Childhood Immunisation: ethical considerations in relation to health promotion strategies

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1 Childhood Immunisation: ethical considerations in relation to health promotion strategies Laura Trolan, 3 rd Year Medical Student, QUB Address for Correspondence: Faculty of Medicine and Health Sciences, QUB, Whitla Medical Building, 97 Lisburn Road, Belfast BT9 7BL T @qub.ac.uk The Government is considering making childhood immunisation compulsory in order to improve the health of the nation. Among proposals to facilitate this objective are withholding child allowance or free schooling for non-vaccinated children and payment of compensation if harm is done to the individual. In this article, the ethical and moral issues arising from the government s aims are considered and the current debate on the MMR triple vaccination is reviewed. J NI Ethics Forum 2005, 2: Introduction Mandatory immunisation has been the subject of extensive debate in the public domain as far back as the 18 th century, when vaccination was first introduced. Since many of the vaccine-preventable diseases are now uncommon, the focus of concern is no longer with the disease itself, rather the alleged adverse effects associated with vaccination. 8 With many parents concerned about adverse outcomes, and unsure of the facts regarding vaccines, an increasing number are deciding against the immunisation of their children. Epidemiological advice suggests that if immunisation rates continue to decline, epidemics could ensue. 4 Although a mandatory immunisation programme could offer a solution to the recent decline in vaccine uptake, there are conflicting views as to whether such a programme is justified in the UK, given the ethical issues that would arise as a result. 102

2 Considering the Problem In order to justify the implementation of any immunisation programme, as well as deciding on the force with which a vaccination is promoted, a number of factors must be considered. Firstly one must determine the severity of the disease being vaccinated against, and the potential harm this could cause to the individual. Secondly, the actual vaccine itself should be examined, with its efficacy in preventing the disease, both through individual and herd community being determined. 7 Serious consideration should also be given to the adverse effects of the vaccine and their severity. Individuals will generally benefit from immunisation if the likelihood of developing morbidity or mortality from the disease is significantly greater before immunisation than after, taking into consideration the likelihood of developing vaccine related complications. 3 Following the public opposition of immunisation programmes in the past, it is evident that particular thought must also be given to the ethical and moral issues that arise from the vaccination, including matters of liberty and justice. 7 For an immunisation programme to be just, there must be equal access to immunisation for all children, fair sharing of both the benefits and the risks of immunisation, as well as due respect for any family who refuse to have their child vaccinated. While a mandatory immunisation programme might lower the individual risk of disease and share more evenly the burdens of maintaining a protective level of herd immunity, it would violate a family s autonomy, with individuals no longer having freedom of choice. 7 The government aims to achieve increased vaccine uptake through offering child allowance and free schooling only to those children that have been vaccinated. This strategy has proved successful in other countries, such as the USA and Australia, where up to date vaccinations are required in order for parents to receive their payment of maternity allowance at 18 months, as well as childcare benefits. 3 Many feel that this is a form of oppression, and ultimately bullies members of society 103

3 into vaccinating their children, without respecting their individual beliefs and views. For a child to be denied education based on a decision made by their parents, is clearly not in the best interests of the child. There are sections of the community, such as followers of The Christian Science Church, and those that use homeopathy, who have protested that their views and beliefs would be violated if immunisations were to become compulsory. 17 In the United States, where children are not allowed to attend school unless they have received the required vaccinations, 12 there are exemption clauses that allow people with philosophical, ethical or religious objections to decide against the immunisation of their children. 3 These are in place to specifically protect members of the public from possible tyranny, and such exemption clauses should be introduced in the UK if immunisations were to become compulsory. The government should evaluate the success of such immunisation programmes that are already in existence, focusing on how the immunisation rates in that country were affected, as well as any change in the publics confidence in the government and healthcare professionals. There are a number of rights that must be considered by the government before the decision is made to make immunisation compulsory. 2 Firstly, the right of parents to raise their children according to their own standards and beliefs, secondly, the right of children to receive healthcare, and finally, the right of the community to be protected from vaccine-preventable infectious disease. Since a child does not have the capacity to make an informed decision regarding their immunisation, the power to consent is that of the parents, or others with parental responsibility. The parents consent will be legally valid if it exercised in the best interests of the child. 5 The problem arises in the ethical debate surrounding the issue of mandatory immunisation when different people hold conflicting rights. For example, the right of child to healthcare may conflict with a parents right to decide what treatment their child receives. The rights of the community may also conflict with that of the child, and a 104

4 solution to the problem of conflicting interests is the view that rights are not necessarily absolute and that, often one right can be considered overriding. 2 By introducing mandatory immunisation, the government is making the health of the community its primary concern, and many feel that such a programme ignores the rights of parents, and to some degree those of children, since their individual needs are not being considered. Rights of Parents In today s liberal society, respect for autonomy is a core ethical principle, with most decisions regarding the welfare of individual children being rightly left to their parents, as outlined in the Child Act When deliberating the vaccination of children the question arises as to whether or not parental autonomy should allow parents to prevent their children from being immunised, even if healthcare professionals feel that the vaccination is in the best interest of the child. Parental rights are based on the duty of parents to care for their children to an acceptable level, and it is largely assumed that parents will make good choices for their children. Some however argue that by preventing the vaccination of their child, a parent is not caring for their child appropriately, and subsequently relinquishes the right to make decisions regarding the welfare of the child. 2 Vaccinations are never immediately life-saving, except in the unlikely case of post-exposure rabies vaccine or smallpox vaccine 10 and therefore it is questionable whether a parents decision against vaccination can be overruled. Paediatricians have historically believed that they have the right and duty to be paternalistic, based on their duty as physicians to promote the child s health and not his/ her autonomy. 18 There is a general acceptance of the correctness of paternalism in society today if a disease poses a significant threat, and there is a proven safe and effective vaccine available to prevent the disease. In such a case the freedom to refuse medical intervention should be overridden by the right of vulnerable children to be protected from harm. However, in the UK most 105

5 immunisations given to children do not show benefits of such magnitude, since most vaccine-preventable disease have become rare and show a significant degree of population immunity, lessening the chances of children contracting them. 2 When the balance of benefits and risks is less apparent, it becomes more difficult to argue that a child has the right to vaccination. Bradley states that, Healthcare professionals cannot justify immunisation for children against parents wishes, purely in terms of the consequences that their actions yield. Parents can be wronged if their wishes are ignored and usually their wishes should be considered overriding. However if children are considered to be in danger of being harmed significantly, their wellbeing is the primary concern. 2 Individual Rights Versus Community Health Another issue that has raised public concern is the idea of individual compensation, i.e. the acceptance of a small risk of complications in a few individuals in order to benefit the public health, by reducing the incidence of an infection or disease in the community. 1 Although there is a general consensus that vaccination offers both individual and communal benefits, the benefits to a non-immunised individual of becoming vaccinated wane as the percentage of vaccinated people in a population increases. 3 When herd immunity levels are high, the risk of the disease to an individual is low, yet the risk of adverse effects from the vaccine remains unchanged. 16 In such an instance it would seem that the safest option for the individual is to be protected from the disease by herd immunity, as any risks from the vaccine are avoided. There are however, individuals in the community for whom certain vaccinations are contraindicated or simply fail to elicit protective immunity. 7 These individuals have to rely on the vaccination of those in the community to essentially act as a barrier against the disease, and if levels of herd immunity were to decline as a result of vaccine avoidance, they would be at an increased risk of contracting the disease. If the government were 106

6 to make vaccination compulsory, children who cannot receive vaccination for medical reasons would be protected, however at the cost of placing many individual children at a minute, yet measurable risk of adverse vaccine effects. The government must consider whether immunising thousands of children unwillingly is justified in order to maintain herd immunity and protect a very small number of children for whom immunisation may be contraindicated, or who are too young to receive the vaccine. 7 This is a case of individual rights versus community health, and in order for individuals to continue to be vaccinated despite the low incidence of the disease, the risks of the vaccine must be minimal and have few adverse effects. 16 Clearly if a vaccine was to be made compulsory by the government, extensive research must first be conducted to confirm that the risk of a child experiencing an adverse effect is very low. 6 This will ensure the public are confident in the immunisation programme, and understand that the vaccination is in the best interests of their children. Right of access to unbiased information In paediatrics and primary care the uphill battle to increase vaccine uptake seems to get increasingly difficult. Countless hours are currently expended in both primary and secondary care counselling parents about the safety of vaccines. This is because the public are becoming more informed, with some of their information coming from the popular press or online information sources, including the well known flawed research by Wakefield. Reports of associations between vaccines and adverse outcomes often receive much public attention, and it becomes difficult to establish if the information being delivered is accurate. 16 Documentation of cases where vaccinated children experienced an alleged adverse effect can often evoke fear and concern in parents, and consequently taint their perception of the safety of the vaccine. 15 This was demonstrated clearly in the recent controversy surrounding the triple 107

7 Measles Mumps and Rubella (MMR) vaccine, and the adverse outcomes that were allegedly associated with the vaccination. The MMR vaccine was introduced in 1988 to immunise children against measles, mumps and rubella. 19 All three conditions can cause serious side effects in those infected, and in small number of cases can even lead to death. Although the MMR vaccine has a few recognised side effects, the public health authorities believe the risks are greatly outweighed by the benefits of the vaccination. A small study of bowel disease and autism, published by Wakefield and his colleagues in 1998 suggested that there was a link between the MMR vaccine and autism. 22 Before the publication of this report the emerging public debate surrounding the possible link between the MMR vaccine and the development of autism had been based on little more than anecdotal evidence. However following the publication of the report there was an explosive public response, fuelled by an ongoing media frenzy. Wakefield s report referred to 12 children, all with a history of normal development, that later experienced a loss of acquired skills, including language, together with diarrhoea and abdominal pain. In a startling 8 out of the 12 children, it was reported that the onset of behavioural symptoms was associated with MMR, and that symptoms were evident on average just 6.3 days after the MMR vaccine. 22 This report however lacked scientific evidence to indicate any link between the vaccine and autism, relying primarily on the reports of parents and families of the 12 children with autism in the study to make their suggestion. 13 The government s refusal to provide the public with single vaccines as an alternative to the triple MMR caused further concern. Some parents believe that multiple vaccines overload their child s immune system and increase the risk of harmful side effects. 3 There is no scientific evidence that suggests a baby s immune system cannot cope with a number of antigens at one time, and the BMA believe that single vaccines are less 108

8 effective that the triple vaccines, and leave a greater number of children unprotected for extended periods. 11 Some parents, however, feel this is the safest option in having their child immunised, as they believe there to be less risks associated with the single vaccines. This issue raises the question, does parental autonomy not require that parents be given the right to choose the type of vaccine used. It could be argued that it would be preferable for the government to provide a less effective vaccine that many parents nevertheless favour, and will use, than take the risk that the child will go unvaccinated altogether. 3 Six years on from Wakefield s paper and the population inoculation rate in Britain is an alarming 79%, with rates as low as 55% in some regions. Such levels of immunity are considerably below the minimum 95% levels recommended by the World Health Organisation 19 to provide nationwide immunity and an epidemic of measles that can maim and even kill, now threatens. While the claims that the MMR vaccine causes autism are now largely accepted to be based on unrepresentative anecdote, and lacking in scientific evidence, the damage that has been done to public confidence in the safety of the vaccine will take considerable time to repair. How can parents possibly make an informed decision regarding the immunisation of their children, when they are being given conflicting advice regarding the vaccine safety? Perhaps in such a situation it would be in the best interests of the children to make vaccinations compulsory since the ability of parents to make an informed decision is compromised, due to their tainted perception of vaccine safety. 9 The media have a powerful influence over public opinion, 15 and it is clear that in order to protect the health of society, more care must be taken to ensure that the information being delivered to the public is accurate, and based on scientific evidence. 21 This will ensure that each family can make an informed assessment of the relative risks known to be associated with the various options, including the risks from being 109

9 unvaccinated. Perhaps the government should view education, and not compulsion as the key to high vaccine uptake rates. 20 Conclusion Clearly no single answer exists as to what immunisation programme best serves the needs of children, parents and the health of the wider community. The most effective method of improving immunity levels of a population will depend on the levels of immunity which already exist, as well as the attitudes of individuals towards vaccinations, and what the perceived benefits and risks are. The government must evaluate the pros and cons of the various methods by which vaccinations can be promoted, whether it be through recommendation, or compulsion. In order for future vaccination programmes to be successful, it is fundamental that factors that contribute to vaccination compliance are determined. More time and effort should be invested in providing parents with a reliable, evidence-based and objective source of information, to enable them to make an informed, rational decision regarding the immunisation of their child. While the immunisation of children against the wishes of their parents is considered justifiable when the child is perceived to be in danger of being harmed significantly, it is not so when the balance of benefits and risks becomes less apparent. Where protection is given for diseases which are not very prevalent, or where there is already a high degree of population immunity, a child who is assumed to be well should not be immunised if the parent has refused. This appears to be the case for most vaccinations in the UK at present. The issue of compulsory immunisation was considered by an Expert Group, as established by the Scottish Executive 14 and it was concluded that, such a policy is not consistent with key elements of the frameworks of principles for immunisation policy. On a practical level, it is not self evident that it would lead to higher levels of immunisation. More substantively, it runs 110

10 counter to the Expert Group s core principle that vaccines should be administered on a voluntary basis. 14 In view of the levels of population immunity that currently exist, it can be concluded that implementing a mandatory immunisation programme in the UK would be unethical, and could prove counterproductive. The government, in association with healthcare professionals, must instead use every means possible to educate and advise the public about the overwhelming benefits of vaccination for their children, and for the community as a whole. However, if immunisation coverage continues to decline, as has been the trend in recent years following the MMR controversy, then compulsory vaccination may well become a morally justifiable option. Laura undertook the 2 nd Year Student Selected Component Ethical Issues in Paediatrics co-ordinated by Dr Mike Shields, School of Medicine, in spring References 1. Boyd KM, Higgs R, Pinching AJ. The New Dictionary of Medical Ethics. London: BMJ Publishing Group, Bradley P. Should childhood immunisation be compulsory? J Med Ethics 1999; 25: British Medical Association. Childhood Immunisation: A guide for Health Professionals. BMA Board of Science and Education Calman K. From the Chief Medical Officer: Measles, mumps, rubella (MMR) vaccine, Chrons disease and autism. London: Department of Health, 1998: Department of Health. Children Act. London: HMSO, Eskola J. Childhood immunisation today. Drugs 1998; 55(6): Feudtner C, Marcuse EK. Ethics and Immunisation Policy: Promoting Dialogue to Sustain Consensus. Pediatrics 2001; 107(5): Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunisations? A national telephone survey. Pediatrics 2000; 106(5):

11 9. Hendrick J. Law and Ethics in Nursing and Health Care. Cheltenham: Stanley Thornes Ltd, Hodges F M et al. Prophylactic interventions on children: Balancing human rights with public health. J Med Ethics 2002; 28: Date Accessed: 20/02/ Date Accessed: 14/02/ Date Accessed: 20/02/ Date Accessed 19/02/ Jackson T. Both sides now. BMJ 2002; 325: King S. Vaccination Policies: Individual rights v community health. BMJ 1999; 319: Lenton S, Randall R, Simpson N. Parental refusal to have children immunised: Extent and reasons. BMJ 1995; 310: McIntyre P et al. Refusal of parents to vaccinate: declaration of duty or legitimate personal choice? MJA 2003; 178: MMR: The Truth behind the Crisis. The Sunday Times 22 nd Feb 2004; pg 1, Personal communication: Dr David Elliman, Consultant in Community Child Health and Dr Helen Bedford, Lecturer, Feb The Vaccine Administration Taskforce. UK guidance on best practice in vaccine administration. London: Shire Halls Communications. 22. Wakefield AJ et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet 1998; 351: