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To hospital administration,

I am writing this letter to inform you that when I take my mandated influenza vaccine I will be doing so under protest and with the understanding that failure to do so could result in loss of my ability to earn income for myself and my family. Unfortunately, I do not qualify for any of the exemptions allowed by our facility. Since I am not religious, I have no religious objections, I am not allergic, and I have never had Guillane-Barre as a result of a flu vaccine. My objection to the vaccine is based on rational evidence and moral indignation.

From the standpoint of rational evidence, I was amused that Dr. Eric Kasowski (of the CDC’s influenza division) in his position paper “Healthcare Workers Must Be Vaccinated Against Influenza” cited no research papers. This is very unusual given that this is a document directed at health care professionals. No papers were cited to support this statement because there are no such papers. The gold standard for evidence-based decision making in health care comes from The Cochrane Collaboration. This group of experts makes recommendations on all aspects of medicine and science based on a pooling of the best research studies and with a strict avoidance of all commercial or coercive interests.

In their paper titled “Vaccines to prevent influenza in healthy adults” the Cochrane group concluded, “In average conditions 100 people need to be vaccinated to avoid one set of influenza symptoms. Vaccine use did not affect the number of people hospitalized or working days lost but caused one case of Guillane-Barre syndrome for every one million vaccinations. Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration. Our results may be an optimistic estimate because company-sponsored influenza vaccine trials tend to produce results favorable to their products and some of the evidence comes from trials carried out in ideal viral circulation and matching conditions and because the harms evidence base is limited.” This is hardly compelling evidence.

The Cochrane paper, “Influenza vaccination for healthcare workers who work with the elderly,” found “that vaccinating healthcare workers who look after the elderly in long-term care facilities did not show any effect on the specific outcomes of interest, namely laboratory-proven influenza, pneumonia or deaths from pneumonia.” Thus, even in the most high-risk health care population and scenario, there is NO evidence that influenza vaccination protects patients. In fact, vaccination may actually increase risk because the health care provider, feeling that they are protected by the vaccine, may be less likely to carry out the behaviors that do protect patients.

In their paper “Physical interventions to interrupt or reduce the spread of respiratory viruses,” the Cochrane group reviewed 67 studies and found that simple measures such as hand washing, and simple masks were effective in reducing viral (including influenza) transmission. Further , they “found no evidence that the more expensive, irritating and uncomfortable N95 respirators were superior to simple surgical masks.” Thus there is NO evidence that not taking a vaccine poses any risks to patients and thus the requirements to wear an arm band (similar to a Star of David or Scarlet Letter) is exposed for what it really is … a way of shaming non-compliers.

In fact, evidence would suggest that it is the vaccinated that are less likely to carry out the behaviors that do work, and it is perhaps they who should wear the arm band. Furthermore, individuals who are coerced to take a treatment are more likely to experience adverse reactions due to the nocebo effect, which is like a placebo effect but with negative effects. Such nocebo reactions would likely result in more days lost than days lost due to influenza contracted because of a lack of vaccination.

I would now like to address my moral objections to this requirement. Let me preface my statement by saying that if the organization had simply been honest and stated that they were requesting employees be vaccinated because less than 90% compliance would be met by a financial penalty from our government payers at a time when the hospital was already under financial stress, I would have been first in line to get my vaccine. Every day I make personal sacrifices in order to support the financial interests of the hospital in which I work. I continue to work in an ER that is severely understaffed relative to its workload. Every shift I arrange for serial ER visits and rechecks of non-paying patients with pyelonephritis, PID, cellulitis, MRSA abscesses, pneumonia, etc rather than having them admitted where they would cost the hospital even greater lost revenues. This is done at great personal expense (and medico-legal risk) to myself and my group. I say this to demonstrate that I would do almost anything to help the hospital’s bottom line, and I believe that is true of almost anyone in the organization. But rather than banking on this goodwill from the employees and staff, the institution chose to frame this as a patient care issue. Worst of all, it portrayed the providers of healthcare as some sort of danger to the patients that the hospital cares for, as if we were potential vectors of disease should we not comply with this mandate; essentially painting as a threat those that provide care under a real threat of contagion, violence, stress, litigation, government fines and circadian disruption. This was all done with overwhelming evidence to the contrary.

But even if it were true that healthcare workers were transmitting flu to patients and that vaccination could prevent this from happening, forcing a professional to do even that which is beneficial is profoundly immoral. Values can only exist when there is freedom of choice. As philosopher Harry Binswanger recently observed; “You cannot achieve anyone’s good by force, because values are objective. Values only exist if they are judged by the acting party as beneficial to him. No one can be forced to make a rational judgement. The only effect of the force is the destruction of the alleged beneficiary (and everyone else).”

This was probably expressed best by the philosopher Ayn Rand who stated: “A value which one is forced to accept at the price of surrendering one’s mind, is not a value to anyone; the forcibly mindless can neither judge nor choose nor value. An attempt to achieve the good by force is like an attempt to provide a man with a picture gallery at the price of cutting out his eyes.” So even if there were a benefit to be had from flu vaccination, it would be wrong to force us to have it. It is even worse when it is done with evidence to the contrary.

I will therefore submit for flu vaccination on or before November 1, 2012; but please be aware that I am doing so under compulsion and the threat of losing my means of earning a living.

Sincerely,

Doug McGuff, MD,



Doug McGuff is an emergency physician.