By Ken Ochs
The recent measles outbreak has led to policy discussions among 2016 presidential hopefuls, a systematic mobilization of public health groups to combat the surging number of cases, and the near-inevitability that tougher laws on vaccinations will soon be debated and subsequently passed in legislatures across the country.
Historically, states have dealt with the issue in remarkably different ways, with very little in common aside from their tolerance for exemptions for medical reasons. California, the source of the current outbreak, allows for “religious” and “philosophical” exemptions—the types of dispensations that would be targeted by new regulations.
It would be far too simplistic to reduce the prospect of more stringent laws to a series of false contradictions between personal freedom and the public good. Nonetheless, these two concepts are at the heart of a much deeper ethics issue: the consequences of forced vaccinations on the principles of biomedical ethics. In other words, patients will have less input in their own healthcare as a direct result of new guidelines. Can it be ethically justified?
Since two doses of the MMR (measles, mumps, and rubella) vaccine are typically given between the ages of one and twelve years old (standard practice involves the first injection occurring before the child’s second birthday, and the second before enrollment in kindergarten) there are special considerations on autonomy and informed consent as this type of medical intervention involves children.
It can be reasonably asserted that establishing a timeframe for the course of treatment—as well as consenting—is typically between a parent and her child’s physician. Stricter vaccination laws threaten to eliminate this dynamic altogether, but one must seriously call into question whether it was valuable in the first place.
A recent study shows that fewer than 90% of preschool students have received the first course of MMR in 17 states. Measles killed 145,700 people in 2013 alone and remains one of the leading causes of death among children worldwide. Startlingly, the rates of vaccination for Ohio and West Virginia (86%) are roughly equivalent to the worldwide vaccination rate (84%).
Ethically, for the effects that it has beyond the individual, vaccination cannot be considered on the same level as most other medical decisions and hence it cannot have similar considerations for autonomy. According to the foundational text on public health ethics by James Childress et al., “general moral considerations have two major dimensions,” one of which “determines the extent of conflict,” while the other “determines when different considerations yield to others in cases of conflict.”
In this instance, a substantial conflict has arisen between personal autonomy and public welfare and one consideration must be prioritized over the other. However, an arbitrary preference for one principle over another is insufficient. In order to justify such a priority, Childress et al. argues that the intervention must be effective, outweigh the infringed upon personal freedoms, be fully necessary to achieve the outcome, seek to minimize infringement, and be justifiable to the general public.
The effectiveness rate for the MMR vaccine, which prevents “the most deadly of all childhood rash/fever illnesses,” is 97% after both doses. In terms of proportionality, one must consider both those who would be mandated to receive the vaccination and those who would be exposed to the contagious condition of those who have not been vaccinated. It is apparent that the controlled process of obligatory vaccinations would be preferred over the death of an unknown number of innocent people and an indefinite scope for outbreaks and epidemics that would follow.
The statistic that measles infects 90% of those who have been exposed to it—coupled with the scientific reality that “natural immunity” and “a healthy lifestyle” will not provide protection—are grounds to classify an intervention as entirely necessary. Because there is no conceivable less-troubling alternative to vaccination, the moral considerations lead to a binary: to mandate, or not to mandate?
Of course, it follows that it would be the responsibility of government health agencies to justify such an action “to the relevant parties, including those affected by the infringement.” Since the affected group is more or less the entire U.S. population, sufficient resources would be necessary to propagate the new guidelines and dispel common falsehoods about vaccinations. This would not a menial task of basic public relations; it is instead a tall order seeing as one-third of American parents erroneously link vaccines to autism.
While parents may be the most crucial actors in this public health matter, viewing the autonomy of the child in a vacuum involving only the parent and the physician would require a total abandonment of respect for beneficence, nonmaleficence, and justice. An article by James Colgrove in the New England Journal of Medicine on the ethics of compulsory HPV vaccination points out, “Bioethicists, who generally hold the values of patient autonomy and informed consent to be preeminent, tend to be skeptical about compulsory vaccination laws.”
However, the same text sets a clear boundary on its skepticism, and makes an important distinction, as it emphasizes, “there is a less compelling rationale for requiring protection against [HPV] than against measles…in the absence of potential harm to a third party, such laws may be considered unacceptably paternalistic.”
Measles, which is highly contagious and spreads rapidly, certainly presents a significant risk of harm to third parties. The principle of nonmaleficence obliges healthcare providers to avoid harming patients, thus allotting to a parent a degree of autonomy potentially causing harm to the patient or the population is gravely problematic.
An accompanying principle—beneficence—calls for actions that function for the improvement of patient health. Aside from the exceptions given to patients for health reasons, the absence of stricter guidelines would only suffice in a hypothetical situation where healthcare workers do not consider community impact in decisions that undeniably require it.
Justice is also a key principle in justifying compulsory vaccination for measles. The failure to vaccinate children against measles when there is no medical contraindication straightforwardly creates and perpetuates the existence of a vulnerable population, according to the American Medical Association’s Journal of Ethics. Children who were exempted by their parents for nonmedical reasons are 35 times more likely to contract measles and, “as more nonmedical exemptions from vaccination are accepted by schools, cases of vaccine-preventable illness rise.” The effort required treating that which could have been prevented is also unfair to populations who have difficulty accessing the vaccine for socioeconomic or geographical reasons.
A medical action with the potential for deadly consequences in the communal realm cannot be justified by a proper understanding of autonomy and its interdependence on the other three principles. Stricter laws on vaccinations in harmony with public health ethics would preserve a balance of biomedical principles, while also supporting the public good inasmuch is necessitated by pertinent studies and literature.
Ken Ochs, FCRH Class of 2015, is a neuroscience major (concentration in cell & molecular neuroscience), theology secondary major, and bioethics minor.