Vaccinations are one of public health’s greatest achievements. However, an ethical dilemma lies in the balance of personal autonomy and choice versus protection of the entire at risk population. Vaccines have become readily available in most parts of the world, yet debates continue as to the appropriateness of requirements for vaccinations, including legal mandates of vaccinations during public health emergencies and more routinely for school entry. This paper addresses ethical issues concerning vaccination requirements in the context of historical as well as current immunization program activities. Five important programmatic focus areas for immunization programs are identified for minimizing conflicts among the relevant ethical principles when developing and implementing vaccination requirements; namely: 1) reviewing and evaluating current vaccination mandates in the relevant health jurisdiction; 2) increasing the use of non-compulsory vaccination strategies; 3) addressing parent/guardian vaccine safety concerns; 4) enhancing public awareness of vaccine-preventable disease risks; and 5) promoting a better public understanding of herd immunity. We suggest that strengthening these programmatic focus areas can lead to a greater public acceptance of vaccination requirements.
Centers for Disease Control and Prevention (CDC). Ten great public health achievements–United States, 1900–1999. MMWR Morb Mort Wkly Rep. 1999;48:241–3.
Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess A, Halsey NA. Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet. 2006;367:436–42.
Bayer R, Fairchild AL. The genesis of public health ethics. Bioethics. 2004; 18:473–92.
Childress JF, Faden RR, Garre RD, Gostin LO, Kahn J, Bonnie RJ, et al. Public health ethics: mapping the terrain. J Law Med Ethics. 2002;30:170–8.
Diekema DS, Marcuse EK. Ethical issues in the vaccination of children. In: Bayer R, Gostin LO, Jennings B, Steinbock B, (editors). Public Health Ethics: Theory, Policy and Practice. New York, NY: Oxford University Press; 2007. p.279–88.
Gostin LO, Bayer R, Fairchild AL. Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats. JAMA. 2003;290:3229–37.
Dudgeon JA. Development of smallpox vaccine in England in the eighteenth and nineteenth centuries. Br Med J. 1963;1(5342):1367–72.
Durbach N. Bodily Matters: The Anti-Vaccination Movement in England, 1853–1907. Durham: Duke University Press; 2005. p.23.
Fraser SM. Leicester and smallpox: the Leicester method. Med Hist. 1980; 24:315–32.
Stewart AJ, Devlin PM. The history of the smallpox vaccine. J Infect. 2006; 52:329–34.
Colgrove J. State of Immunity: The Politics of Vaccination in Twentieth-Century America. Berkeley, CA: University of California Press; 2006.
Mariner WK, Annas GJ, Glantz LH. Jacobson v Massachusetts: it’s not your great-great-grandfather’s public health law. Am J Public Health. 2005;95:581–90.
Jacobson v. commonwealth of Massachusetts, 197 U.S. 11 (1905).
Zucht v. King, 260 U.S. 174 (1922).
Gostin LO, (editor). Public Health Law and Ethics: A Reader. Rev. & Updated 2nd ed. Berkeley, CA: University of California Press; 2010.
Buchanan DR. Autonomy, paternalism, and justice: ethical priorities in public health. Am J Public Health. 2008;98:15–21.
Author’s personal experience with Los Angeles County Department of Children and Family Services and local courts.
Balog JE. The moral justification for a compulsory human papillomavirus vaccination program. Am J Public Health. 2009;99:616–22.
Centers for Disease Control and Prevention (CDC). Recommendations on the use of quadrivalent human papillomavirus vaccine in males–Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1705–8.
Charo RA. Politics, parents, and prophylaxis-mandating HPV vaccination in the United States. N Engl J Med. 2007;356:1905–8.
Opel DJ, Diekema DS, Marcuse EK. A critique of criteria for evaluating vaccines for inclusion in mandatory school immunization programs. Pediatrics. 2008; 122:e504–10.
Human Papillomavirus vaccination and reporting Act of 2007. D.C. Act 17–39, D.C. Law. No. 17–10. District of Columbia Register 2007;54:5146–8.
An act relating to immunization against Human Papillomavirus, HB 1098, 80thR. Sess. (TX 2007).
An act to amend section 6926 of the Family Code, relating to minors, AB no. 499. 2011–2012 Sess. (Ca 2011).
Williamson S. One hundred years ago: anti-vaccination leagues. Arch Dis Child. 1984; 59:1195–6.
Retraction—Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010; 375:445. Retraction of: Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637–41.
Isaacs D, Kilham H, Leask J, Tobin B. Ethical issues in immunisation. Vaccine. 2009;27:615–8.
Gerber JS, Offit PA. Vaccines and autism: a tale of shifting hypotheses. Clin Infect Dis. 2009;48:456–61.
Edwards KM, Decker MD. Pertussis vaccines. In: Plotkin S, Orenstein W, (editors). Vaccines. 5th ed. Philadelphia, PA: Saunders; 2008. p.467–518.
Immunization levels in child care and schools. Available from URL: http://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationLevels.aspx (Accessed 20 November 2012).
Centers for Disease Control and Prevention (CDC). National, state, and local area vaccination coverage among children aged 19–35 months-United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;6135:689–96.
Washington State Department of Health. News release: May 17, 2012. Available from URL: http://www.doh.wa.gov/Newsroom/2012NewsReleases/12061VaccineExemptionDecrease.aspx (Accessed 20 November 2012).
California Assembly Bill No. 2109. An act to amend Section 120365 of the Health and Safety Code, relating to a communicable disease. Available from URL: http://www.leginfo.ca.gov/pub/11–12/bill/asm/ab_2101–2150/ab_2109_bill_20120930_chaptered.pdf (Accessed 20 November 2012).
The future of legislation on vaccination. Br Med J. 1896;2:1397–8.
Guide to Community Preventive Services. Vaccinations to prevent diseases: universally recommended vaccinations. Available from URL: www.thecommunityguide.org/vaccines/universally/index.html (Accessed 20 November 2012).
Offit PA, Davis RL, Gust D. Vaccine safety. In: Plotkin S, Orenstein W, (editors). Vaccines. 5th ed. Philadelphia, PA: Saunders; 2008. p.1629–50.
Evans G, Levine EM, Saindon EH. Legal issues. In: Plotkin S, Orenstein W, (editors). Vaccines, 5th ed. Philadelphia, PA: Saunders; 2008. p.1651–176.
Serpell L, Green J. Parental decision-making in childhood vaccination. Vaccine. 2006;24:4041–6.
Larson HJ, Cooper LZ, Eskola J, Katz SL, Ratzan S. Addressing the vaccine confidence gap. Lancet. 2011;378:526–35.
Diekema DS. Improving childhood vaccination rates. N Engl J Med. 2012; 366:391–3.
Gust DA, Darling N, Kennedy A, Schwartz B. Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics. 2008;122:718–25.
Parikh RK. Fighting for the reputation of vaccines: lessons from American politics. Pediatrics. 2008;121:621–2.
Dawson A. Vaccination and the prevention problem. Bioethics. 2004;18:515–30.
Omer SB, Enger KS, Moulton LH, Halsey NA, Stokley S, Salmon DA. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol. 2008;168:1389–96.
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Amin, A.N.E., Parra, M.T., Kim-Farley, R. et al. Ethical Issues Concerning Vaccination Requirements. Public Health Rev 34, 14 (2012). https://doi.org/10.1007/BF03391666
- vaccine mandates
- personal belief exemption