I found an interesting article on the recent measles cases in the U.S. and how whether you get vaccinated or not actually affects people. What do you think?
In The Medical Profession as a Moral Community, Pellegrino discusses the two opposing moral orders that the medical profession faces: their ethical obligations to the sick and their obligation to self-interest and the marketplace. There is no resolution to the two conflicting orders, and those in the medical profession are usually forced to choose one or the other. Today, that is exactly what we see happen in the medical community today. Physicians are often conflicted with their moral obligation to treat, care, and give patients the best possible options and their obligation to their own personal interests. Pellegrino already provides us a couple examples in his essay of how physicians protect their own interests, such as taking part in physician sponsored corporations, unions or strikes or refusing to see poor, Medicare, Medicaid, or AIDS patients (pg. 224).
The American Medical Association (AMA) is one of the largest associations of physicians in the United States. According to the AMA website, its mission is “to promote the art and science of medicine and the betterment of public health.” The AMA website also provides a list of past and current physician ethics that it uses to set standards for medical education. Some examples from the AMA’s 2001 version of Principals of Medical Ethics include:
- “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
- A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
- A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interest of the patient.
- A physician shall support access to medical care for all people.”
As you can see, many of the AMA medical ethics serve to protect the physician as well as the patients. However, I find this set of AMA medical ethics rather ironic. Historically, the AMA has been known to oppose any legislation that does not benefit the physician even though it benefits other people, such as universal healthcare. Many times throughout our history, some form of universal healthcare has been proposed but it has been opposed by the AMA, physicians, and insurance companies. Rather than acting in the interest of patients, physicians and leaders of the AMA have acted in self-interest. This very concerning since the AMA has a lot of influence over physicians and the government. No longer is medicine a moral community, but it is a community that acts in the self-interest.
Pellegrino proposes that American health care system needs moral leadership and medical statesmanship, and I completely agree. Associations, like the AMA, insurance companies, and the government currently have a lot of power over our health care. However, their interests are power and money, which is not what medicine and health care should be about. I have heard stories about physicians go into medical school with a moral obligation to help the sick. However, once they finish, their priorities change. They get trapped into this system created by the AMA, insurance companies, and the government. While they are not morally “bad,” sometimes physicians are forced to refuse patients on Medicare or Medicaid because they need to pay off their medical debts or have an obligation to the hospital. I think if our generation of future physicians is able to stand together as a moral community, change is possible. If everyone is going into the profession with a moral obligation to help the sick, we might have very different leaders serving at these powerful organizations and perhaps medicine can truly be a moral community.
Pellegrino, E. D. “The Medical Profession as a Moral Community.” Bulletin of the New York Academy of Medicine 66.3 (1990): 221-32. NCBI. Web. 20 Apr. 2014
In Arguing for Bioethics, Issacs et al. look at the different arguments for and against compulsory immunization. They come to a conclusion that compulsory immunization is justifiable but state coercion should be kept at a minimum because similar results can be achieved through education and inducements. Australia provides the perfect example as they have achieved over 90% childhood immunization without compulsory immunization. Earlier, I came upon an interesting case in Canada, where there is no compulsory immunization.
According to the Public Health Agency of Canada, “immunization is not compulsory or “forced” in Canada.” Provinces can require children to have certain vaccines before they can enter school. However, parents, or children who are old enough, can choose whether to be immunized or not. If they choose to not be immunized, then the child must stay home from school if there is an outbreak. Recently, there was a case in British Columbia (Canadian province), in which a couple’s 14-year-old daughter was vaccinated without their consent. The girl was pulled out of class by public health nurses and received a vaccine against tenanus, diphtheria, and pertussis without checking her medical history or asking for the parents’ consent. The parents had chosen not to vaccinate their children because they worry that the vaccine might cause an adverse reaction and cause death, which is what happened to their first daughter.
Under the British Columbia Infants Act, parents do not need to sign a consent form for children age 14 or older to be immunized, as long as the doctor or nurse believes the child is mature enough to understand and make a decision. So legally, the nurses technically did not do anything “wrong.” However, I think it becomes an issue when nurses are actively attempting to increase the immunization rates, which is 84% in Canada. While the nurses are required to ask if there are any contradictions to the vaccine, could that be something that they disregard when they are only focused on increasing the numbers? In this particular case, the girl said the nurses didn’t ask about any medical history of an adverse reaction.
Vaccines are important because they can potentially save a lot of lives. Of course, there are people who are against vaccination. While I completely understand the parent’s concern about vaccination, I think they should have taken extra steps to education themselves about the possible adverse reactions from vaccines. The vaccine might have, or might not been the cause of their first daughter’s death. The first daughter was also battling cerebral dysgenesis at the time, so was it the pre-existing condition or the vaccine? As human beings, it’s easier to put the blame on something if there is a negative outcome, even if that one thing might not be the cause of it (Issacs et al.). Furthermore, individuals react differently to vaccines. Just because the older sister reacted to the vaccine does not mean the younger sister will as well. The parents should have taken extra measures (if possible) to see if vaccination will actually harm their younger daughter instead of making assumptions.
The parents are not the only ones who should be attacked for not vaccinating their child and not taking extra measures. Doctors and nurses should look at the issue of vaccines differently. It should not be all about the numbers. Instead, they should take the time to educate and ask patients about their concerns about the vaccine. We can’t just give vaccines to everyone with no concern about how it might affect them. It’s not someone’s fault if his or her body reacts badly to a vaccine. The benefits of vaccines may outweigh the negative outcomes, but they should not be given blindly. We need to make sure it is medically safe before giving vaccines.
While I don’t know the measures that Canada takes to education their people about vaccines, I agree with Issacs et al. that education is very important and should be something that doctors and public health officials should focus on. In the case above, education might have allowed the parents to make a more informed or rational decision about immunization. Simply attempting to force vaccines upon people may not be as effective as educating them about it.
Issacs et al. “Should Routine Childhood Immunizations be compulsory?” Arguing about bioethics. London: Routledge, 2012. 398-406. Print.
The idea of informed consent has evolved over the years along with changes in medical practice. In the past, medical care was based on paternalism, in which the doctor knew what was best for the patient. Now, medical care has become more patient-centered as reflected in the informed consent forms patients sign before medical procedures. According to the article, informed consent is when the physician is required to obtain the patient’s consent after disclosing relevant information about the treatment (Liz et al, 299). However, does that piece of document really represents its definition or does it simply represent the idea of autonomy?
Although physicians are required to disclose relevant information to patients before obtaining their consent, there are also legal standards as to what information must be disclosed. Legal standards also vary by state. For instance, “New York requires only that the practitioner provide information about reasonable foreseeable risks and alternative treatments, while the new Georgia statute requires disclosure of the nature of the treatment, any several specified risks, the likelihood of success, practical alternatives, and prognosis if treatment is declined” (Schuck, 916-917). States have already designated what physicians must disclose to patients. But does that leave the patient with any real autonomy? What if the patient would rather not be provided with the information? Or what if the patient wanted to be disclosed with all material risks?
Health care has increasingly become a legal matter. Health care providers not only have a moral duty to act in the patient’s interest, but also a legal duty. Physicians may find themselves in a court case if he or she did not follow state standards. In Arato v. Avedon, the court considered a claim made by a deceased pancreatic cancer victim’s widow and children that the physician failed to disclose information concerning the statistical life expectancy of pancreatic cancer patients, which violated their duty to obtain his informed consent. They claimed that if the patient had been properly informed of the high probability of early death, he would not have gone through painful therapies and would have avoided economic losses due to failure to put business and financial affairs into order. The court eventually ruled that there was no rule of law that mandated the disclosure of specific information like statistical life expectancy (Schuck, 917-918). This example makes me question how much influence the state has on informed consent. The law doesn’t always determine what is moral and immoral. When people think of informed consent, they usually talk about doctor-patient relationship. I think it’s important to take into consideration what the law says because it greatly affects people’s actions. In the court case discussed above, the court ruled in favor of the physician but does that mean the patient actually received all the relevant information regarding his condition? Maybe yes, maybe no.
The law plays a big part in medical practice. Not only does it tell physicians what they can and cannot do, it can also shape how people view what is considered informed consent. The law exists to protect the people. But is it too influential? Childress states that “the ideal of autonomy must be distinguished from the conditions for autonomous choice” (309). People can choose who or what to yield to when making decisions. But does real autonomy exists when the state can ultimately decide what kind of information patients can receive? Should the state be determining what is regarded as “important and relevant” information or should that be left up to the patients to decide? Can patients make a real autonomous decision when a third-party can influence what information is given?
Childress, James F. “The Place of Autonomy in Bioethics.” Arguing about bioethics. London: Routledge, 2012. 308-316. Print.
Lidz, Charles W., Meisel, Alan, Osterweis, Marian, Holden, Janice L., Marx, John H., Munetz, Mark R. “Barriers to Informed Consent.” Arguing about bioethics. London: Routledge, 2012. 299-307. Print.
Schuck, Peter. “Rethinking Informed Consent.” The Yale Law Journal 103.4(1994): 899-959. Retrieved from: http://www.jstor.org/stable/pdfplus/797066.pdf?acceptTC=true&acceptTC=true&jpdConfirm=true.