic drift" as well as "past history of vaccination" (p. 319). In short, there is no easy ethical solution to this problem as, first, it is unclear (unanimously speaking) whether vaccinations are harmful or helpful in the long run in terms of preventing flu outbreaks, and, two, without knowing the effect of vaccination it is impossible to identify the best approach to serving the common good. Thus, the most ethical approach to this issue is the libertarian approach, which upholds the individual right to reject vaccination. For this reason, other issues must be addressed and assessed from an ethical standpoint.

Controlling Media Reporting, Quarantining, and Other Issues

These issues concern effecting quarantines, emergency response, the banning of public outings in response to an outbreak of pandemic influenza, controlling mass media hysteria, and providing the order for employees to stay at home and not report to work. Each of these issues has its own ethical problems. This paper will now proceed to examine ethical approaches to controlling media hysteria and the issue of implementing a quarantine.

Controlling the mass media can be particularly problematic, as the ethical issue related to this situation is the right of free speech. However, in the SARS outbreak in Toronto, the mass media played a critical part in spreading panic, which made emergency response teams' jobs that much more difficult.

In Toronto, mass media portrayed the outbreak of SARS in near-apocalyptic terms, meaning that ICS had to perform educational tasks in order to calm rapidly escalating public fear, paranoia, etc. As a result of fear of spreading SARS, staff workers were isolated from communities and their morale had to be lifted via conference calls, where they were encouraged and congratulated for their hard work and perseverance on the "front lines" (Hawryluck, Lapinsky, Stewart, 2005). The ICS was responsible for managing the routines of the hospital emergency staff. Only for this reason, the scope of the crisis management was much more focused than that, for example, in New Orleans in the wake of Hurricane Katrina. It was also much more manageable as different sectors were prepped and trained on how to implement ICS beforehand.

In the case of pandemic influenza, however, managing a hysterical media can be essential as media relies upon ratings to procure revenue from advertisers and nothing spells ratings like impending disaster. Nonetheless, networks should be advised that responsible reporting can be just as effective at generating ratings as sensational reporting and can actually be more helpful from a public good perspective (and thereby give networks the possibility of being publicly honored later on). On top of this, management response teams should be made aware of the way in which irresponsible reporting on the part of mass media can lead to immense public fears and they should be prepared to combat tidal waves of paranoia, fear, low morale. Educative forces should also be dispatched so as to better facilitate public understanding. The best ethical solution here, is to focus on the common good and devise a strategy for maintaining order among emergency response crews after the manner of the ICS in Toronto following the SARS outbreak.

Effecting quarantines, moreover, comes with its own ethical issues, too. According to Singer, Benatar, Bernstein et al. (2003) there are "five ethical values associated with this issue" and the first, as usual, involves personal liberty (p. 1342). At the same time, the issue of personal liberty is impacted by the issue of public safety -- just as in the case of vaccinations. A third value or factor to consider is "proportionality," which includes "exercising public health powers ... in a way that is relevant, legitimate, and necessary" (Singer, Benatar, Bernstein et al., 2003, p. 1342). Transparency and Reciprocity are the remaining two values and they allude to the issue of stakeholders being well-informed at all times and those being quarantined being in a position where they are assured of receiving the care they require. Thus, if these five values can be attended to with alacrity, then the issue of quarantining civilians during a pandemic of influenza will largely solve itself. At root of this approach is a balance between the utilitarian approach and the libertarian approach. Both can work together if there is clear evidence that the practice (in this case quarantining) is unanimously agreed to be a good. To date there is no indication in research that quarantining can lead to even more of an outbreak; thus, the solutions to this situation are much clearer than they are in the case of issuing a mandate for vaccinations.

Other ethical values that would have to be considered in relation to quarantines, however, would include the right to privacy, the protection of communities from receiving a stigma, the duty to give efficient care, the need for solidarity, and the issue of equity.

The overall issue of quarantining is a challenging one as large-scale quarantines have not been effected in the U.S., though smaller ones have (Barbera, Macintyre, Gostin, Inglesby, O'Toole, DeAtley, Tonat, Layton, 2001). Many concerns such as logistics and implementation would need to be considered and there are ethical issues here as well. The main approach to this situation that would solve the issue, as far as ethics are concerned is transparency and the duty to care. These are the big factors in deciding a utilitarian/libertarian ethical approach, which is the balance that should be attempted, as has already been put forward previously. Unintended consequences can arise from large-scale quarantines and the primary duty to care does not stop at treating those affected by the spread of influenza; it should also extend to those unintended and unforeseen consequences, as this is part of what it means to be ethically responsible for one's actions and purposeful in one's decisions to implement a plan that is oriented within an ethical framework.

Cetron and Landwirth (2005) note that the bulk of the responsibility "for public health matters within their borders rests with state and local governments" (p. 327). However, in the matter of pandemic influenza, it would be necessary for state and local governments to coordinate with federal officials and agencies in the matter, as was seen in the aftermath of Hurricane Katrina. This would mean effecting communications and efficient centers of control, with clear management in place to guide the implementation of plans.

The Model State Emergency Health Powers Act was recently passed in order to facilitate cooperation between states in case of such a pandemic as the influenza case in question. It alludes to the types of ethical, professional and legal responsibilities that public health authorities should be aware of. Likewise, the Public Health Service Act special authority to the Centers for Disease Control and Prevention, which may "detain, medically examine, or conditionally release individuals reasonably believed to be carrying a communicable disease" (Cetron, Landwirth, 2005, p. 327). It is important to be aware of Acts such as these so that the proper ethical approach can be considered when it comes time to develop an adequate solution.

In any case, it is important to keep in balance the two ethical approaches promoted in this study: the libertarian approach that supports individual rights and the utilitarian approach that supports measures that will ensure the common good. In some cases, these two approaches can be at odds with one another (as in the case of mandating vaccinations). In such cases, if it is unknown whether the outcome will be truly beneficial, it is best to adopt only the libertarian approach so as to ensure that at the very least the individual rights of persons are respected.

Regarding the question of quarantining, the issue is just as complex for, according to the Principles of the Ethical Practice of Public Health put forward by the Public Health Leadership Society, "community health shoud be achieved in a way that respects the rights of individuals and the community" (Cetron, Landwirth, 2005, p. 328).

As is noted, such a "potential dichotomy" can be problematic, but it does not necessarily have to be (Cetron, Landwirth, 2005, p. 328). One way in which a resolution or solution to this problem can be attained is by way of an educative process in which the public is educated about the benefits of quarantining and in which assurances are made regarding privacy, equity, social stigma, and care. It is important in this process to be as educative as possible because, unlike with the issue of vaccinations, there is no substantial evidence to consider quarantining as potentially hazardous to one's health, although this may be objected to by citizens who are otherwise healthy who do not want to be stuck in a quarantined zone out of fear of infection. This is an understandable fear and this where education comes into play. The public's fears will most likely be aggravated by media hysteria (which is why controlling the media can also be an issue that must be addressed). At the same time, it must be understand that quarantines cannot, by law, be effected without clear scientific cause. Therefore, if quarantine is put in place, there is good reason for it, and civilians should be made to understand this through a public education process. That is the first step towards providing an ethical solution to the issue.