1. Olsen, Douglas P. PhD, RN

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'The most compelling aspect of the debate is the number of nurses who don't trust the data.'


Two respected nursing leaders have provided thoughtful opinions, and rather than take sides, I aim to highlight the strong and weak arguments in both, as well as any ethical arguments they missed. To be fair, I must disclose that if I were asked to choose sides, I would go with Mr. O'Neal, but it's a close call. Previously in AJN (Ethical Issues, October 2006), I concurred with nurses who were resisting mandatory flu vaccination at a specific hospital, yet on the AJN blog (August 26, 2009;; under "Categories," click on "H1N1 virus [swine flu]") I stated, "I feel that the evidence of benefit and risk is credible enough that there's a moral obligation for nurses to get vaccinated."


The antimandate argument. The strongest argument against mandatory vaccination, which Ms. Converso implies throughout her opinion, is that we should have exceptionally high standards for the justification of any form of forced health care. She makes the excellent point that vaccination isn't the sole avenue of flu prevention and that there's a danger of becoming complacent about other techniques when vaccination is overemphasized. (That doesn't mean, however, that mandatory vaccination isn't justified.)


Ms. Converso uses a compelling (if ultimately irrelevant) emotional appeal, referring to nurses as "smart, skilled professionals" who should be trusted-and in AJN readers, including those favoring mandatory vaccination, she's likely to find her choir. Unfortunately, despite widespread agreement and empirical demonstrations that vaccination protects patients, voluntary vaccination programs aren't widely used.1 (Ms. Converso in fact notes that the vaccination mandates stem from low vaccination rates among health care workers.)


She tackles head-on the fairly convincing promandate argument that vaccination against several diseases (polio, measles, and rubella) has been mandatory for some time with little controversy, citing an increased risk of adverse events from yearly vaccination, as compared with those lifetime immunizations. Unfortunately for her, this leads to the weakest point of the antimandate stance-the data.


Assessment of the ethics surrounding mandatory vaccination involves balancing the potential benefits against the risks incurred by nurses, and the data are unambiguous: the risk to nurses is extraordinarily low,1 and the benefits to patients are potentially substantial.2


The promandate argument. The heart of the promandate argument, which Mr. O'Neal alludes to peripherally, citing examples of caregivers' past fears about treating patients with dangerous diseases, is that nurses have an obligation to incur some risk when treating patients because society privileges us through licensure, with the understanding that we will provide health care even under difficult circumstances and because it's what we owe patients as part of the nurse-patient relationship. However, this argument requires trust in the data and the system that produced them.


Mr. O'Neal's own appeal to history, the references to the fear of contracting diseases such as SARS and HIV, is compelling, yet it doesn't bear directly on a formal ethical justification. And his argument in favor of mandatory vaccination does reference (as Ms. Converso predicted some would) the historically noncontroversial requirements for vaccination against other diseases.


A personal decision that getting vaccinated is the right thing to do isn't sufficient to justify mandatory vaccination for all; a higher standard is required. Mr. O'Neal conflates these ideas in his last paragraphs. Despite the emotional appeal, it doesn't follow that because he's determined that vaccination is right for him, it should be mandated for all.


The most compelling aspect of the current debate is the number of nurses and others who don't trust the data. This mistrust should not be dismissed as wacky, as if we were discussing government-sanctioned implantation of microchips into unsuspecting patients. Such mistrust stems from two sources, the belief that the data and system themselves are faulty and the belief that the government and authority are untrustworthy. Nurses' mistrust of mandatory vaccination likely has roots in both, and both are legitimate avenues of inquiry.


In the end, both nurses are courageous to have submitted their views to ethical analysis and wise to advise pursuing education and debate for the safety of nurses and patients. I'm honored to have the privilege of commenting on their exceptional work.




1. Harper SA, et al. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2005;54(RR-8):1-40. [Context Link]


2. Salgado CD, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004; 25(11):923-8. [Context Link]