Department of Family Medicine and Clinical Epidemiology, University of Pittsburgh, 3518 Fifth Avenue, Pittsburgh, PA 15261, United States.
Vaccine. 2013 Dec 16;31(52):6172-6. doi: 10.1016/j.vaccine.2013.10.066. Epub 2013 Nov 1.
Health care worker (HCW) influenza vaccination rates are modest. This paper provides a detailed ethical analysis of the major options to increase HCW vaccination rates, comparing how major ethical theories would address the options. The main categories of interventions to raise rates include education, incentives, easy access, competition with rewards, assessment and feedback, declination, mandates with alternative infection control measures, and mandates with administrative action as consequences. The aforementioned interventions, except mandates, arouse little ethical controversy. However, these efforts are time and work intensive and rarely achieve vaccination rates higher than about 70%. The primary concerns voiced about mandates are loss of autonomy, injustice, lack of due process, and subsuming the individual for institutional ends. Proponents of mandates argue that they are ethical based on beneficence, non-maleficence, and duty. A number of professional associations support mandates. Arguments by analogy can be made by mandates for HCW vaccination against other diseases. The ethical systems used in the analyses include evolutionary ethics, utilitarianism, principalism (autonomy, beneficence, non-maleficence, and justice), Kantism, and altruism. Across these systems, the most commonly preferred options are easy access, assessment and feedback, declinations, and mandates with infection control measures as consequences for non-compliance. Given the ethical imperatives of non-maleficence and beneficence, the limited success of lower intensive interventions, and the need for putting patient safety ahead of HCW convenience, mandates with additional infection control measures as consequences for non-compliance are preferred. For those who opt out of vaccination due to conscience concerns, such mandates provide a means to remain employed but not put patient safety at risk.
医护人员（HCW）的流感疫苗接种率并不高。本文对提高 HCW 疫苗接种率的主要选择进行了详细的伦理分析，比较了主要伦理理论如何解决这些选择。提高接种率的主要干预措施类别包括教育、激励、便捷途径、与奖励竞争、评估和反馈、拒绝接种、带有替代感染控制措施的授权令、以及带有行政行动作为后果的授权令。除了授权令之外，上述干预措施几乎没有引起伦理争议。然而，这些努力需要耗费大量的时间和精力，而且很少能将接种率提高到 70%以上。对于授权令，主要关注的问题是自主权的丧失、不公正、缺乏正当程序以及为了机构目的而牺牲个人。授权令的支持者认为，它们基于善行、不伤害和义务是合乎道德的。许多专业协会支持授权令。可以类比地将 HCW 接种疫苗预防其他疾病的授权令进行论证。在分析中使用的伦理系统包括进化伦理学、功利主义、原则论（自主性、善行、不伤害和公正）、康德主义和利他主义。在这些系统中，最常被选择的选项是便捷途径、评估和反馈、拒绝接种以及带有感染控制措施作为不遵守规定的后果的授权令。考虑到不伤害和行善的伦理要求、低强度干预措施的有限成功，以及将患者安全置于 HCW 便利性之前的必要性，带有额外感染控制措施作为不遵守规定的后果的授权令是首选。对于那些因良心问题而选择不接种疫苗的人，这样的授权令为他们提供了一种既能继续工作又不会使患者安全受到威胁的方式。
