January 22, 2003 -- The ethics of co-operating with the smallpox vaccination


This is from today's NY Times Ethics column (1-22-03).

On the Vaccine Scene

January 19, 2003 By RANDY COHEN

As an infectious-disease specialist, I will be called on to be vaccinated
early to counter any terrorist smallpox attack. I believe the chances of
this are vanishingly small and that the policy is primarily an effort to
spread fear and build support for a war with Iraq. If I am vaccinated, I
will be complicit with a policy I morally oppose and unnecessarily endanger
my own health. (The vaccine is one of the most dangerous available.) Yet I
feel dutybound to be available to those suffering adverse effects from the
vaccine. Should I be vaccinated? Hal Martin, M.D., M.P.H., Minneapolis

While your decision has political implications, it is above all a medical
matter. You are not being asked to endorse the president's Iraq policy but
to decide if vaccination is called for in your circumstances. Believing as
you do that there is no medical necessity, you have no ethical obligation to
be vaccinated simply because the president urges it.

As a doctor, you can judge the risks of vaccination. As a citizen of a
democracy, you must decide if the president has made a persuasive case that
a smallpox attack is likely enough to justify that risk. If you and your
colleagues overwhelmingly reject the president's call, this may indeed be
interpreted as a rebuff of his policy, but that should be a byproduct of
your decision, not your reason for making it.

Right now, you must weigh your duty to your fellow health-care workers, only
a small percentage of whom are expected to become ill from the vaccine. This
means that the vast majority of those health-care workers who choose to be
vaccinated will be available to attend that ailing few -- a self-selecting,
self-treating group -- and thus your participation is not essential.

You would face a tougher choice if the president called for the vaccination
of the general population. You might feel an obligation to your longtime
patients to be available to treat those affected by the vaccine. This would
mean either being vaccinated yourself or remaining unvaccinated and
accepting the hazard of exposure as a matter of conscience.

And if you are wrong and there is a smallpox attack? That would be
horrific. But you cannot escape the burden of choice by simply following
orders.

There is another aspect of this question that concerns not only physicians
but all Americans. Financing an expensive smallpox vaccination program
necessarily means neglecting many pressing medical problems, both here and
abroad. In our era of tight budgets, deciding how to allocate health-care
resources is a question with both moral and political dimensions.

Send your queries to ethicist@nytimes.com or The Ethicist, The New York
Times Magazine, 229 West 43rd Street, New York, N.Y. 10036, and include a
daytime phone number.