Milt Hammerly, MD
Vice President, Practice Innovation
Catholic Health Initiatives
Denver, CO

Over 90 years ago, Dr. Shinobu Ishihara developed the well-known screening test for color blindness that still goes by his name.¹ The fact that I routinely fail this test does not make me a bad person. It does make for interesting debates about color in our home — which my wife always wins!

The incidence of color blindness or deficiencies in the USA is about eight percent in males and 0.4 percent in females. If news stories are any indication, ethical blindness is far more prevalent than color blindness. While color blindness can often be predicted based on genetics, ethical blindness may be anticipated based on education, occupation and other factors that shape one's world view. Using the equivalent of an ethical Ishiraha test to identify ethical blindness may be a useful way to compensate for differences in perception that undermine mutual understanding and block constructive solutions.

A case in point, to illustrate the use of an ethical Ishihara, is the appallingly low rate of influenza vaccinations among health care providers (HCPs). Despite the fact that the Centers for Disease Control and Prevention has recommended annual flu vaccinations for HCPs since 1981, and the documented benefits of HCP influenza vaccination on patient outcomes and HCP absenteeism as well as reducing influenza infection among staff, fewer than half of HCPs are vaccinated.² The unions (or individuals) that adamantly oppose mandatory flu vaccinations for HCPs are not evil — they simply have a variant of ethical blindness that needs to be recognized, addressed and compensated for.

The traditional principles of American medical ethics (beneficence and nonmaleficence) toward the patient, patient autonomy, fidelity toward the patient, and justice make it clear that HCPs have a moral/ethical/professional obligation to be vaccinated to avoid harming patients and to stay true to what is in patients' best interests. A concern for the common good and for community well-being further underscore such an obligation. We could even legitimately argue that to honor patient autonomy, patients should be informed as to the vaccination status of health care workers so they can choose whether or not they want to be treated by that provider. In light of the underlying ethical issues at stake, it is a scandalous failure that vaccination rates are so low among HCPs. The union perspective of seeing everything as an opportunity to advocate for worker's rights is blind to the ethical principles that should guide the behaviors of health care providers.

If there are contraindications and the risk (or perceived risk) to the health care worker (competing values) is greater than the potential benefit to the patient, then the decisional balance changes. Clearly there are exceptions and in those situations the values and rights of all parties can be respected by having non-vaccinated providers wear masks. Unfortunately, some unions are even opposed to unvaccinated HCPs being required to wear masks during flu season.³ Reflexively defending the freedom and autonomy of workers to the exclusion of all other values (medical ethics), rights (of patients not to be harmed) and professional responsibilities is not an intentionally malevolent act by unions. However, the consequences of this ethical blindness are bad for patients, health care workers and unions (whose unbalanced behavior only undermines their credibility and effectiveness).

Unlike color blindness, for which there is not yet any commercially available cure⁴, there is a potential remedy for ethical blindness. In the Ishihara color blindness test, accentuating the contrast between different colors allows even color blind people (like me) to see the hidden letters/numbers, etc. By clearly spelling out and accentuating the contrast between the different ethical issues ("colors"), even those who have ethical blindness will be able to see.

The specific ethical issues involved need to be identified, named, illustrated and contrasted "so that he who runs may" see. In the case of flu vaccination for HCPs, worker rights and autonomy must be contrasted with the ethical obligations of nonmaleficence and fidelity as well as justice and the common good. Where these are in conflict, honorable solutions can be found. Unfortunately, when we have different perspectives, the tendency to dig our heels in and attribute negative motives, intentions or characteristics to the opposition does not lead to constructive solutions. Getting stuck in arguments about right and wrong, blue and green, is not useful when based on totally different perceptions and realities.

The ethical Ishihara can just as easily be applied to the deteriorating dialogue on health care reform or any problem where differences in perspective have created an unconstructive impasse. At times, in certain situations, we all suffer from varying degrees of ethical blindness. The point of the ethical Ishihara is not to manipulate others to see things our way but to honor what everyone sees, recognize and name what is not seen and create contrasts that everyone can recognize. The quality of the dialogue and probability of desirable outcomes can increase significantly with this approach.

While it's fun to occasionally banter with my wife about colors, we are able to move on because, thanks to Dr. Ishihara, I understand she is always right on this topic.

NOTES

1. Ishihara Color Test. Accessed online at: http://en.wikipedia.org/wiki/Ishihara_color_test
   
   
2. Influenza Vaccination of Health-Care Personnel. MMWR, February 24, 2006 / 55(RR02);1-16. Accessed online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm
   
   
3. Nurses File Lawsuit Over Mandatory Flu Vaccine. Accessed online 10-2-09 at:http://www.komonews.com/news/local/63144732.html
   
   
4. Mancuso K, et al. Gene therapy for red–green colour blindness in adult primates. Nature advance online publication 16 September 2009. Accessed at: http://www.nature.com/nature/journal/vaop/ncurrent/abs/nature08401.html
   
   

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