In responding to the “Letter to the Editor” from Dr. Wolfgang Lederer we will not
reargue the ethics of the COVID vaccine mandate in healthcare professionals. We believe
we were very explicit in our paper “An Ethical Analysis of the Arguments Both for
and Against COVID-19 Vaccine Mandates for Healthcare Workers”. We made it clear that
we were not debating CDC guidelines, FDA approval processes, or politics that dominated
and continue to dominate discussions on the mandate. However, we will now seek to
further examine the ethical arguments between individual rights and social responsibilities.
Modern just societies, which we will define as societies that respect the rights of
individuals and ensure basic liberties to all members of its society must balance
the needs of individuals in the protection of a “public good”. This battle of individual
rights versus doing the best for society remains an ongoing struggle since the birth
of democracies. Long before philosopher Jeremy Bentham brought the concept of utility
to the forefront of intellectual debate in the 1780’s, the ancient Greek philosophers
Aristotle, Plato, and Socrates were deliberating such concepts.1
In the case of healthcare, we accept the importance of individuals’ freedoms and rights
to choose or decline services, and reference that this has been largely found and
upheld from the 14th Amendment's Due Process Clause in the United States Constitution.
The requirement to obtain informed consent from a patient is codified in American
law as far back as 1852.2 However, it has also been determined, as far back as 1905
in Jacobson v Massachusetts, that society (via the “state”) must protect the health
of all, over the individual liberties of some.3 Although we take great pride in our
individual freedoms in the US and other modern democracies, we oftentimes forget that
no right is absolute. This is both just and appropriate ethically because society
would fall into chaos if every individual's rights were separately held as de facto
and supreme. Healthcare is no exception, especially as it concerns its practitioners
and their fiduciary duties to society.
Public health laws are similarly balanced to generally respect the rights of individuals
while ensuring the overall health and well-being of society at large is maintained.
Generally speaking, individuals have the right to refuse all manners and degrees of
care for themselves only if there is minimal impact to the wellbeing of society.4
Additionally, most bioethicists and appellate courts have upheld public health laws
over individual liberties to impose restrictions on individuals in the cases of certain
infectious diseases that have the potential to harm other members of society.5 Examples
include infectious tuberculosis, cholera, smallpox, yellow fever, and many more.6
So what are social responsibilities? There is probably no single correct or accepted
answer, as individuals, industries, cultures, and periods in history seem to define
it differently. Our definition is the responsibilities or obligations an individual
has to their community. However, we strongly believe it is intrinsically tied with
the rules of social engagement. It involves the unwritten and written contracts we
all are under when born in a civilized society. Social responsibility is built into
the rules that govern how we behave around others. It is the lining up or waiting
your turn in line, and not just pushing others in front of you out of the way because
you feel your individual rights and desires trump others. In yester year, we called
this part of one's “civic duty”.
As physicians and officers in the US Army, all three of us believe strongly in service
for others’ benefit many times over duties to the self. At times, and commonly seen
during military service, when one signs up to put on the uniform, one's conduct and
expectations may differ from those who do not elect to wear the uniform. We must consider
the interests of others more so when we agree to wear the uniform, even if it may
conflict with our own personally held views. This is our social responsibility.
Drs Urdaneta and Giwa have written on this topic, and in fact crafted the American
Academy of Emergency Medicine's (AAEM) Principles of Ethics based around certain professional
responsibilities when physicians’ put on their “uniforms”. Social responsibility calls
for holding the interests of those around you, and especially the patients you serve,
in higher regard than your own. Interestingly, many leadership scholars are utilizing
this philosophy and calling it “Servant Leadership” and have found great success in
leading multicultural and multigenerational workforces.7
How do we resolve the seeming conflict between individual rights and social responsibility?
A better question to pose may be do you as an individual believe in a need for social
responsibility? If so, then the discussion can be channeled to what degree are you
willing to sacrifice your individual rights vs your obligations to being socially
responsible. If you do not believe in social responsibility, despite living in a world
built around the premise that harmony amongst individuals can only be achieved if
there is order, rules, and a respect for the rights of others, then you will live
a life in constant conflict with other members of society, and further discussion
is a moot point. As Drs Urdaneta and Giwa wrote, our oaths as physicians compel us
to uphold fiduciary duties as enshrined in our roles as physicians. This duty comes
even in the face of potential harm to our individual rights.
This normative ethic may seem more of a cry from the days of the “Great War” and a
society all united in response to an external threat. However, in several polls on
society's expectations of physicians, even when faced with potential danger to the
physician, the respondents overwhelmingly believed physicians should put their lives
on the line to save a patient's life.8 So while we may be immersed in a social media
world claiming “it's all about me”, society still maintains old world views on its
expectations of physicians. Notwithstanding, most medical schools still require all
entrants or graduates to recite an oath, which generally speaking, vows to uphold
a patient's interests over their own.9 So if society expects it, and our own training
ensures we swear an oath to uphold it, how can a physician argue against social responsibility
to their own patients?
So we conclude and restate our acknowledgement of individual rights, but stress that
as physicians, we must maintain the interests of society above our own and uphold
social responsibility when there are clear cut cases of a need to protect the public
health over individual objections not based on clear-cut science. Again, we limited
our arguments to only physicians because they are explicitly held to oaths and societal
obligations to protect society and put their personal beliefs aside for the sake of
patients.
The views expressed herein are those of the authors and do not reflect the official
policy or position of Brooke Army Medical Center, the U.S. Army Medical Department,
the U.S. Army Office of the Surgeon General, the Department of the Army, the Department
of the Air Force, the Department of Defense, or the U.S. Government.
References
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Kelly PJ. Utilitarianism and distributive justice: Jeremy Bentham and the Civil Law.
1990;
2
Kapp MB. Patient autonomy in the age of consumer-driven health care: informed consent
and informed choice. J Health & Biomedical L. 2006;2:1.
3
Farber D. The Long Shadow of Jacobson v. Massachusetts: Public Health, Fundamental
Rights, and the Courts. San Diego L Rev. 2020;57:833.
4
Jones MM, Bayer R. Paternalism & its discontents: motorcycle helmet laws, libertarian
values, and public health. American Journal of Public Health. 2007;97(2):208-217.
5
Cole JP, Swendiman KS. Mandatory Vaccinations: Precedent and current laws. Congressional
Research Service, the Library of Congress; 2014:
6
Legal Authorities for Isolation and Quarantine | Quarantine | CDC. Published July
20, 2022. Accessed February 27, 2023. https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html
7
Parris DL, Peachey JW. A systematic literature review of servant leadership theory
in organizational contexts. Journal of business ethics. 2013;113:377-393.
8
Jacobs LM, Burns KJ. The Hartford consensus: survey of the public and healthcare professionals
on active shooter events in hospitals. Journal of the American College of Surgeons.
2017;225(3):435-442.
9
Askitopoulou H, Vgontzas AN. The relevance of the Hippocratic Oath to the ethical
and moral values of contemporary medicine. Part II: interpretation of the Hippocratic
Oath—today's perspective. European spine journal. 2018;27:1491-1500.