Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

The Sexual Ethics of HPV Vaccination for Boys

Abstract

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.

This is a preview of subscription content, log in to check access.

Notes

  1. 1.

    The term ‘discrimination’ appears to have two different uses. Although it is sometimes used to denote any form of differentiation between individuals, we want to focus only on illegitimate, unjust or prejudiced forms of discrimination, which arise when individuals are given differential treatment on the basis of characteristics that are not relevant to the case at hand.

  2. 2.

    In the remainder of the paper we will speak of boys’ moral duty to become vaccinated against HPV, even though their parents are to accept vaccination given that the vaccine would be offered in their early teens. We thus speak of boys’ duty to accept vaccination as shorthand for the parents’ duty to accept vaccination for their sons on behalf of their sons.

  3. 3.

    Given the fact that HPV vaccination is most effective before one’s sexual debut and is thus best administered in children’s early teens, this concern for health is to be framed in terms of the parents’ moral duties towards their children. In fact, arguing that individuals have the moral duty to promote their own health may be more controversial than arguing that parents have the moral duty to take care of their children’s health (Archard and Benatar 2010).

  4. 4.

    Whereas the usefulness of sex for the continuation of humanity is obvious, this is in itself no judgment regarding the desirability of humanity and societies continuing to exist. A case against the latter can be found in Benatar (2006).

References

  1. Achkar, J. M., & Macklin, R. (2009). Ethical considerations about reporting research results with potential for further stigmatization of undocumented immigrants. Clinical Infectious Diseases, 48(9), 1250–1253. doi:10.1086/597587.

  2. Ali, H., Guy, R. J., Wand, H., Read, T. R., Regan, D. G., Grulich, A. E., Fairley, C. K., Donovan, B. (2013). Decline in in-patient treatments of genital warts among young Australians following the national HPV vaccination program. BMC Infectious Disease, 13, 140. doi:10.1186/1471-2334-13-140.

  3. Arbyn, M., Castellsague, X., de Sanjose, S., Bruni, L., Saraiya, M., Bray, F., et al. (2011). Worldwide burden of cervical cancer in 2008. Annals of Oncology, 22(12), 2675–2686. doi:10.1093/annonc/mdr015.

  4. Archard, D., & Benatar, D. E. (2010). Procreation and parenthood: The ethics of bearing and rearing children. Oxford: Oxford University Press.

  5. Barroso, L. F., I. I., & Wilkin, T. (2011). Human papillomavirus vaccination in males: The state of the science. Current Infectious Disease Reports, 13(2), 175–181. doi:10.1007/s11908-010-0163-7.

  6. Beauchamp, T., & Childress, J. (2001). Principles of biomedical ethics (5th ed.). Oxford: Oxford University Press.

  7. Benatar, D. (2006). Better never to have been: The harm of coming into existence. Oxford: Oxford University Press.

  8. Beutels, P. (2001). Economic evaluations of hepatitis B immunization: A global review of recent studies (1994–2000). Health Economics, 10(8), 751–774. doi:10.1002/hec.625.

  9. Beutels, P., & Jit, M. (2010). A brief history of economic evaluation for human papillomavirus vaccination policy. Sex Health, 7(3), 352–358. doi:10.1071/SH10018.

  10. Beutels, P., Scuffham, P. A., & MacIntyre, C. R. (2008). Funding of drugs: Do vaccines warrant a different approach? The Lancet Infectious Disease, 8(11), 727–733. doi:10.1016/S1473-3099(08)70258-5.

  11. Brankovic, I., Verdonk, P., & Klinge, I. (2013). Applying a gender lens on human papillomavirus infection: Cervical cancer screening, HPV DNA testing, and HPV vaccination. International Journal for Equity in Health, 12, 14. doi:10.1186/1475-9276-12-14.

  12. Brisson, M., van de Velde, N., Franco, E. L., Drolet, M., & Boily, M. C. (2011). Incremental impact of adding boys to current human papillomavirus vaccination programs: Role of herd immunity. Journal of Infectious Diseases, 204(3), 372–376. doi:10.1093/infdis/jir285.

  13. Burls, A., Jordan, R., Barton, P., Olowokure, B., Wake, B., Albon, E., et al. (2006). Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine, 24(19), 4212–4221. doi:10.1016/j.vaccine.2005.12.043.

  14. Chaturvedi, A. K. (2010). Beyond cervical cancer: burden of other HPV-related cancers among men and women. Journal of Adolescent Health, 46(4 Suppl), S20–S26. doi:10.1016/j.jadohealth.2010.01.016.

  15. Daniels, N., Kennedy, B., & Kawachi, I. (2000). justice Is good for our health: How greater economic equality would promote public health. Boston Review, 25(1), 4–19.

  16. Dawson, A. (2007). What are the moral obligations of the traveller in relation to vaccination? Travel Medicine and Infectious Disease, 5(2), 90–96. doi:10.1016/j.tmaid.2006.01.005.

  17. Dawson, A. (2009). Herd protection as a public good: Vaccination and our obligations to others. In A. Dawson & M. Verweij (Eds.), Ethics, prevention and public health. Oxford: Oxford University Press.

  18. Doorbar, J., Quint, W., Banks, L., Bravo, I. G., Stoler, M., Broker, T. R., et al. (2012). The biology and life-cycle of human papillomaviruses. Vaccine, 30(Suppl 5), F55–F70. doi:10.1016/j.vaccine.2012.06.083.

  19. Ed. (2013). GAVI injects new life into HPV vaccine rollout. The Lancet, 381(9879), 1688.

  20. Fine, P., Eames, K., & Heymann, D. L. (2011). “Herd immunity”: A rough guide. Clinical Infectious Diseases, 52(7), 911–916. doi:10.1093/cid/cir007.

  21. Gautret, P., Yong, W., Soula, G., Parola, P., Brouqui, P., & DelVecchio Good, M. J. (2010). Determinants of tetanus, diphtheria and poliomyelitis vaccinations among Hajj pilgrims, Marseille, France. European Journal of Public Health, 20(4), 438–442. doi:10.1093/eurpub/ckp196.

  22. Gillison, M. L., & Shah, K. V. (2003). Chapter 9: Role of mucosal human papillomavirus in nongenital cancers. National Cancer Institute Monographs, 31, 57–65.

  23. Harris, J., & Holm, S. (1995). Is there a moral obligation not to infect others? BMJ, 311(7014), 1215–1217.

  24. Hinman, A. R. (2004). Immunization, equity, and human rights. American Journal of Preventive Medicine, 26(1), 84–88.

  25. Judd, A., Hickman, M., Hope, V. D., Sutton, A. J., Stimson, G. V., Ramsay, M. E., Gill, O. N., Parry, J. V. (2007). Twenty years of selective hepatitis B vaccination: Is hepatitis B declining among injecting drug users in England and Wales? Journal of Viral Hepatitis, 14(8), 584–591. doi:10.1111/j.1365-2893.2007.00844.x.

  26. Kim, J. J., Andres-Beck, B., & Goldie, S. J. (2007). The value of including boys in an HPV vaccination programme: A cost-effectiveness analysis in a low-resource setting. British Journal of Cancer, 97(9), 1322–1328. doi:10.1038/sj.bjc.6604023.

  27. Kirby, T. (2012). Australia to be first country to vaccinate boys against HPV. Lancet Oncology, 13(8), e333.

  28. Kolf, C. (2012). QnAs with Harald zur Hausen [Biography Historical Article Interview]. Proceedings of the National Academy of Sciences of the United States of America, 109(5), 1378. doi:10.1073/pnas.1120821109.

  29. Kubba, T. (2008). Human papillomavirus vaccination in the United Kingdom: What about boys? Reproductive Health Matters, 16(32), 97–103. doi:10.1016/S0968-8080(08)32413-6.

  30. Lefevere, E., Hens, N., Theeten, H., Van den Bosch, K., Beutels, P., De Smet, F., et al. (2011). Like mother, like daughter? Mother’s history of cervical cancer screening and daughter’s Human Papillomavirus vaccine uptake in Flanders (Belgium). Vaccine, 29(46), 8390–8396. doi:10.1016/j.vaccine.2011.08.039.

  31. Luyten, J., Dorgali, V., Hens, N., & Beutels, P. (2013). Public preferences over efficiency, equity and autonomy in vaccination policy: An empirical study. Social Science and Medicine, 77, 84–89. doi:10.1016/j.socscimed.2012.11.009.

  32. Luyten, J., Vandevelde, A., Van Damme, P., & Beutels, P. (2011). Vaccination policy and ethical challenges posed by herd immunity, suboptimal uptake and subgroup targeting. Public Health Ethics, 4(3), 280–291. doi:10.1093/Phe/Phr032.

  33. Machalek, D. A., Grulich, A. E., Jin, F., Templeton, D. J., & Poynten, I. M. (2012). The epidemiology and natural history of anal human papillomavirus infection in men who have sex with men. Sex Health, 9(6), 527–537. doi:10.1071/SH12043.

  34. Malmqvist, E., Helgesson, G., Lehtinen, J., Natunen, K., & Lehtinen, M. (2011). The ethics of implementing human papillomavirus vaccination in developed countries. Medicine, Health Care and Philosophy, 14(1), 19–27. doi:10.1007/s11019-010-9285-9.

  35. Malmqvist, E., Natunen, K., Lehtinen, M., & Helgesson, G. (2012). Just implementation of human papillomavirus vaccination. Journal of Medical Ethics, 38(4), 247–249. doi:10.1136/medethics-2011-100090.

  36. Manhart, L. E., & Koutsky, L. A. (2002). Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia? A meta-analysis. Sexually Transmitted Diseases, 29(11), 725–735.

  37. Marra, F., Cloutier, K., Oteng, B., Marra, C., & Ogilvie, G. (2009). Effectiveness and cost effectiveness of human papillomavirus vaccine: A systematic review. Pharmacoeconomics, 27(2), 127–147. doi:10.2165/00019053-200927020-00004. 4 [pii].

  38. Mill, J. S. (1869). On liberty. London: Longman, Roberts & Green.

  39. Munoz, N., Bosch, F. X., de Sanjose, S., Herrero, R., Castellsague, X., Shah, K. V.,Snijders, P. J., & Meijer, C. J. (2003). Epidemiologic classification of human papillomavirus types associated with cervical cancer. The New England Journal of Medicine, 348(6), 518–527. doi:10.1056/NEJMoa021641.

  40. Newall, A. T., Beutels, P., Wood, J. G., Edmunds, W. J., & MacIntyre, C. R. (2007). Cost-effectiveness analyses of human papillomavirus vaccination. The Lancet Infectious Disease, 7(4), 289–296. doi:10.1016/S1473-3099(07)70083-X.

  41. Parkin, D. M., & Bray, F. (2006). Chapter 2: The burden of HPV-related cancers. Vaccine, 24(Suppl 3), S3/11–S3/25. doi:10.1016/j.vaccine.2006.05.111.

  42. Postma, M. J., Bos, J. M., Beutels, P., Schilthuis, H., & van den Hoek, J. A. (2004). Pharmaco-economic evaluation of targeted hepatitis A vaccination for children of ethnic minorities in Amsterdam (The Netherlands). Vaccine, 22(15–16), 1862–1867. doi:10.1016/j.vaccine.2003.11.012.

  43. Salo, H., Leino, T., Kilpi, T., Auranen, K., Tiihonen, P., Lehtinen, M.,…,Nieminen, P. (2013). The burden and costs of prevention and management of genital disease caused by HPV in women: A population-based registry study in Finland. International Journal of Cancer. doi:10.1002/ijc.28145.

  44. Schiller, J. T., Castellsague, X., & Garland, S. M. (2012). A review of clinical trials of human papillomavirus prophylactic vaccines. Vaccine, 30(Suppl 5), F123–F138. doi:10.1016/j.vaccine.2012.04.108.

  45. Slote, M. (2000). Virtue ethics. In H. Lafollette (Ed.), The Blackwell guide to ethical theory (pp. 325–347). Malden, MA: Blackwell.

  46. Thaler, R. H., & Sunstein, C. (2008). Nudge: Improving decisions about health, wealth and happiness. New Haven, NJ: Yale University Press.

  47. Trottier, H., & Burchell, A. N. (2009). Epidemiology of mucosal human papillomavirus infection and associated diseases. Public Health Genomics, 12(5–6), 291–307. doi:10.1159/000214920.

  48. Wellman, C. (2001). Toward a liberal theory of political obligation. Ethics, 111(4), 735–759.

  49. Whitley, R. J., & Roizman, B. (2001). Herpes simplex virus infections. The Lancet, 357(9267), 1513–1518. doi:10.1016/S0140-6736(00)04638-9.

  50. Wu, X., Watson, M., Wilson, R., Saraiya, M., Cleveland, J., & Markowitz, L. (2012). Human papillomavirus-associated cancers—United States, 2004–2008. Morbidity and Mortality Weekly Report of Centers for Disease Control and Prevention, 61(15), 258–261.

Download references

Author information

Correspondence to Jeroen Luyten.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Luyten, J., Engelen, B. & Beutels, P. The Sexual Ethics of HPV Vaccination for Boys. HEC Forum 26, 27–42 (2014). https://doi.org/10.1007/s10730-013-9219-z

Download citation

Keywords

  • Infectious disease
  • Public health
  • Immunization
  • Efficiency
  • Sexually transmitted infection
  • HPV