Festivus Grievances: Are Mandatory Influenza Vaccination Policies and Banning White Coat Ceremonies Ethically Equivalent?

"Welcome, new comers. The tradition of Festivus begins with the airing of grievances. I got a lot of problems with you people! And now you're gonna hear about it!"  - Frank Costanza

BB8 is for BBE
(Warning: Mild Star Wars spoiler at the end, although I surveyed folks here and no one complained)

Outside my recent posts on influenza vaccine mandates, I have very few infection control grievances to air this year. To start, 2015 saw the return of original science to the annual SHEA spring meeting, a tradition that will continue in the May 2016 meeting chaired by Silvia Munoz-Price and Tom Talbot. And the year ended with NIH planning to spend $461 million in FY 2016 on antimicrobial resistance research, an increase of $100 million over FY 2015. On a personal note, University of Iowa was selected as one of CDC's new Prevention Epicenters. Our team is honored and excited to join the other 5 new centers for the kick-off meeting this January. Thus, things are truly looking up in our fight against antimicrobial resistant bacteria. If we can convince congress, NIH and CDC to continue to gradually increase research funding over the next decade, we should have many things to celebrate in 2025. That is, if we can fix the ID fellowship match and the reimbursement issues that have plagued us the past 10+ years.

...but back to influenza vaccine mandates. Several folks have wondered how we bloggers could support banning white coats and at the same time question influenza vaccine mandates, especially since both interventions have similar levels of evidence (i.e. biological plausibility, math models, observational data, limited RCT data). This is an interesting question. Just to clarify, Mike is against compulsory influenza vaccine policies and I grudgingly support them and neither of us wants to ban white coats - we favor voluntary policies that make it OK not to wear a white coat - which is exactly what Mike instituted at VCU and plans here at Iowa, starting in 2016.

Yet ignoring our policy stances, the assertion that bare below elbow policies are somehow equivalent to vaccine mandates from an ethical standpoint is incorrect. Let's consider the current situation in the US with white coat ceremonies and the pressure that medical students, housestaff and faculty are under to wear white coats. If white coats are harmful (and many would agree that it is equally likely that white coats harm patients as influenza vaccines protects patients), then the current situation would be the ethical equivalent of forcing healthcare workers to not get vaccine.

That is, white coat ceremonies force healthcare workers to cause harm to their patients, which is not morally or ethically the same as requesting healthcare workers to help protect themselves and their patients by receiving an influenza shot. In a Star Wars context, forcing FN-2187 to murder villagers on Jakku (wearing white coats) is not ethically equivalent to requesting that Finn defend the people of Takodana from a First Order attack (influenza vaccine). 

Forcing healthcare workers to wear white coats that they deem to be harmful is wrong. We need to eliminate white coat ceremonies and stop coercing healthcare workers into wearing white coats.


  1. Love that you are promoting conversation on oft-neglected issues. Plus, extra credit for linking Festivus to vaccines and infection control.

    If by "ethical" you mean "valuable," the answer to your question about directionality depends on whether we start from scratch, or from the status quo. Put another way, it depends on whether we consider the directionality of effort required to effect change.

    If we start from scratch, and thus assume nothing of prior behavior or cultural habits, a program that aims to promote a likely beneficial vaccine has the opposite value of a program promoting white coats to (for instance) medical students. One is likely beneficial, one is possibly harmful. I phrase it that way because I believe there is stronger evidence supporting the likely benefit of vaccine mandates given clear evidence that vaccines prevent disease compared to white coats which have not been directly implicated in human-to-human transmission - but the directionality argument holds up nonetheless.

    By contrast, if we examine the question from the point of view of the status quo, and the value of effort expended by any intervention made today to change it, then instituting a mandatory vaccine policy to overcome unacceptably high non-vaccination rates has equivalent value (with the evidentiary caveat above) to instituting a white coat ban designed to overcome existing white coat wearing habits.

    Cognitive gymnastics aside, I believe flu shots likely protect vulnerable patients at the cost of very small associated harms to HCW and I imagine abolishing white coat ceremonies might protect patients with an infinitesimal risk of harm (shortsighted protestations from traditionalists notwithstanding).

    1. Thanks Tim. I wasn't specifically asking about value, but rather ethics. To me this is an omission vs commission situation. Is failing to help the poor the equivalent to stealing? Not getting a flu vaccine would be an omission and forcing someone to wear a white coat is a commission. In this setting, forcing me to wear a white coat also has an intention behind it - a sign of intention to cause harm.

      I'm convinced that if bacteria can spread from hands to patients then it is highly that bacteria can spread from coat sleeves to patients - it doesn't seem like we would need a trial there. Well, I think Mike has even done such a study. To then require a trial to see if bacteria on a patient causes an infection seems redundant with the many hand hygiene studies dating back to Semmelweis. Thus, I think it is unethical for my Chair of Medicine to make me wear a white coat like happened back at Maryland.

  2. Often in medical ethics writers justify actions by saying they align with professional obligations, or it derives a population good, or it evinces good intentions, i.e. the typical ethical tropes. For any action that has justifiable clinical value, one could trot out such justifications fairly generically in a fashion I'm unsure adds much to the conversation. Seen through that lens, what defensibly valuable thing is not "ethical?"

    The real question you were asking - I think - was about the directionality of value. You wrote, "the assertion that bare below elbow policies are somehow equivalent to vaccine mandates from an ethical standpoint is incorrect." If you consider this a question about directionality of value, it depends on your vantage point. If you are considering effort applied today to change the status quo, then banning white coats and mandating flu shots have the same directionality of value since both aim to improve patient outcomes through effort applied today. On the other hand, flu shot mandates align with educational drives that promote flu shots whereas white coat bans contradict forces in medical culture that promote white coats, so from that vantage point the two acts could be seen as having opposite ethical value.

    It all depends, my esteemed colleague, and at a certain point the pragmatist in me starts feeling like this asks how many angels we can fit on the head of a pin. To me, it's most useful to focus on how to improve patient outcomes by applying effort to change the status quo, because that is after all what determines tomorrow's plan. Therefore, I believe the effort applied to BBE efforts has the same ethical weight as a flu vaccine mandate. Both require effort applied to improve patient outcomes based on imperfect data and common sense.

    Your reply clarifies I should out an implicit assumption: acts of omission have equal ethical weight as acts of commission. The most commonly discussed clinical example of this point occurs in end-of-life care, where withholding ventilatory support at the end of life has equal ethical weight as withdrawing ventilatory support at the end of life even though the latter act, by virtue of being more active, can *feel* quite different from the former. Your feels Eli, aren't about ethics much as I'm glad you are in touch with them. :)

    In your original post, and in your rejoinder above, though, you mentioned forced use of white coats. I didn't address this point originally because, frankly, I lumped it in with your Star Wars and Seinfeld analogy as the stuff of fiction, an absurdity mentioned to spice the dish but not the main nutritious ingredient. With your clarification, though, that this really occurred, and recalling that we've heard recently from students who have been compelled to wear white coats, I admit it's reasonable to address this (hopefully more rarely relevant) sub-point. It does require this ethical conversation risk joining the swollen ranks of ethical commentaries that are completely freaking obvious, which in the long run undermines the value of ethical commentaries, so, if the gods of ethics are watching, I apologize in advance.

    But to get there, I have to post a second time because - gasp! - I've gone over the word limit. Stay tuned.

  3. Alright I'm back, let the harangue resume:

    Here goes: yes, it's completely freaking unethical to require a clinician to do something that arguably could cause patient harm without some demonstrable countervailing benefit. How unethical requiring clinicians to wear white coats is really comes down to the magnitude of harm and the degree of certainty we have about it. Hospital transmission of pathogenic bug is epidemic, so the magnitude of potential harm is large. We hang up on the degree of certainty question, because reasonable people see different things in the evidentiary Rorschach blot. Rather than summarizing debates already hashed out elsewhere, I'd say that there are 6.4 ounces of conjecture on the side of the scale suggesting harm from white coats (transmission via fomites), and 5.2 ounces of conjecture on the side suggesting benefit (tradition, professional identity, ameliorating discrimination, carrying stuff, etc), and to me and many commentators that adds up to leaving that white coat on the hanger. More simply put, if it might harm patients and the benefits are pretty intangible, I think the most prudent next step is to realize those intangible benefits via other safer mechanisms. Primum non nocere. Seen through that lens, compelling a clinician to wear a white coat is most likely harmful, and thus most likely unethical. How unethical? It's unethical in the sense that driving over the speed limit or not washing your hands after going to the bathroom is unethical, since it prioritizes one person's haste over another person's safety. Given the controversy and uncertainty, this doesn't raise to the same level of unethicality as other physician sins, such as, for instance, making money by recommending unindicated invasive procedures to patients or shilling products for pharma without disclosure. Sometimes people hear that a sin is a small sin and conclude it is okay to commit it because, hey, everybody's doing it. I disagree: that is the dark side of the Force whispering in your ear. (See how I looped back around?)

    There. You asked for it, so you got it. I've bloviated. Happy now?

    1. Bloviated. Harangued. Either way, I really appreciate your comments and how you looped it back to Star Wars. Clearly we need to catch dinner at one of the ID meetings so I can ask more questions - not fair to make you go into multiple comments. I will end with...

      Fear of being yelled at for not wearing white coats, leads to angry and unclean clinicians and angry and unclean clinicians lead to suffering (HAI or other medical errors)


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