“I am no longer trying to dig up evidence to prove vaccines cause autism. There is already abundant evidence……This debate is not scientific but is political” (Ayoub, D. (2006).Using your knowledge of immunology, discuss the arguments for and against the use of vaccination.

Vaccination has become an extensively useful strategy for the prevention of infectious disease and continues to be one of the most successful health interventions and

remains one of society’s best healthcare investments (ref). Never in the history of human progress, wrote the pathologist Geoffrey Edsal, “Has a better and cheaper method of preventing illness been developed than immunisation at its best (ref).

The mainly ambitious aim of vaccination is eradication of the disease. This has been achieved for smallpox; the eradication of polio is being attempted and there has been a dramatic downward trend in the incidence of most of the diseases against which vaccines are currently used. The incidence of the invasive disease Haemophilus influenza, which causes bacterial meningitis in children has decreased in the United States of America by an impressive 99%, sby introducing the vaccine in 1988 (ref). Children born in the U.S. are fully vaccinated from the age of 1 years old to adolescence, saving approximately 33,000 lives and an estimated 14 million infections (ref). However, as long as any focus of infection remains in the community, the main effect of vaccination will be the protection of the individual against the disease (ref). The success of a vaccination programme relies not only on the development and use of vaccines themselves, but also on an understanding of the epidemiologic aspects of disease transmission (ref).Vaccination aims to prime the adaptive immune system to the antigens of a particular microbe so that a first infection induces a secondary response. The principle of vaccination is simple; to induce a “primed” state so that on first contact with the relevant infection, a rapid and effective secondary immune response will be mounted, leading to prevention of disease. Vaccination depends upon the ability of lymphocytes, both

B and T cells, to respond to specific antigens and develop into memory cells, and therefore represents a form of activity enhanced adaptive immunity (ref).In 1999, the Centres for Disease Control (CDC) and the American Academy of Paediatrics (AAP) requested that vaccine makers should remove a organomercury compound called thiomersal from vaccines (ref). This was phased out of the United States of America and European vaccines, except for some preperations of influenza vaccine (ref). The CDC and the AAP decided that there was no harm in exercising caution, even if it did turn about to be unwarranted, however the actions sparked confusion and controversy which result in the diversion of attention and resources away from the efforts to determine the causes of autism (ref). Child vaccines which contained the thiomersal was alleged to contribute to autism (ref), however in 2004 the Institute of Medicine (IOM) committee rejected any causal relationship between autism and thiomersal-containing vaccines (ref). However the incidence of autism increased steadily despite the removal of thiomersal from childhood vaccine (ref). thiomersal exposure has not been accepted as a factor in causing autism (ref).

Immunisation safety is a real concern because all vaccines may cause side effects. Both healthcare workers and patients need reminding that immunisation is an induced controlled stimulus to the immune system, so therefore some adverse reactions can be expected. Most of the reactions however, are transient and mild. Immunisation safety concerns have existed since the day of the first available vaccine. Since the introduction of Jenner’s cowpox vaccine, the benefits of saving children from tragic outcomes of common diseases outweigh the risks of perceived adverse events following immunisation.

Immunisation safety concerns are different from concerns about other medical interventions because they are administered to generally healthy individuals and the tolerance of adverse events following immunisation is subsequently lower compared to adverse events following medication for an existing illness (ref).

The success of immunisation programmed depends on the public confidence in their safety despite the side effects vaccines may cause.

Concerns about immunisation safety often follow a pattern: a medical condition is suggested as an adverse effect of the vaccination, then a premature announcement is made of the alleged effects which then results in several years to try and regain the public’s confidence in the vaccine (ref). Vaccination in the United Kingdom became widespread in the ear;y 1800’s after the work by Jenner (ref).

Vaccination acts were brought in to force to encourage vaccination and it was made mandatory that all infants in 1853 were vaccinated (ref). Refusal to have the vaccinations received the highest penalty resulting in a prison sentence (ref). The relationship between the British State and its citizens significantly changed, causing a public backlash.

In 1867, a law extended the requirements to the age of 14 years old, however, opponents focused in 1898 on it causing an infringement of individual’s freedom, which resulted in a law allowing for conscientious objection to compulsory vaccination (ref). Compulsory vaccination policies at various times provoked opposition from people who believe that the government should not be infringing on individuals freedom to choose what medications they take, even if this increases a risk of disease to themselves and others (ref).

Some vaccine critics claim that public health has never had any benefits from vaccination (ref). They argue that any reduction on communicable diseases, which were rampant in conditions where overcrowding, poor sanitation, poor diet and an almost non-existent hygiene existed, reduced due to the changes in the conditions excepting vaccination (ref).

Others dispute that vaccines only give a temporary immunity and therefore boosters are required, whereas those who have survived the disease develop a permanent immunity (ref). Children who have survived diseases such as diphtheria go on to develop a natural immunity which will remain longer than any immunity developed by the vaccination (ref). Some critics argue that the benefits of reducing the mortality rates among the general population outweigh all health risks associated to older or weaker adults (ref). Vast improvements have been made to public health (ref). Despite vaccines causing side effects and immunisation safety is a real concern, public attention shifts away from the risks as the success of the immunisation programme increases (ref) and the incidence of disease decreases (ref).

However health authorities are finding it challenging to preserve public support for the vaccination programmes (ref).The rate in diagnosis of autism has had a worldwide increase (ref) , driven by the broadened diagnostic criteria and increased awareness concerns have been fuelled that vaccines might cause autism (ref). Theories for this alleged association have mainly centred on the measles-mumps-rubella (MMR vaccine (ref). however, studies in biology and epidemiology have failed to support these claims (ref).

The MMR vaccine in the United Kingdom was the subject of controversy, when a paper was published in The Lancet in 1998. The paper written by a Gastroenterologist Dr Andrew Wakefield et al, reporting a small study of 12 children, whom mostly with autism spectrum disorders with sudden onset after administration of the Vaccine (ref). During a 1998 press conference, Andrew Wakefield suggested that it would be safer to give children the vaccine in three separate doses rather than a single vaccination. This suggestion was never supported by the paper and subsequent peer-reviewed studies failed to find any association between the autism and the vaccine (ref). In 2001 and 2002, the controversy grew momentum. In 2001 26% of family doctors felt that the government had failed to prove that there was no link between autism and the MMR (ref). By 2002, over 1257 stories were published (ref). The confidence in the MMR fell as a result of the scare, from 59% to 41% (ref). A survey of 366 family doctors in the United Kingdom in 2003, reported that 77% would recommend giving the child the MMR vaccine, even if there was a close family history of autism (ref). In the same study an extremely small number, 3% of the family doctors thought that autism could sometimes be the caused by the MMR vaccine (ref).

A similar survey (ref) found that confidence in the MMR had been increasing over the previous two years (ref). Most of the UK National Health Service doctors only had the combined vaccine and those who did not want to give their children the combined vaccine had to pay for the separate vaccines or not vaccinate their children (ref), which added to the controversy of the MMR.

Tony Blair, who was the Prime Minister at the time, strongly supported the vaccines stating “the vaccine was safe” (ref mmr vaccine). However, on several occasions Tony Blair would refuse on grounds of personal privacy whether his son had received the vaccine, in contrast the now immunised (ref), The risks of children catching the disease while waiting for the full immunisation coverage decreases with the administration of the combined vaccine instead of separate vaccines (ref). The combined vaccine’s two injections cause the children less pain and distress, rather that the six injections required by the separate vaccines, and there is the likelihood of some being delayed or missed due to extra clinic visits (ref).

Vaccination uptake had significantly increased in the UK when the MMR became available in 1988 (ref mmr vaccine). Health professionals have heavily criticised media coverage of the controversy from triggering a decline in vaccination rates (ref mmr).

MMR vaccination compliance dropped significantly after the controversy began in the UK, from 92% in 1996 to 84% in 2002. In 2003, in some London boroughs, it was a low as 615, which is far below the rate needed to avoid an epidemic of measles (ref).

The incidence of the three diseases increased significantly in the UK (ref). 56% cases of measles were confirmed in the 1998, this increased over the years and in 2006, 449 cases were reported in first five months of the year (ref)m and the first death since 1992, these cases occurred in children who were inadequately vaccinated (ref).

In 1999, cases of mumps began to rising after years of very few cases and by the year 2005, there was a mumps epidemic with nearly 5000 notifications in January 2005 alone (ref).

Disease outbreaks also caused casualties in nearby

countries. In Ireland an outbreak in 2000 resulted in 1500 cases and 3 deaths, all as a result of the decrease vaccination rates following the MMR controversy (ref)

Measles was declared an endemic in the UK in 2008 for the first time in 14 years. A population of susceptible children who would spread the disease was created following the low MMR vaccination rates (ref). MMR vaccination rates amongst English children have remained unchanged in 2007-08, a level to low to prevent another serious measles outbreak (ref).

It later emerged that Andrew Wakefield had not informed the medical authorities or colleagues that he had received funding from litigants against vaccine manufacturers (ref). Wakefield has been heavily criticised for instigating a decline in the vaccination rates and medically (ref) especially on the way the research was conducted ethically (ref)

The Sunday Times in 2009 reported that patient data was manipulated by Wakefield and misreported the results in his 1998 paper, creating the appearance of a link between autism and the MMR (ref).

A systematic review of 31 scientific studies by the Cochrane Library in 2005 concluded that there is no credible evidence to support any links between Autism and the MMR vaccine, and that the MMR is necessary in the prevention of disease with carries the potential rick of complication and even death in some cases (ref). The report also highlighted that the lack of confidence in the MMR has damaged public health and that the design and reporting of the safety outcomes was largely inadequate (ref). Ensuring the safety of vaccination is a major component of the national immunisation programmes of most countries. A major part of this effort is surveillance, and scientific studies about the possible occurrence of adverse events following immunisation. Although a number of vaccine safety studies

is increasing, this is not in response to any evidence about the true safety of vaccines, but in response to the increasing number of new vaccines being used and the complex nature of these vaccines.

A number of vaccine safety studies have been conducted or are in progress, some in reaction to the climate of concern, some carried out proactively and others as part of ongoing surveillance. However, because the number of safety-orientated studies is increasing, one should be aware that this fact in itself could contribute to the concern.

The internet has increasingly become a powerful means of international communication and an almost inexhaustible source of information, capable of playing an influential role in both the positive and the negative sense. It represents a direct and efficacious tool to spread a positive message and to stress the health benefits, economic attractiveness and safety of vaccination. However, inaccurate, misleading or simply wrong information regarding potential side effects or dangers of vaccination spreading through the internet exacerbates

worries about vaccine safety and may cause parents to postpone or refuse vaccination of their children. A wide range of issues concerning vaccine safety is being taken up by anti-vaccination groups as well as by other groups whose concerns may reflect local customs, or religious, political or other beliefs.

Anti-vaccination lobbies have also understood the possibilities of the internet can be exploited and could strengthen their means to campaign against vaccination. This is demonstrated by the occurrence of a multitude of specific websites heavily relying on emotional appeal while proclaiming a message that undermines the benefits of vaccination.

Vaccine scares continue to have an impact on immunisation coverage. To respond to this challenge, there is a need to develop vaccine communication strategies that provide a balance between evidence-based information and advocacy and lobbying activities. Furthermore, compiling independent, international reviews of vaccine safety issues is required, together with relevant statements from authoritative neutral expert groups. This should be done within a strong international collaboration, with direct, early and clear statements agreed on by authorities and other key parties, preceding public communications.

Creating a positive environment for immunisation can be achieved by supporting evidence-based information thus repositioning the importance and value of vaccines and vaccination. This will ultimately ease the task of health care decision makers, especially in developing proactive communication strategies to deal with crises that have a potentially negative impact on vaccine coverage, and consequently on the health status of children.

Loss of public confidence in vaccination is one of the greatest threats to public health and must be addressed by local, national and international bodies, pooling resources, to prepare for possible issues that might be taken up by anti-vaccination groups or the media. The health care community should actively promote, and personally recommend, the benefits and safety of vaccination in language that is readily and easily understood by the targeted audience.

Euthanasia is an emerging argument seen all over the world. In this argument includes the role of the nurse and the four ethics the nurse is to abide by, justice, beneficence, autonomy and non-maleficence. This paper will explore how these four ethics can play a part in how the nurse may feel about the idea of euthanasia, and how these four ethics can play a part in the deciding factor of whether euthanasia of humans is something that should be carried out or not, regardless of person’s physical health. It will examine which ethical principles is the argument for or against euthanasia, is the involvement of the nurse ethically justified, and if so, can it be considered good nursing care?

The practice of nursing has long had a high regard for, and treasuring, of life. If it is the job of the nurses to save and protect lives, then how can the consideration of euthanasia fit into nursing practice? Many consider helping a person to find peace and to gain some control over their death as a means of treasuring life. It provides the person with the chance to die in a dignified manner, and to not suffer. The nurse infarcts four moral codes into everyday practice; respect for autonomy, non maleficence, beneficence and justice. These moral codes are brought into light exponentially when the request for euthanasia has been made by a patient and the nurse must find a way to not only adhere to the

ethics of practice

, and advocate for the patient, but to be in tune with their own ethical thoughts and feelings.

In regards to respect for autonomy, euthanasia can be argued as a good practice. It can be justified from the basis of respect for the individuals’ autonomy (Quaghebeur, Dierckx de Casterle & Gastmans, 2009). Providing care for the patient and respecting their autonomy means respecting the request of euthanasia from the patient, though it may not correlate with the nurse’s personal feelings of euthanasia, or their ability(physical or mental) to carry out the requested task (Quaghebeur, et al 2009) Professional integrity of nurses can be used to support euthanasia from the standpoint of autonomy as well. It is this integrity that is responsible for fellow humans, therefore having respect for their autonomy. In congruence with this responsibility for fellow humans, euthanasia is now compatible with the integrity of nursing. The nurse with this professional integrity respects the patient autonomy, therefore providing compassionate care and promoting optimal well being of the patient. As as result of this care, euthanasia is now in accordance to the idea of the nursing profession, as human dignity is protected, patient interest is promoted, and the patient is being cared for(White, 1999)

In accordance to the moral point of justice, in order to protect the patients interests, euthanasia can be seen as good care for the patient, ethically justified as a form of a good death. It could be argued that it would be not only unjust, but cruel to refuse the request of euthanasia (Quaghebeur, et al 2009).

The ethical principle of non -maleficence means to do no harm (Potter and Perry, 2010). However, nurses harm their patients everyday simply by administering treatments such as chemotherapy for a patient with cancer. These treatments are seen as acceptable however, because the benefit is greater than the initial harm(McCabe, 2007). The Hippocratic oath, an oath that is traditionally upheld by all nurses and medical professionals, has proscribed the event of abortion and surgery. Despite the true definition of this oath to do no harm, these practices are allowed because they serve the ability to promote patient well being. Along the same instance of promoting patient well being, a patient may need the nurse to assist them to die when prolonging life is indeed harming the patient. In this situation, death would be a benefit (White, 1999)

This brings around the idea of beneficence, the nurse is the patient advocate who must do good, promulgate the best interest of others (Quaghebeur et al 2009). The nurse is very often the first to receive the request of euthanasia from the patient due to the closeness and depth of involvement the nurse has in a person’s life. In a study of American nurses, the reasons claimed for having even participated in euthanasia was a feeling of responsibility for their patients welfare, and a way to help relieve the patient of their pain and suffering (De Bal, Gastmas, Dierckx de Casterle, 2008). Indeed, ending pain and suffering can be seen as doing no harm, but bringing about peace and comfort. For instance, the right thing for a nurse to do when confronted by the pain of a patient is to alleviate that pain, because healing is what the activity of nursing is directed at, easing the suffering and restore the sense of well-being to a patient. This is to act morally well, because this act assuaged the pain of the patient. (McCabe, 2007) Nurses are committed to not only preventing and minimizing the effects of disease and promoting health, but to relieve pain and suffering that can be brought about by these maladies (White, 1999)

Several criticisms can be seen going against the idea of euthanasia being a morally good practice because it is based upon respect for the patient’s autonomy (Quahgebeur et al 2009). It is argued that the nurse who is obliging to advocate for the patient wishing for euthanasia, while respecting the patients autonomy, is not respecting their own autonomy. Respecting a patients autonomy in regards to life, or the lack thereof, is undermining the importance of social community, as dying as a social practice, much as life is a social practice (Quaghebeur et al, 2009) Euthanasia is argued to in fact not administer justice to the autonomy of a patient (Quaghbeur et al 2009). If a patient does indeed receive euthanasia, though it may be respecting their autonomy by carrying out the request, once the patient has passed on, they are no longer able to enjoy that autonomy (Quaghebeur et al 2009).

In the literature of nursing ethics, the principle of non-maleficence outright rejects euthanasia, due to the irreversible damage made to the patient’s life, it is seen as too drastic of an intervention to be even used (Quaghebeur et al 2009). According to the principle of non-maleficence,euthanasia is not considered good ethical nursing practice owing to the sanctity of human life Human life is deserving of respect, despite a growing population and people now living longer than before due to the advances of technology. Each human life is of both equal dignity and sacrosanct(Quaghebeur et al 2009). The American Nurses Association holds the position on this issue that assisting an individual to die is not compatible with the nurse’s role in society. Non-maleficence means to do no harm and this is the pledge nurses make to society. By assisting the patient in suicide, the trust between the nurse and the patient is destroyed. (ANA 2001)

Doing good for the patient doesn’t always mean ending their life when they have stated they want to die, as there is a difference between stating the desire to die as opposed to actually having the desire to be killed (Quaghebeur et al 2009). If the nurse wants to do good by the way of the patient, then quality and dignity of life must be examined. A patient’s interests are never served by fulfilling the request of death, even if the patient believes otherwise. Is it possible to actually judge how worthwhile someone’s life actually is, that there is a life that is not worth being lived? (Quaghebeur et al 2009). Ethics of desire may outshine the ethics of reason, and with that, a threat of moral relativism disseminating a patients interest determines good ethical nursing practice (McCabe 2007).

In a case where preservation of life can no longer be attained, then the nurse will continue to heal through practice of ensuring physical and emotional comfort, support of the patient and their loved ones, assisting the patient to a place of security, comfort and peace (McCabe, 2007). Society places a great deal of trust upon the nursing profession and by engaging in measures to end a patients life, this professional integrity contravenes and undermines this trust that has been placed upon them. (McCabe, 2007)

A nurse as an individual will need to clarify their own values, as the implications of euthanasia are enormous. As a nurse, a definitive decision on their position in regards to this issue must be made. All aspects of the issue must be looked at, fully understood, and only then a decision on position should be made. A nurse needs to respect not only a patients autonomy, but their own as well, and need to remain true to their own values as well.

Many different controversial issues will be confronted during the career of a nurse, including assisted suicide. The nurse needs to be not only educated on the implications of such actions, but educated in their own opinions, with the ability to think critically about these controversial issues. A nurse will need to be involved in their politics to maintain their emotional integrity when confronted with a situation that may or may not be ethical to them. Within time, there is a greater chance of more and more states passing laws allowing human euthanasia to occur, as well as against, and the the ability to apply the oath to do no harm will be examined again and again.

This writer believes that the act of euthanasia in nursing is a subject that needs to be considered very deeply. If the values of nursing ethics include autonomy, beneficence, justice, and non-maleficence, then the concept of euthanasia, in a positive way, reflects all four ethics. A patient who is hurting, and a nurse who continues to prolong a life that is physically demoralizing and painful (indeed causing the patient harm, when a nurse is to do no harm), has a duty to that patient to ease the pain and suffering to the furthest extent possible to the request of the patient.

Though it may seem irrelevant to the care of the patient, this writer has always had a firm belief of euthanasia. If a person puts their pet to sleep because the pet is no longer able to live a good quality of life, the owner does right by the pet by euthanizing it, though the pet cannot say in so many words that it is suffering and wants this to be over. A human being has the ability to express what his or her feelings on continuing their life, regardless of the quality, is. To deny a person who is fully capable of making their own decisions, the ability to end a life that will be soon be over and is wrought with pain and suffering, is wrong. To not allow the patient peace and comfort, and relief from pain that a nurse is supposed to give, impedes on the top ethic of medical practice, do no harm. Indeed by not complying with the patients wish of the pain to end, the nurse is doing harm, mentally and physically, and not just with the patient, but with the patients family as well.

Though this writer will have to continue to educate herself on the practices that may or may not involve human euthanasia, it is the belief that this is a subject that will be brought up again and again, especially in the critical care settings, where pain, death and dying is at its greatest.

Conclusion

While there many arguments for and against assisted suicide, the answer to the question of whether it is right or wrong remains ambiguous. One reason for the lack of clear cut answers is that assisted suicide is an ethical issue which is dependent on a person’s values, morals, religion, and experiences. In general, the topic of end-of-life decision making is very sensitive and evokes strong emotions and opinions. Instead of debating the issues involved with assisted suicide, this paper merely describes pertinent arguments that have been presented by both sides.

There are many nursing implications that are associated with assisted suicide. Among these is the importance for nurses to be aware of their own beliefs about end-of-life care. Self-awareness will prepare nurses for obstacles they will face when dealing with death. Another implication is that nurses need to be cognizant of politics and legal authority. Becoming active in political processes, nurses can work to ensure that they will not be forced into doing procedures that come in direct conflict with their beliefs.

In final conclusion, the code of ethics a nurse is to oblige by can come across as a very gray area. There does not seem to be any cut and dry reasoning behind whether the practice of euthanasia is good or bad, or something that a nurse should or should not participate it. The ethics can be construed to fit any need necessary, whether it is in favor of the act of euthanasia, which can be argued that by ending a life one is removing the pain. Or it can be argued that by administration of such lethal drugs to carry out the act, one is indeed harming by bringing about death.