In bioethics vaccine refusal is often discussed as an instance of free riding on the herd immunity of an infectious disease. However, the social science of vaccine refusal suggests that the reasoning behind refusal to vaccinate more often stems from previous negative experiences in healthcare practice as well as deeply felt distrust of healthcare institutions. Moreover, vaccine refusal often acts like an exit mechanism. Whilst free riding is often met with sanctions, exit, according to Albert Hirschman’s theory of exit and (...) voice is most efficiently met by addressing concerns and increasing the quality and number of feedback channels. If the legitimate grievances responsible for vaccine refusal are not heard or addressed by healthcare policy, further polarization of attitudes to vaccines is likely to ensue. Thus, there is a need in the bioethics of vaccine refusal to understand the diverse ethical questions of this inflammable issue in addition to those of individual responsibility to vaccinate. (shrink)

One proposal to significantly reduce cardiovascular disease is the idea of administering a ‘polypill’—a combination of drugs that reduce the risk of heart disease and carry few side effects—to everyone over the age of 55. Despite their promise, population strategies like the polypill have not been well-accepted. In this article, I defend the polypill by appealing to fairness. The argument focuses on the need to fairly distribute the costs to individuals. While the fact that population strategies like the polypill impose (...) minor costs on everyone has primarily been used to criticize such strategies, I argue that it gives us a reason to support them. I argue that implementing a population strategy with the polypill contributes to the public good of ‘health system capacity’. I then explain that public goods have widely accepted obligations: they carry an obligation to fairly distribute the costs of the goods and prevent free-riding. Thus, we have at least one pro tanto moral reason to implement the polypill. As such, this article challenges the current literature on the topic, which has largely held adopting population strategies like the polypill to be unjustifiable. (shrink)

Preventive vaccination can protect not just vaccinated individuals, but also others, which is often a central point in discussions about vaccination. To date, there has been no systematic study of self- and other-directed motives behind vaccination. This article has two major goals: first, to examine and distinguish between self- and other-directed motives behind vaccination, especially with regard to vaccinating for the sake of third parties, and second, to explore some ways in which this approach can help to clarify and guide (...) vaccination debates and policy. I propose conceiving of vaccination in terms of three basic elements: the vaccination decision-maker, the vaccine recipient and the primary beneficiary. I develop a taxonomy based on the relations between these elements to distinguish four kinds of vaccination: self-protective, paternalistic, altruistic and indirect. I finally discuss the case of human papillomavirus vaccine regulation for men and women to show how each kind of vaccination is associated with and raises specific ethical questions. (shrink)

We argue that, from the point of view public health ethics, vaccination is significantly analogous to seat belt use in motor vehicles and that coercive vaccination policies are ethically justified for the same reasons why coercive seat belt laws are ethically justified. We start by taking seriously the small risk of vaccines’ side effects and the fact that such risks might need to be coercively imposed on individuals. If millions of individuals are vaccinated, even a very small risk of serious (...) side effects implies that, statistically, at some point side effects will occur. Imposing such risks raises issues about individual freedom to decide what risks to take on oneself or on one’s children and about attribution of responsibility in case of adverse side effects. Seat belt requirements raise many of the same ethical issues as vaccination requirements, and seat belt laws initially encountered some opposition from the public that is very similar to some of the current opposition to vaccine mandates. The analogy suggests that the risks of vaccines do not constitute strong enough reasons against coercive vaccination policies and that the same reasons that justify compulsory seat belt use—a measure now widely accepted and endorsed—also justify coercive vaccination policies. (shrink)

We argue that individuals who have access to vaccines and for whom vaccination is not medically contraindicated have a moral obligation to contribute to the realisation of herd immunity by being vaccinated. Contrary to what some have claimed, we argue that this individual moral obligation exists in spite of the fact that each individual vaccination does not significantly affect vaccination coverage rates and therefore does not significantly contribute to herd immunity. Establishing the existence of a moral obligation to be vaccinated (...) despite the negligible contribution each vaccination can make to the realisation of herd immunity is important because such moral obligation would strengthen the justification for coercive vaccination policies. We show that two types of arguments—namely a utilitarian argument based on Parfit’s Principle of Group Beneficence and a contractualist argument—can ground an individual moral obligation to be vaccinated, in spite of the imperceptible contribution that any single vaccination makes to vaccine coverage rates. We add a further argument for a moral obligation to be vaccinated that does not require embracing problematic comprehensive moral theories such as utilitarianism or contractualism. The argument is based on a “duty of easy rescue” applied to collectives, which grounds a collective moral obligation to realise herd immunity, and on a principle of fairness in the distribution of the burdens that must be borne to realise herd immunity. (shrink)

Public health is concerned with increasing the health of the community at whole. Insofar as health is a ‘good’ and the community constitutes a ‘public’, public health by definition promotes a ‘public good’. But ‘public good’ has a particular and much more narrow meaning in the economics literature, and some commentators have tried to limit the scope of public health to this more narrow meaning of a ‘public good’. While such a move makes the content of public health less controversial, (...) it also strips important goals from the realm of public health, goals that traditionally have been, and morally should be, a part of it. Instead, I will argue, while public health should be defined by public goods, it should be defined by a broader conception of public goods that I shall call ‘normative public goods’, goods that ought to be treated as if they were public goods in the more narrow sense. (shrink)

The United States may justifiably exclude unvaccinated aliens, perhaps even under the assumption of Open Borders, according to which people should generally be permitted to settle in countries of their choosing. Furthermore, there are good reasons to endorse the Centers for Disease Control and Prevention’s (CDC’s) current vaccination-related exclusion criteria, which were last revised in 2009. I frame my discussion around CDC’s 2008 decision to permit immigrant girls and women to be excluded if they were not vaccinated against human papillomavirus (...) (HPV)—a decision that was quickly reversed and that led to the 2009 revisions to CDC’s vaccination-related immigrant exclusion criteria. (shrink)

This paper is concerned with how public health policy makers should respond to the public’s perception of risks. I suggest that we can think of this issue in terms of two different models of responding to the public’s view of such perceived risks. The first model I will call the public perception view (PP view) and the second the public good view (PG view). The PP view suggests that the public’s perception of any risks is so important that public health (...) policies should be formulated in direct response to knowledge about them. I will consider two possible ethical arguments that might be offered in support of such a view: the first argument is an autonomy argument and the second a consequences argument. I suggest there are serious problems with both arguments. I then outline an alternative model of public health policy formation that I call the public good or PG model. This model focuses on drawing distinctions between the clinical and the public health context, and argues that most of public health policy is primarily concerned with the creation and maintenance of various public goods. This latter fact means that the PP model is inappropriate for public health policy formation. (shrink)

Techniques from behavioral economics—nudges—may help physicians increase pediatric vaccine compliance, but critics have objected that nudges can undermine autonomy. Since autonomy is a centrally important value in healthcare decision-making contexts, it counts against pediatric vaccination nudges if they undermine parental autonomy. Advocates for healthcare nudges have resisted the charge that nudges undermine autonomy, and the recent bioethics literature illustrates the current intractability of this debate. This article rejects a principle to which parties on both sides of this debate sometimes seem (...) committed: that nudges are morally permissible only if they are consistent with autonomy. Instead, I argue that, at least in the case of pediatric vaccination, some autonomy-undermining nudges may be morally justified. This is because parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and because the interests of both the vaccinated child and other members of the community can sometimes be weighty enough to justify autonomy-infringing pediatric vaccination nudges. This article concludes with a set of worries about the effect of pediatric vaccination nudges on parent-physician relationships, and it calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges. (shrink)

Human papillomavirus (HPV) is one of the most common sexually transmitted infections. It is a leading cause of cervical cancer in women but the virus is increasingly being linked to several other cancers in men and women alike. Since the introduction of safe and effective but also expensive vaccines, many developed countries have implemented selective vaccination programs for girls. Some however argue that these programs should be expanded to include boys, since (1) HPV constitutes non-negligible health risks for boys as (...) well and (2) protected boys will indirectly also protect girls. In this paper we approach this discussion from an ethical perspective. First, on which moral grounds can one justify not reimbursing vaccination for the male sex? We develop an ethical framework to evaluate selective vaccination programs and conclude that, in the case of HPV, efficiency needs to be balanced against non-stigmatization, non-discrimination and justice. Second, if vaccination programs were to be expanded to boys as well, do the latter then also have a moral duty to become immunized? Two arguments in favor of such a moral duty are well known in vaccination ethics: the duty not to harm others and to contribute to the public good of public health. However, we argue that these are not particularly convincing in the context of HPV. In contrast, we believe a third, more powerful but also more controversial argument is possible. In our view, the sexual mode of transmission of HPV constitutes an additional reason to believe that boys in fact may have a moral obligation to accept vaccination. (shrink)

When exercising their public health powers, states claim various rights against their subjects and aliens. The paper considers whether public health considerations can help justify some of these rights, and explores some constraints on the justificatory force of public health considerations. I outline two arguments about the moral grounds for states’ rights with regard to public health. The principle of fairness emphasizes that those who benefit from public health measures ought to contribute their fair share in upholding them. Alternatively, states’ (...) rights might be justified by a natural duty of justice to uphold and not to obstruct institutions implementing public health policies. I indicate some reasons for preferring the latter justification. I further argue that the assignment of some rights to states via public health-based justification is undermined on several counts. Domestic political institutions cannot effectively perform some of their functions in protecting public health. Furthermore, transborder public health threats pose collective action problems at the global level. Finally, concerns about human rights work against the assignment of some rights to states. I conclude by arguing that these concerns call for global coordination, and that some rights claimed by states ought instead to be assigned to global institutions. (shrink)

Despite worldwide efforts to reduce the consumption of tobacco, legislative and educational measures have failed to eradicate the practice of cigarette smoking. Indeed, in many populations, particularly in the developing world, its prevalence is increasing. Consequently were alternative strategies to become available to address the problem, they would deserve serious consideration. One potential strategy which may become a real possibility in the future might be the vaccination of children against the pleasurable effects of nicotine. Were such a vaccine to become (...) available, children who had been inoculated would be less likely to start smoking, and even if they did, would be able to quit more easily. However, as Hasman and Holm discussed, vaccinating against a behavior rather than a disease is not ethically unproblematic, and they concluded that inoculation of infants and young children with a permanently effective nicotine conjugate vaccine should not take place, as it robbed children of the right to a smoking future. In this article, I will re-evaluate some of their arguments, and will conclude that in fact the private and public goods that inoculation with a ‘smoking vaccine’ would produce, outweigh the possible impingements on future autonomy that may result from such vaccination programme. (shrink)

In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to policies that do not (...) allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility. (shrink)

Strategies to increase influenza vaccination rates have typically targeted healthcare professionals and individuals in various high-risk groups such as the elderly. We argue that they should focus on increasing vaccination rates in children. Because children suffer higher influenza incidence rates than any other demographic group, and are major drivers of seasonal influenza epidemics, we argue that influenza vaccination strategies that serve to increase uptake rates in children are likely to be more effective in reducing influenza-related morbidity and mortality than those (...) targeting HCPs or the elderly. This is true even though influenza-related morbidity and mortality amongst children are low, except in the very young. Further, we argue that there are no decisive reasons to suppose that children-focused strategies are less ethically acceptable than elderly or HCP-focused strategies. (shrink)

How should liberal-democratic governments deal with emerging vaccination hesitancy when that leads to the resurgence of diseases that for decades were under control? This article argues that vaccination policies should be justified in terms of a proper weighing of the rights of children to be protected against vaccine-preventable diseases and the rights of parents to raise their children in ways that they see fit. The argument starts from the concept of the ‘best interests of the child involved’. The concept is (...) elaborated for this context into the dual regime structure in which parents have fiduciary authority over what they consider to be best for their child, and the state has fiduciary authority over a child’s basic interests. This argument leads to conditional mandatory vaccination programs that should be informed by a correct balancing of the two legal principles of proportionality and precaution. This results in contextual childhood vaccination policies of upscaling interference: a three-tiered approach of increased intrusion, from voluntary program when possible and mandatory or even compulsory programs when necessary to protect the child’s basic interests. (shrink)

Ethical considerations from both the clinical and public health perspectives have been used to examine whether it is ethically permissible to mandate the seasonal influenza vaccine for healthcare workers (HCWs). Both frameworks have resulted in arguments for and against the requirement. Neither perspective resolves the question fully. By adding components of justice to the argument, I seek to provide a more fulsome ethical defence for requiring seasonal influenza immunisation for HCWs. Two critical components of a just society support requiring vaccination: (...) fairness of opportunity and the obligation to follow democratically formulated rules. The fairness of opportunity is informed by Rawls’ two principles of justice. The obligation to follow democratically formulated rules allows us to focus simultaneously on freedom, plurality and solidarity. Justice requires equitable participation in and benefit from cooperative schemes to gain or profit socially as individuals and as a community. And to be just, HCW immunisation exemptions should be limited to medical contraindications only. In addition to the HCWs fiduciary duty to do what is best for the patient and the public health duty to protect the community with effective and minimally intrusive interventions, HCWs are members of a just society in which all members have an obligation to participate equitably in order to partake in the benefits of membership. (shrink)

A particularly strong reason to vaccinate against transmittable diseases, based on considerations of harm, is to contribute to the realization of population-level herd immunity. We argue, however, that herd immunity alone is insufficient for deriving a strong harm-based moral obligation to vaccinate in all circumstances, since the obligation significantly weakens well above and well below the herd immunity threshold. The paper offers two additional harm-based arguments that, together with the herd immunity argument, consolidates our moral obligation. First, we argue that (...) individuals should themselves aim not to expose others to risk of harm, and that this consideration becomes stronger the more non-vaccinated people there are, i.e., the further we are below herd immunity. Second, we elaborate on two pragmatic reasons to vaccinate beyond the realization of herd immunity, pertaining to instability of vaccination rates and population heterogeneity, and argue that vaccinating above the threshold should serve as a precautionary measure for buttressing herd immunity. We also show that considerations of harm have normative primacy in establishing this obligation over considerations of fairness. Although perfectly sound, considerations of fairness are, at worst secondary, or at best complementary to considerations of harm. (shrink)