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A recent poll indicated that 48 per cent of Canadians might refuse the H1N1 vaccination - and that number went up to 51 per cent in an online poll reported in yesterday's Globe and Mail. These figures suggest that many Canadians are not considering the public good and have a misguided understanding of their personal interest.

According to Canada's Chief Public Health Officer, David Butler-Jones, the risk of experiencing severe side effects after receiving the shot is one in a million, compared with the 20 to 35 per cent of the population who will get sick from this pandemic flu without protection. "If every single Canadian is inoculated," he said, "then 30 Canadians could have the potential for a severe side effect, compared to 10 million people sick, 100,000 people in hospital and 10,000 people dead."

In the face of such numbers, Canadians should consider not just the risks to themselves, their loved ones and those with whom they come in contact, but also to our health-care system.

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The public nature of Canadian health care creates both individual rights and individual responsibilities. But people can assert rights to a public resource without recognizing a responsibility toward its limited nature. This problem was brilliantly described in 1968 by ecologist Garrett Hardin in the journal Science as "the tragedy of the commons." In this hypothetical case, individual actors operate on self-interest and ultimately destroy a shared limited resource - even when such destruction is clearly not to anyone's long-term benefit. Canadians are familiar with this tragedy because it describes the collapse of the Atlantic cod fishery.

Mass H1N1 vaccination refusal similarly might destroy (at least temporarily) our health-care system, with the threatened 100,000 people in hospital. We have a limited number of hospital beds and respirators and a finite number of people who know how best to use them. Every vaccinated person increases the likelihood that health-care professionals will be free to treat other people. What's more, inoculation reduces transmission. If unvaccinated people make health-care workers sick, they cannot look after other patients.

While the tragedy of the commons can shed light on vaccination choice, it cannot explain why an individual would choose to act against his or her self-interest. (The cod fishers who depleted the fish stocks to the detriment of future generations at least enjoyed immediate personal benefit.)

Although vaccine refusers seem motivated to avoid personal risk, they are really acting from misinformation and a one-sided view of risk. Public-health officials have tried to transfer their considerable knowledge to those fearful of vaccination. But they are up against the Internet, which makes plentiful both good and bad information.

Moreover, lay people can be confused by publicly available scientific information because they don't understand the scientific method or conversations scientists have among themselves. If a scientist were 99-per-cent certain that something is true, the scientist would reveal and discuss the 1-per-cent uncertainty. Therefore, for lay people to state that the scientist is uncertain is to misstate the conversation.

Some vaccination refusers also imply that public-health officials are in the pocket of the pharmaceutical industry. But we pay these officials to act in the public interest. And, almost certainly, their moral disposition is to act in the public interest. Moreover, the Canadian public service has systems to ensure that its officials are not directed by private or foreign interests.

If half of Canadians refuse vaccination, our limited health-care resources (people, medical supplies and physical infrastructure) will probably be depleted. How can we avoid such a tragedy?

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This year's Nobel Prize in economics was awarded to Elinor Ostrom for demonstrating that if those people who are threatened by the depletion of scarce resources repeatedly interact, then they change their behaviour to safeguard the threatened commons.

Such interaction includes talking. Perhaps the gravity of the current situation requires unusually frank conversation among Canadians, such as, "My diabetic child needs ongoing access to health care that you, refusing H1N1 vaccination for yourself and your children, might block."

It seems better to have these conversations now than next year when it might be too awful to speak about how vaccination refusal put such a strain on health-care resources that loved ones with other conditions died.

Canadians share a common plight: an influenza pandemic; an already overstretched public health-care system tending to a vulnerable and aging population; the availability of a safe and effective H1N1 vaccine; and our Chief Public Health Officer's recommendation to become vaccinated as soon as possible.

These facts require citizens to decide how best to assess personal interest and to reconcile it with the duty to protect the public good.

We are entitled to share in limited health-care resources. How much will we demand? We are invited to be vaccinated against H1N1. How will we each respond?

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Juliet Guichon holds a doctorate in law and is senior associate in the Office of Medical Bioethics at the University of Calgary. Ian Mitchell is a professor of pediatrics and bioethics at the University of Calgary.

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