Ethical considerations in the uptake of influenza vaccination by healthcare workers.

OBJECTIVES: The World Health Organization (WHO) recommends annual seasonal influenza vaccination of healthcare workers (HCWs). Under the current voluntary scheme in England, uptake of vaccine in this group remains well below the 75% target. A mandatory scheme may improve rates, but raises the ethical issue of imposed vaccination. However, the existing voluntary scheme could also potentially infringe autonomy if those not wanting to join feel pressured or coerced into vaccination. The aim of this study was to explore HCW views and experiences with the current influenza vaccination programme. STUDY DESIGN: Questionnaire survey. METHODS: Between March 2015 and April 2016, a total of 140 questionnaires were completed across seven HCW groups, with the demographic, vaccination and opinion data statistically analysed using the chi-squared test, Kruskal-Wallis test and Mann-Whitney U-test as appropriate. RESULTS: No staff group met the national influenza vaccination target of 75% and vaccination rates varied between HCW groups. All groups reported some degree of external pressure to be vaccinated and there were mixed views on the concept of mandatory vaccination, with a lack of certainty over the vaccine's efficacy and/or a lack of information the most common reasons for not supporting it. CONCLUSION: The current voluntary influenza vaccination scheme has a number of flaws. Improvements in the quality and availability of information provided to employees may help Trusts increase vaccination rates, or achieve acceptance of any proposed mandatory programme.

Arguments in favour of compulsory treatment of opioid dependence.

Twelve agencies of the United Nations, including the World Health Organization, have issued a joint statement that calls on Member States to replace the compulsory detention of people who use opioids in treatment centres with voluntary, evidence-informed and rights-based health and social services. The arguments in favour of this position fall into three broad categories: Compulsory treatment centres infringe on an individual's liberty, they put human beings at risk of harm, and evidence of their effectiveness against opioid dependence has not been generated. The United Nations statement underscores that although countries apply different criteria for sending individuals to compulsory treatment centres, detention often takes place without due process, legal safeguards or judicial review. This clearly violates internationally recognized human rights standards. Furthermore, people who are committed to these centres are often exposed to physical and sexual violence, forced labour and sub-standard living conditions. They are often denied health care, despite their heightened vulnerability to HIV infection and tuberculosis. Finally, there is no evidence, according to the statement, that these centres offer an environment that is conducive to recovery from opioid dependence or to the rehabilitation of commercial sex workers or of children who have suffered sexual exploitation, abuse or lack of care and protection. The author of this paper sets forth several arguments that counter the position taken by the United Nations and argues in favour of compulsory treatment within a broader harm reduction strategy aimed at protecting society as well as the individual concerned.

Douze agences des Nations Unies, parmi elles l'Organisation mondiale de la Santé, ont émis une déclaration commune qui appelle les États membres à remplacer la détention obligatoire des consommateurs d'opioïdes dans des centres de traitement par des services sanitaires et sociaux volontaires qui s'appuient sur des données probantes et soient fondés sur le droit. Les arguments en faveur de cette position se répartissent en trois grandes catégories: les centres de traitement obligatoire empiètent sur la liberté de l'individu, ils exposent les êtres humains à des risques et la preuve de leur efficacité contre la dépendance aux opioïdes n'a pas été démontrée. La déclaration des Nations Unies souligne que même si les pays appliquent des critères différents pour l'envoi des individus dans des centres de traitement obligatoire, leur détention survient souvent sans procédure régulière, protection légale ou contrôle juridictionnel. Cet état de fait contrevient clairement aux normes des droits de l'homme reconnues au niveau international. En outre, les personnes remises à ces centres sont souvent exposées à des sévices physiques et sexuels, à du travail forcé et à des conditions de vie inférieures aux normes. Ils se voient souvent refuser des soins de santé en dépit de leur vulnérabilité accrue à l'infection par le VIH et à la tuberculose. Enfin, il n'y a aucune preuve, selon cette déclaration, que ces centres offrent un climat propice à la récupération de la dépendance aux opioïdes ou à la réinsertion des professionnels du sexe ou des enfants victimes d'exploitation sexuelle, de maltraitance ou de manque de soins et de protection.L'auteur de ce document de travail avance plusieurs arguments contraires à la position adoptée par les Nations Unies et milite en faveur d'un traitement obligatoire participant d'une stratégie élargie de réduction des risques visant à protéger la société, mais aussi l'individu concerné.

Doce agencias de las Naciones Unidas, entre ellas la Organización Mundial de la Salud, han emitido una declaración conjunta que insta a los Estados miembros a reemplazar la retención obligatoria en centros de tratamiento de personas que hacen uso de opiáceos por servicios sociales y sanitarios voluntarios, basados en pruebas científicas y en sus derechos. Los argumentos a favor de esta postura se clasifican en tres amplias categorías: Los centros de tratamiento obligatorio atentan contra la libertad individual, ponen a las personas en riesgo y no existen pruebas de su eficacia contra la dependencia de opiáceos. La declaración de las Naciones Unidas enfatiza que, aunque cada país aplica criterios distintos a la hora de enviar a los individuos a los centros de tratamiento obligatorio, es frecuente que la retención se lleve a cabo sin el debido proceso, la seguridad jurídica ni el examen judicial correspondiente, lo que viola claramente las normas de los derechos humanos reconocidas a nivel internacional. Además, las personas internadas en dichos centros se ven expuestas, con frecuencia, a violencia física o sexual, trabajos forzados y condiciones precarias de vida, y es frecuente que se les niegue la atención sanitaria a pesar de ser más vulnerables a la infección por VIH y a la tuberculosis. Por último, no hay ninguna evidencia, de acuerdo con la declaración, de que dichos centros ofrezcan un ambiente propicio para la recuperación de la dependencia a los opiáceos o para la rehabilitación de trabajadores sexuales o de niños que han sufrido explotación sexual, abusos o falta de cuidado y atención.El autor del presente artículo describe numerosos argumentos que rebaten la posición adoptada por las Naciones Unidas a favor de un tratamiento obligatorio en el ámbito de una estrategia más amplia enfocada a la reducción del daño y cuyo objetivo es proteger tanto a la sociedad como al individuo afectado.

Opt-out HIV testing: an ethical analysis of women's reproductive rights.

As the HIV epidemic continues to grow worldwide, women are increasingly and disproportionally affected. With the introduction of anti-retroviral medications that have been found to effectively prevent perinatal transmission of HIV, the approach to HIV testing in pregnant women has grown increasingly more controversial. In recent years, the model of voluntary counseling and testing (VCT) has come into question with opt-out testing now advocated for by the Centers for Disease Control and occurring widely in pregnancy. The benefits of opt-out testing are numerous and may justify its use in replacing the VCT that many have come to see as insufficient. An ethical analysis of opt-out testing suggests it may be at odds with true informed consent and involve a degree of coercion that would not be allowed outside the prenatal setting. If opt-out testing is going to remain the standard of care then the ethical issues it raises must be made transparent. Strategies need to be designed for ensuring that HIV counseling and testing in pregnancy is done in accordance with ethical and reproductive rights principles.

The cultural moral right to a basic minimum of accessible health care.

(1) The conception of a cultural moral right is useful in capturing the social-moral realities that underlie debate about universal health care. In asserting such rights, individuals make claims above and beyond their legal rights, but those claims are based on the society's existing commitments and moral culture. In the United States such a right to accessible basic health care is generated by various empirical social facts, primarily the conjunction of the legal requirement of access to emergency care with widely held principles about unfair free riding and just sharing of costs between well and ill. The right can get expressed in social policy through either single-payer or mandated insurance. (2) The same elements that generate this right provide modest assistance in determining its content, the structure and scope of a basic minimum of care. They justify limits on patient cost sharing, require comparative effectiveness, and make cost considerations relevant. They shed light on the status of expensive, marginally life extending, last-chance therapies, as well as life support for PVS patients. They are of less assistance in settling contentious debates about screening for breast and prostate cancer and treatments for infertility and erectile dysfunction, but even there they establish a useful framework for discussion. Scarcity of resources need not be a leading conceptual consideration in discerning a basic minimum. More important are the societal elements that generate the cultural moral right to a basic minimum.

From compulsory to voluntary immunisation: Italy's National Vaccination Plan (2005-7) and the ethical and organisational challenges facing public health policy-makers across Europe.

Increasing geographical mobility and international travel augment the ease and speed by which infectious diseases can spread across large distances. It is therefore incumbent upon each state to ensure that immunisation programmes are effective and that herd immunity is achieved. Across Europe, a range of immunisation policies exist: compulsion, the offer of financial incentives to parents or healthcare professionals, social and professional pressure, or simply the dissemination of clear information and advice. Until recently, immunisation against particular communicable diseases was compulsory in Italy. The Italian National Vaccination Plan (NVP) (2005-7) paved the way for regions to suspend the sanctions associated with compulsory vaccinations for children when certain criteria are met--for example when immunisation coverage is high and when effective monitoring/surveillance systems are in place--and thus marked a milestone in the move from compulsory to voluntary immunisation. The forthcoming NVP for 2008-10 confirms the liberal approach to vaccination in Italy as it entrusts to the regions responsibility for the achievement and maintenance of herd immunity. This paper reviews the arguments for and against compulsory and voluntary immunisation in relation to the Italian NVP (2005-7) and in the context of the diverse immunisation policies that exist across Europe. It concludes with cautious support for the NVP and an associated shift from compulsory to voluntary immunisation in Italy, and draws similarities between issues concerning regional variation in immunisation policy in Italy and national variation in immunisation policy across Europe and beyond.

Hey Buddy can you spare a DNA? New surveillance technologies and the growth of mandatory volunteerism in collecting personal information.

The new social surveillance can be defined as scrutiny through the use of technical means to extract or create personal or group data, whether from individuals or contexts. Examples include: video cameras; computer matching, profiling and data mining; work, computer and electronic location monitoring; biometrics; DNA analysis; drug tests; brain scans for lie detection; various forms of imaging to reveal what is behind walls and enclosures. There are two problems with the new surveillance technologies. One is that they don't work and the other is that they work too well. If the first, they fail to prevent disasters, bring miscarriages of justice, and waste resources. If the second, they can further inequality and invidious social categorization; they chill liberty. These twin threats are part of the enduring paradox of democratic government that must be strong enough to maintain reasonable order, but not so strong as to become undemocratic.

Ethical considerations in testing workers for the -Glu69 marker of genetic susceptibility to chronic beryllium disease.

OBJECTIVE: The most compelling real-world example of genetic testing for susceptibility to a workplace exposure involves those industries that process or fabricate beryllium. We examined ethical issues associated with testing for susceptibility to chronic beryllium disease. METHODS: Using ethical and clinical criteria, we examined voluntary employer-sponsored testing programs in which individual results are reported directly to workers in a confidential manner. RESULTS: Under reasonable assumptions, the longitudinal positive predictive value of the HLA-DPB1-Glu69 marker of susceptibility to beryllium disease is 12%. Interpretive challenges further limit the utility of the test and may inadvertently suggest a false sense of safety among workers. Concerns about confidential participation and pressures to be tested also must be addressed. CONCLUSIONS: Difficulties surrounding the interpretation of the HLA-DPB1-Glu69 marker, lack of assurance regarding the protection of worker confidentiality, and the potential lowering of social barriers to the implementation of mandatory worker screening combine to make testing beryllium workers inappropriate at this time.

Ethical principles for collective immunisation programmes.

Ethical issues arise in discussion of both the content and implementation of collective immunisation programmes. In this paper we propose and discuss seven principles that may guide reflection and debate in this controversial area. Whilst this paper is not intended to be a final and complete account of the relevant principles for collective immunisation programmes we hope that it can help stimulate more active discussion of these issues. Debate about these principles may help to make moral conflicts more explicit and open up the possibility of resolution. We argue that analysis and discussion of the ethical issues should be part of any justification of collective vaccination programmes.

Outpatient commitment: a therapeutic jurisprudence analysis.

This article analyzes the legal and therapeutic jurisprudence considerations raised by outpatient commitment. Although older forms of outpatient commitment have both legal and therapeutic advantages, preventive outpatient commitment raises serious legal problems and potential antitherapeutic consequences that may outweigh its claimed therapeutic value. As a result, alternatives are proposed, including wider availability of community treatment and outreach and case management services, assertive community treatment, police and mental health court diversion programs, and creative uses of advanced directive instruments and behavioral contracting. Proposals also are made for how preventive outpatient commitment can be applied more therapeutically, including hearings that accord patients a sense of procedural justice and techniques designed to motivate individuals facing such hearings to agree to accept treatment voluntarily.