Public Health and Ethics

There has been a lot of ink spilled lately about the preparation of flu shots for the upcoming flu season, with many agencies in the United States advocating that anyone from an at-risk group (e.g. small children and the elderly) be immunized, and since this year it looks as if there will be enough vaccine to go around, anybody else who is likely to be exposed to the flu get vaccinated as well. Some companies and agencies are offering flu shots essentially at cost; a number of retail establishments have been using them as “loss leaders” – merchandise offered at below cost as a measure to bring people into the store, where they will, presumably, make additional purchases at regular price. Other sources are offering the shots at a reasonable markup, and many insurance companies cover these vaccinations through regular health care providers.

It seems like a good idea, if you consider the statistics. The World Health Organization estimates that there are 25 to 50 million cases of influenza in the United States each year, resulting in 150,000 people being hospitalized and 30,000 to 40,000 dying. On a global scale, WHO estimates somewhere between 3 and 5 million people will be ill enough to require hospitalization (whether they get it or not) and as many as 500,000 will die. Historically, there were about 1.5 million deaths in the 1957 flu season (the so-called Asian Flu), and about 40 million in the 1918-1920 Spanish Flu epidemic – more than the total number of soldiers killed in both World Wars combined. In fact, the WHO estimates that more people have died in the last hundred years from the flu than perished in the Black Plague outbreaks.

So why is this an ethical question?

The problem here is that the people who are advocating that the public all get flu shots, advertising the effectiveness of flu shots, and lobbying politicians at various levels to support influenza immunization programs are the same companies who are making the flu vaccines in the first place – and that none of these companies are nonprofit organizations. Here’s a typical example: the website about influenza paid for by Sanofi Pasteur. The wide availability of these vaccines, and the large number of potential sources for them, helps keep the price down, but these companies are still urging the public to make use of a product on which they make money, for the public good.

It doesn’t sound like a big problem; influenza is a genuine risk to public health, and the vaccines really do help to prevent it. But this is a slippery slope argument; it’s one very small step from there to advocating that any product your company makes that could prevent illness or improve overall public health be universally purchased, and only a slightly larger step from there to arguing that any product or service that serves the public good (anti-missile defense units, oil wells in sensitive public lands, hidden surveillance cameras build into all public places) be made available as a public service. The debate over socialized medicine is full of these sorts of questions, and I don’t propose to settle or even raise that issue here; my question is much simpler: Is it ethically sound to permit people to advocate an action that will earn them a large profit as being for the public good? Even if it really IS for the public good? And if so, where do we draw the line on companies charging money (often very large amounts of money) to relieve human suffering? It’s not as simple as it looks…