In 2019, the WHO declared vaccine hesitancy as one of the world`s top ten global health threats (WHO, 2019). It was reported that vaccination rates, in Scotland that year, dropped in fourteen of the seventeen immunizations for children under six (Health Scotland, 2019). The reasons behind parental refusal are inherently complex, but many factors (such as misinformation about vaccinations, particularly religious and cultural beliefs, and historically fatal vaccination experiments) have created an ingrained stigma against vaccination (McKee et al., 2016). While a decision surrounding a medical intervention will usually revolve around an individual patient, vaccination is unique because of its implications on the wider society due to the communicability of infectious diseases. Herd immunity, a result of mass vaccination, is desirable as it results in resistance to a disease within a population and provides a measure of protection for immunologically vulnerable individuals (Rashid et al., 2012). This brings into question whether mandatory vaccination should be used to achieve sufficient vaccination levels. By first explaining the presence of a moral obligation to vaccinate, an ethical framework arises that strengthens the case for enforced vaccination. However, this essay will then present that this view is paternalistic as it fails to acknowledge the practice of autonomy and non-maleficence along with the complex reasons behind refusal. This essay will conclude therefore, that state coercion can only be justified when herd immunity is not achieved and otherwise, education and other public health strategies should be employed.
To explore the moral obligation to be vaccinated, the principle of justice can be applied. In public health, practicing justice involves an equal contribution to the control of communicable diseases through showing solidarity by giving up one`s own interests, in this case by being vaccinated, to serve the common good. Acting with beneficence and showing altruism in this way, is considered morally correct. Therefore, these notions suggest society has a prima facie obligation to protect the vulnerable, such as the young or immunosuppressed, who are unable to be vaccinated themselves, so rely on the collective responsibility of those who can be vaccinated to maintain herd immunity. Additionally, some argue that it is the duty of those who live in countries with free and accessible healthcare to ensure that their children are vaccinated, as many parents globally are not given this option. Beneficence also provides the basis of John Stuart Mill`s principle of utilitarianism. In the context of vaccination, herd immunity provides the maximization of utility as the costs of vaccination for an individual are generally low (because of high vaccine safety) and are outweighed by resulting gains in reductions in disease incidence and preventative health. These advantages contribute to the well-being of the population and, in the long term, conserve resources and money by reducing the need to care for those infected with the disease. Hence, under these frameworks of beneficence and utility maximization, it seems there exists a moral obligation to vaccinate and therefore, compulsory vaccination helps the lay population realize this duty.
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Conversely, it can be argued that, particularly when herd immunity is realized, the difference a single vaccination makes is negligible and thus an individual refusing vaccination causes no additional risk to others which would suggest compulsory vaccination is unjustified. This interpretation would imply that utilitarianism is less relevant as causing pain or potential side effects to a healthy individual implies an ethical cost to that person greater than the benefit from their contribution. However, taking a deontological approach by using the generalization test, refusing vaccination is wrong because universal non-vaccination would have grave consequences as the disease could spread rapidly. Moreover, herd immunity is a collective effect: it requires the contribution of a sufficiently large number of individuals to be realized. The virtue of fairness requires that such burdens be distributed fairly across individuals and therefore if an individual recognizes that they benefit from some collective action then they have an obligation to accept their share of the burden. Hence, compulsory vaccination can act as a mode for agents to realize this duty and avoids the incidence of free-riding where individuals accept the benefits of others' actions, i.e. herd immunity, while choosing to forego the small associated risk or disbenefit, of being vaccinated.
However, compulsory vaccinations often involve the infringement of bodily integrity and this leads to debates as to whether the state is justified in violating these rights for the sake of public health. Bodily integrity is predicated on the right to autonomy and self-determination over one`s own body which, in practice, is exercised through informed consent or informed refusal. Therefore, an unconsented physical intrusion, such as vaccination, can be considered a human rights violation. Democracies are built on freedom and hence, it is argued that people should be able to make choices about their healthcare. Many believe that violation of autonomy goes against the principles of non-maleficence and beneficence, degrading people`s trust in the healthcare system, which is necessary for a constructive patient-physician relationship. However, some argue that autonomy is not an absolute principle but should be balanced by other values, considering social responsibilities and communal goals. For example, the harm principle dictates that the actions of certain individuals can be limited to prevent harm to others which suggest compulsory vaccination can be justified. Moreover, under the parens patriae jurisdiction, the state has a duty in protecting vulnerable individuals and therefore should intervene if they are at risk. Arguably then, if the parental refusal is not acting in the best interests of a child, as it leaves them exposed to infectious diseases, the state should be able to override the parent's decisions. However, some feel this argument is flawed as the government's external judgment of the best outcome may be paternalistic, failing to recognize specific individual`s interests and therefore overlooking autonomy is not warranted.
Moreover, a blanket approach to increasing vaccination may ignore the subtleties of vaccine hesitancy and neglects to solve the many complex reasons why people refuse vaccination. People may oppose vaccination due to religious or moral based beliefs, for example, due to the use of materials from cell lines derived from aborted fetuses, and therefore forcing them to go against these values can cause suffering. Liberal and multiculturalist ideals demand that people be allowed to act upon their own beliefs, realize their values, and practice their customs whenever possible. Therefore, it is proposed that mandatory vaccination infringes on these liberties and the individual cost of being vaccinated would be so great as to outweigh the expected negative contribution of non-vaccination. Moreover, there may be cultural and social barriers against access and confidence in vaccines such as long-standing mistrust in the health systems and government and education or language barriers to understanding accurate health information. While a deontological argument would suggest it is acceptable to hold all groups to the same vaccine rules, it may be more effective in these communities to address the underlying cause of the problem. Through targeting low uptake groups with bottom-up education schemes that are culturally sensitive and delivered in native languages, voluntary uptake of vaccinations would hopefully improve and unease and mistrust towards future vaccinations would be mitigated.
Conclusion
To conclude, the debate surrounding compulsory vaccination is inherently complex due to conflicts between respect for autonomy, the child`s best interest, and just contribution to herd immunity. Therefore, only when herd immunity is not achieved and there is a high incidence of disease (e.g. in a pandemic) should the state coerce individuals to vaccinate when the public health perspective prevails over an individual-centered approach. Voluntary compliance with vaccination requirements is the most desirable as it achieves the benefits of herd immunity without infringing on autonomy and ensures groups feel listened to and supported by the medical profession. Therefore, to achieve adequate levels of responsibility, a trustful dialogue between healthcare providers and patients should be educated about the safety and community benefit of vaccination.
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