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By Leo Lam and Taylor Nichols.
The COVID-19 pandemic has greatly disrupted the operation of our society. To cope with a novel virus to which humans had no immunity, public health authorities took a multitude of actions such as lockdowns, mandates on non-pharmaceutical interventions such as masks, and later on vaccines in specific circumstances to protect the population. Naturally, whenever mandatory actions are enforced, ethical questions regarding liberty and the question of choice arise and the answers are not always clear.
One way to help guide us through such an ethical dilemma is to perform a risk and benefit analysis on the individuals and the community affected by these actions. This is also not a simple task as some risks/benefits may be superficially qualitative and as such, quantitative comparisons must be formulated carefully to avoid bias and therefore skewing the outcome of the analysis. Ethical positions must be informed by scientifically justifiable facts, not cherry-picked values that support preconceived notions.
In another word, the risk profiles for the risk and benefit must be closely matched for the analysis to be fair, defensible, and scientifically justifiable. Without this consideration, merely comparing numbers may create an illusion that sways the argument one way or the other, while the actions that optimally benefit society and individuals languish in the noise.
Vaccine mandates, especially those that apply to college campuses, have been a point of contention among experts and general society because the risk and benefit analysis is not as clear cut for the college-aged population as, for example, those who are over 65. The college-aged group does not get as sick when infected, and the death rate is lower. Yet regardless of age, some risks do exist and such risks must be carefully balanced against the perceived lowering benefit as we progress down the age groups.
To perform a robust analysis for this younger age group, details matter when it comes to examining the risk profiles. On the benefit side for this age group in decreasing severity, vaccines reduce the number of deaths, reduce the number of cases of severe diseases that require resource-intensive hospitalizations, reduce the overall number of cases, and lower the chance of Long COVID even for mild cases. Each one of these benefits reflects different levels of resource consumption for treatments and individual suffering with long-term and short-term implications. It is also clear that there are public health benefits that affect other age groups when this group is vaccinated. On the negative side, receiving the vaccines comes with risks such as Severe Adverse Events (SAEs), reactogenicity, and myocarditis, especially for the males in the group. Each one of these risks also requires the consumption of resources to treat and represent varying levels of personal suffering.
For example, using the number of cases to quantify the risk of SAEs seems straightforward, but the severity of such SAEs would determine which benefits should be compared. The SAEs reported in the Pfizer vaccine trial were “moderate persistent tachycardia, moderate transient elevated hepatic enzymes, and mild elevated hepatic enzymes” all of which were reported to be transient, self-resolved events that did not require hospitalization in the trial. It would be, therefore, inappropriate to compare this low level of severity to death or even to hospitalized cases of COVID given the differential in treatment resources and suffering. While still imperfect, it would be more reasonable to compare it to the number of COVID cases prevented. There is a spectrum of severity in COVID cases, some resources are still needed to treat on average, and with Long COVID being a non-insignificant possible outcome, the risk profile of a COVID case is still higher than the reported SAEs. Here, the precautionary principle applies, and erring on underestimating the benefits is not unreasonable to prevent harm.
Our paper that examines the ethics of college vaccine mandates uses the same process to identify the correct comparison pairs for SAEs, reactogenicity, and the chance of myocarditis. It can be demonstrated that the resources saved via vaccine mandates far exceed the resources needed to treat the risks and that the population in that age group benefits from vaccination far more than the risk they are exposed to from vaccination when risk profiles on both sides are carefully balanced. Attending college is also a privilege, not a right. We concluded that the vaccine mandates carry more benefits than risks on both an individual level and on a societal scale on quantifiable grounds. And thus, college mandates are ethical.
Paper title: The ethics of college vaccine mandates, using reasonable comparisons
Authors: Leo Lam, Taylor Nichols
Affiliations: University of Washington, University of San Francisco
Competing interests: None
Social media accounts of post authors: @SeattleiteLeo @tnicholsmd
The post College vaccine mandates benefitted students and society appeared first on Journal of Medical Ethics blog.
By Karel-Bart Celie.
In a recent issue of JAMA, Ahmed et al. published data on healthcare unionization in the United States between 2009 and 2021. Despite the observed association between unionization and higher wages, better benefits, and more equitable compensation, unionization among healthcare workers has evidently remained low. Richman and Schulman (R&S) wrote a commentary focused specifically on unionization by physicians. They argued that physician unionization helps (1) restore some governance of healthcare systems and (2) provide a mechanism by which to deploy professional ethics in the service of patient welfare.
To the first point, more than half of all U.S. physicians are now employed by hospitals or other health systems. This shift in the landscape has resulted in a decrease in “professional sovereignty” threatening the loss of professional independence—something unionization might help prevent. Regarding the second point, leaders of large health systems have at best a divided loyalty; they are obligated to prioritize the fiscal concerns of their institutions. For example, one way to maximize profits is to minimize staffing despite a burned-out workforce and evidence that such practices can lead to worse outcomes. Physicians, on the other hand, have less of a commitment to the financial bottom line of the institution. And in any case, deeply-ingrained professional ethics serve as a corrective that “counters market incentives.” Unionization provides physicians with a “means to exert influence” on large health systems, in a manner that reflects the profession’s dedication to patient welfare.
I agree with these points and would like to submit two additional observations.
First, the age-old call to “at least do no harm” cited by R&S, which appears in Book I of the Epidemics, is often interpreted in relation to patient care. However, there is also a contextual argument for a similar duty to colleagues in the Hippocratic corpus. The Hippocratic Oath devotes a sizeable second paragraph to describing the respect and care with which one should treat one’s teachers and pupils. This paragraph accounts for nearly a third of the total text, and exhorts its reader to regard both teachers and pupils as family. It serves to remind us that our duties are not only to patients, but to each other as well. This is an aspect that is under-emphasized, to the detriment of a profession that is so inexorably collegial. How we consult with physicians from other specialties, with nurses and other allied staff, and with those who are learning from and teaching us, all have an impact on “the profession” and how its values are applied. The doctor-patient relationship—recipient of much attention—exists only in the context of physicians who constantly learn from, teach, and interact with each other.
The communal aspect of our professional ethics is obliquely understood, for example, when reporting unprofessional conduct. However, we do not have to stop at the negative. Physicians are accountable to each other in a positive sense also. Unionization is one way of giving this positive, intra-professional obligation a voice. It does so by promoting an environment of mutual support, collegiality, and legitimate concern for the wellbeing of members of the profession.
Second, housestaff unionization merits special attention at a time when burnout and depression remain prevalent among trainees in medicine. Unions help ensure fair wages and benefits; at my institution, wages for first-year doctors have risen by 15% since 2020. The accrediting body for graduate medical education (the ACGME) in the U.S. has increased initiatives to improve wellness in graduate medical education since 2017. However, it wields its punitive power over residency programs which are often themselves under pressure of the demands put upon it by institutions. Residents and their teaching faculty are often together in the proverbial “trenches.” Complaints to the ACGME are therefore challenging and often last-resort options for help, since everyone knows that doing so may simply shift the burden to another demographic (e.g., by removing trainees from a rotation, the same patient volume falls on the remaining faculty). Take for example the rule—a definite step in the right direction—that trainees are to work no more than 80 hours per week (caveat: averaged over 4 weeks!). Environments with low levels of staffing and high patient volumes virtually guarantee unacceptably high housestaff work hours. How could it not, especially where patient care is prioritized? Unions by contrast are more capable of addressing root causes, such as low levels of staffing, by directly confronting institutional stakeholders without necessarily compromising patient care. They also have the potential to spur legislation which holds institutions accountable for the treatment of their staff.
It is also important to note that housestaff unions can have a direct impact on improved patient care. The Patient Care Fund (PCF) was established by the Committee for Interns and Residents (CIR) in Los Angeles County in 1975 as a funding mechanism for trainee-driven improvements in patient care equipment. Since then, similar funds have been established by CIR across the country. In the last three years, housestaff from my own division have acquired a combined pulsed dye laser (PDL) and neodymium yttrium aluminum garnet (Nd:YAG) laser for burn reconstruction, as well as a new microscope for free flap reconstruction and digital replantation. All together this equipment represents nearly $300,000 invested in patient care at one of the busiest county hospitals in the country.
In summary, unionization by physicians in the U.S. provides a mechanism for us to apply our professional ethics, and thereby honor our (underemphasized) duties to each other. As a surgical trainee, I have also found that unions hold the potential to provide a more direct path to housestaff wellness than those currently afforded by educational organizations. For these reasons physician unionization merits continued support, despite the low rates reported by Ahmed et al.
Author: Karel-Bart Celie
Affiliations:
Competing Interests: None declared
Social media accounts of post author: Instagram @celie.md
The post Housestaff unionization in the United States and our duties to each other appeared first on Journal of Medical Ethics blog.
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