Last week’s post ended in high dudgeon at the prospect of hearing professionals violating the Harm Principle by foregoing flu shots. In the meantime, the flu marches on: For the second week in a row, flu deaths exceeded the epidemic threshold; 49.6% of hospital flu admissions were in those 65 and over, 48 states reported the highest category of flu activity (see map — Brown is Bad). As a reminder, 90% of flu deaths are in the 65 and over age group, regardless of strain or year.
Are Audiologists Compelled to “Do No Harm” ?
Sort of, maybe. It’s hard to tell when it comes to flu. Harm language appears in the Codes of Ethics of our membership organizations, almost always cloaked in the limiting framework of professional competence, directing Members to:
- AAA’s PRINCIPLE 2, Rule 2c : “..maintain high standards of professional competence in rendering services. … exercise all reasonable precautions to avoid injury to persons in the delivery of professional services… “
- IHS’s Section 1, Rule j. Safety and Sanitation. The IHS member shall at all times practice accepted standards of infection control and shall exercise reasonable precaution to maximize patient safety.
- ADA’s PRINCIPLE V, Rule 1: “…engage in conduct which shall enhance the status of the profession. … honor their responsibility to the public, their profession and their colleagues.
- ASHA’s Principle I, Rule Q: “… hold paramount the welfare of persons they serve professionally. … Individuals whose professional services are adversely affected by substance abuse or other health-related conditions shall seek professional assistance and, where appropriate, withdraw from the affected areas of practice. ” (bold ital added)
ASHA wins on specificity, IHS comes in second, but there’s ample room to argue over what is meant by “reasonable” “injury” “responsibility” and “adversely affected.” You can see why we need philosophers, attorneys, and public health policy.
There’s no room to quibble about one thing: We lag behind other professions in the Harm department. No Audiology organization is represented on the Honor Roll for Patient Safety–the list of professional health organizations supporting the proposition that:
health care workers have a professional and ethical responsibility to help prevent the spread of infectious pathogens among patients and themselves, and that health care workers should receive annual influenza vaccinations as a condition of employment and professional privileges.
John Stuart Mill – a fun guy
Philosophy of the Harm Principle
Once again, we turn to our old friend John Stuart Mill {{1}}[[1]]Mill, JS. “On Liberty,”1869.[[1]] As noted in a previous post,
“Economics and Ethics join up in the philosophy of Utilitarianism, espoused by famous 19th century Economist and Philosopher John Stuart Mill and encapsulated in this summary statement of his opinion: “Actions are right to the degree that they tend to promote the greatest good for the greatest number.”
Mills’ harm principle says that “the only justification for interfering with the liberty of an individual, against her will, is to prevent harm to others.” Note that “harm” encompasses “credible threats” to economic as well as physical health. Mills’ harm principle underlies arguments for public health policies for infectious disease control:
An important role for public health ethics is to continue to look critically at the role and specific methods of economic and decision theory strategies for establishing priorities and regulatory standards in public health, recognizing that considerations of cost-benefit and efficiency are essential to public health programming and policy.
Implementation of the Harm Principle in Public Policy
Flu vaccination policies and programs are part and parcel of application of the harm principle for the Greater Good.{{2}}[[2]]This section is summarized and paraphrased from Swendiman KS. Mandatory Vaccinations: Precedent and Current Laws. Congressional Research Service (CRS) Report for Congress. February 24 2011.[[2]] Primary responsibility for protecting the public health lies with state and local governments. State laws mandate public school vaccinations for certain diseases, for instance, and there are laws for mandatory vaccination procedure laws in place in times of public health emergencies. The Federal Government gets involved via the Commerce Act because diseases tend to ignore state lines (see map). If the flu ever got to that point, there is no Federally mandated vaccination policy; instead, quarantine procedures go into effect.
A number of states have passed portions of the Model State Emergency Health Powers Act drafted for the CDC by working groups at Georgetown and Johns Hopkins Universities. In times of public health emergencies, such as the one declared 2 weeks ago by the Governor of New York for flu, the Model Act authorizes qualified personnel to vaccinate the populace for protection and control of contagious spread, or quarantine those who forego vaccination “for reasons of health, religion, or conscience.”
Mandatory flu vaccination for healthcare workers is legislated in only a few states; weaker laws exist in other states, usually associated with voluntary influenza immunization programs and employee education for healthcare staff. Laws, when they exist, apply narrowly to definitions of “hospital,” “designated healthcare facility” and the like. The CDC website keeps an updated state database of vaccination requirements. I’m surely no expert but I’m guessing Audiologists in private practice, along with their employees, probably fall through the cracks in those systems.
In my state (Arizona), the question is moot — there are no laws, mandatory or weak. All ye with hearing loss, come see me at your own risk.
Now What?
This 3-part series will conclude next week by looking at private vs public sector efforts to vaccinate and protect, being mindful that we need to protect not only ourselves and our patients, but our professional livelihoods. It’s a perfect blend of Economics and Ethics.
In the meantime, let’s start lobbying our Audiology membership organizations to do two things:
- Task a staff member to identify the relation of “Audiologist” to definitions of healthcare worker in each state, table the data, and update it periodically on the organization’s website. It would be nice to access such information directly rather than parsing individual state licensure and health laws one at a time.
- Get Audiology representation on that Honor Roll for Patient Safety.
I don’t think that’s too much to ask, do you?
