ACOG Answers Ethical Questions Regarding Vaccination
Two newly released Committee Opinions issued by the Committee on Ethics of the American College of Obstetricians and Gynecologists (ACOG) address the ethical responsibility of obstetricians and gynecologists (ob-gyns) regarding vaccinations.1,2
Spurred by "the growing importance of infectious disease prevention in the individual patient and the larger community," the goal of the committee was for ob-gyns to "be prepared to navigate the practical and ethical challenges that come with vaccination."1
- ACOG Fellows should "recognize that they have responsibilities to both the individual patient and the general population."
- Physicians should be "knowledgeable about current standards of practice regarding vaccines, including their indications, benefits, and risks."
- Patient counseling should be conducted in an "evidence-based manner that allows patients to make an informed decision about the use of these agents in their health care."
- It should be emphasized to patients that "no evidence exists of risk to the fetus from vaccinating pregnant women with noninfectious virus or bacterial vaccines, or toxoids."3 A separate Committee Opinion2 focuses specifically on the tetanus, diphtheria, and pertussis vaccination (Tdap), noting that infants do not begin their own vaccine series against diphtheria and pertussis until two months of age, but the majority of morbidity and mortality attributable to pertussis occurs in infants three months of age or younger.4,5 Current recommendations of the CDC's Advisory Committee on Immunization Practices (ACIP) call for pregnant women to receive a dose of Tdap during each pregnancy, irrespective to the patient's prior history of receiving Tdap. Optimal timing is between 27 weeks and 36 weeks of gestation, although it can be administered at any time during pregnancy.6,7
- The vaccination of adolescents "poses unique ethical challenges . . . related to privacy, confidentiality, and informed consent."8 Fellows should "respect the importance of protecting the adolescents' access to reproductive health care services, including HPV vaccination, while adhering to local and national professional norms and applicable legal requirements."
- College Fellows are ethically obligated to "follow recommendations for vaccines themselves . . . any perceived burdens or potential risks to clinicians themselves from vaccination do not supersede their responsibility to limit the spread of potentially harmful infectious diseases."
- In the event of a vaccination shortage, health care professionals should "understand and comply with guidelines and recommendations regarding vaccination administration promulgated by local or regional healthcare jurisdictions." They note that College Fellows should be "willing to provide professional expert advice to local public health jurisdictions in determining allocation and distribution guidelines."
Barriers to Vaccination
The authors note that some ob-gyns are concerned about potential liability in administering vaccinations to pregnant women.9 Additional barriers to vaccination concern limited time and resources, the cost and infrastructure needed to stock and administer specific vaccines, and the lack of sufficient insurance reimbursement.9,10 The Committee Opinion advises ob-gyns facing these obstacles to provide patients with information about alternative sources for vaccination, such as state or local health department clinics.
Vaccination administration must be preceded by informed consent, including the indications, risks, and benefits of the vaccine and available alternatives, as well as possible consequences from non-vaccination.2 In the case of pregnant women, the "benefits, risks, and uncertainties" should be discussed. For example, recent reports indicate that the influenza immunization of pregnant women is highly effective in reducing hospitalization rates due to influenza-like illness of their infants for up to six months of age.11,12
Health care providers should respect the "informed refusal" of vaccinations in patients with conflicting personal or cultural beliefs or concerns about vaccine safety. Patients should be informed about the implications of this refusal not only for themselves, but for household members as well as the population at large. In this event, patients should be educated in monitoring and managing symptoms at home and behavioral approaches to reduce risk associated with infection and transmission.
Vaccinations of Health Care Professionals
The Committee strongly urges ob-gyns to "avoid personal contribution to the spread of disease" by obtaining vaccinations themselves. This "ethical imperative" allows more health care professionals to be available to patients during a pandemic, and also "sends an important message to patients about the benefits of vaccination." "Recognized exceptions" for physicians include medical contraindications and conscientious objections to vaccinations."