Human papillomavirus (HPV) infection is the world’s most common sexually transmitted infection. It is a prerequisite for cervical cancer, the second most common cause of death in cancer among women worldwide, and is also believed to cause other anogenital and head and neck cancers. Vaccines that protect against the most common cancer-causing HPV types have recently become available, and different countries have taken different approaches to implementing vaccination. This paper examines the ethics of alternative HPV vaccination strategies. It devotes particular attention to the major arguments for and against one strategy: voluntary, publicly funded vaccination for all adolescent boys and girls. This approach seems attractive because it would protect more people against cervical cancer and other HPV-related cancers than less inclusive alternatives, without the sacrifice of autonomy that a comparably broad compulsory programme would require. Also, the herd immunity that it would likely generate would protect those who remain unvaccinated, a major advantage from a justice perspective. However, there is a possibility that a HPV vaccination programme targeting all adolescents of both sexes is not considered sufficiently cost-effective. Also, it might pose more difficulties for achieving informed consent than comparable vaccination programmes against other diseases. Ultimately, society’s choice of HPV vaccination strategy requires careful consideration not only of the values at stake but also of available and emerging scientific evidence.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Agosti, J.M., and S.J. Goldie. 2007. Introducing HPV vaccine in developing countries–key challenges and issues. New England Journal of Medicine 356: 1908–1910.
Arbyn, M., M. Rebolj, I.M.C.M. De Kok, M. Fender, N. Becker, M. O’Reilly, and B. Andrae. 2009. The challenges of organising cervical screening programs in the 15 old member states of the European Union. European Journal of Cancer 45: 2671–2678.
Auvinen, E., M. Niemi, C. Malm, R. Zilliacus, A. Trontti, R. Fingerroos, M. Lehtinen, and J. Paavonen. 2005. High prevalence of HPV among female students in Finland. Scandinavian Journal of Infectious Diseases 37: 873–876.
Balog, J.E. 2009. The moral justification for a compulsory human papillomavirus vaccination program. American Journal of Public Health 99: 616–622.
Barnabas, R.V., P. Laukkanen, P. Koskela, O. Kontula, M. Lehtinen, and G.P. Garnett. 2006. Epidemiology of HPV 16 and cervical cancer in Finland and the potential impact of vaccination: Mathematical modeling analyses. PLoS Medicine 3: e138.
Bauch, C.T., M. Li, G. Chapman, and A.P. Galvani. 2009. Adherence to cervical screening in the era of human papillomavirus vaccination: How low is too low? Lancet Infectious Diseases 10: 133–137.
Beauchamp, T.L., and J. Childress. 2009. Principles of biomedical ethics, 6th ed. Oxford: Oxford University Press.
Blower, S.M., and A.R. McLean. 1994. Prophylactic vaccines, risk behavior change, and the probability of eradicating HIV in San Fransisco. Science 265: 1451–1454.
Brabin, L., S.A. Roberts, F. Farzaneh, and H.C. Kitchener. 2006. Future acceptance of adolescent human papillomavirus vaccination: A survey of parental attitudes. Vaccine 24: 3087–3094.
Brabin, L., S.A. Roberts, R. Strech, D. Baxter, G. Chambers, H. Kitchener, and R. McCann. 2008. Uptake of first two doses of human papillomavirus vaccine by adolescent schoolgirls in Manchester: Prospective cohort study. British Medical Journal 336: 1056–1058.
Bradley, P. 1999. Should childhood immunisation be compulsory? Journal of Medical Ethics 25: 330–334.
Brewer, N.T., and K.I. Fazekas. 2007. Predictors of HPV vaccine acceptability: A theory-informed, systematic review. Preventive Medicine 45: 107–114.
Brown, D.R., S. Kjaer, K. Sigurdsson, et al. 2009. The impact of quadrivalent human papillomavirus (HPV; Types 6, 11, 16, 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in generally HPV-naïve women aged 16–26 years. Journal of Infectious Diseases 199: 926–935.
Colgrove, J. 2006. The ethics and politics of compulsory HPV vaccination. New England Journal of Medicine 355: 389–391.
Collins, S., S. Mazloomzadeh, H. Winter, P. Bloomfield, A. Bailey, L.S. Young, and C.B. Woodman. 2002. High incidence of cervical human papillomavirus infection in women during their first sexual relationship. BJOG: An International Journal of Obstetrics and Gynaecology 109: 96–98.
Dempsey, A.F., G.D. Zimet, R.L. Davis, and L. Koutsky. 2006. Factors that are associated with parental acceptance of human papillomavirus vaccines: A randomized intervention study of written information about HPV. Pediatrics 117: 1486–1493.
EMA (European Medicines Agency). 2009. Human medicines—Cervarix. Available: http://www.emea.europa.eu/humandocs/Humans/EPAR/cervarix/cervarix.htm. Accessed 23 Aug 2010.
EMA (European Medicines Agency). 2010. Gardasil. Available: http://www.emea.europa.eu/humandocs/Humans/EPAR/gardasil/gardasil.htm. Accessed 23 Aug 2010.
Faden, R.R., and T.L. Beauchamp. 1986. A history and theory of informed consent. New York: Oxford University Press.
Feinberg, J. 1987. The moral limits of the criminal law. Vol. 1: Harm to others. New York: Oxford University Press.
French, K.M., R. Barnabas, M. Lehtinen, O. Kontula, E. Pukkala, J. Dillner, and G.P. Garnett. 2007. Strategies for the introduction of human papillomavirus vaccination: Modelling the optimum age- and sex-specific pattern of vaccination in Finland. British Journal of Cancer 96: 514–518.
FUTURE II Study Group. 2007. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. New England Journal of Medicine 365: 1915–1927.
Garnett, G.P. 2005. Role of herd immunity in determining the effect of vaccines against sexually transmitted disease. Journal of Infectious Diseases 191(Suppl. 1): S97–S106.
Hoover, D.R., B. Carfioli, and E.A. Moench. 2000. Attitudes of adolescent/young adult women toward human papillomavirus vaccination and clinical trials. Health Care for Women International 21: 375–391.
Insinga, R.P., E.J. Dasbach, and F.H. Elbasha. 2008. Structural differences among cost-effectiveness models of human papillomavirus. Expert Review of Vaccines 7: 895–913.
Isaacs, D., H.A. Kilham, and H. Marshall. 2004. Should routine childhood immunizations be compulsory? Journal of Paediatrics and Child Health 40: 392–396.
Isaacs, D., H. Kilham, J. Leask, and B. Tobin. 2009. Ethical issues in immunisation. Vaccine 27: 615–618.
Jakobsson, M., M. Gissler, J. Paavonen, and A.M. Tapper. 2009. Loop electrosurgical excision procedure and the risk of preterm birth. Obstetrics and Gynecology 114: 505–510.
Javitt, G., D. Berkowitz, and L.O. Gostin. 2008. Assessing mandatory HPV vaccination: Who should call the shots? Journal of Law Medicine & Ethics 30: 384–395.
Kass, N.E. 2001. An ethics framework for public health. American Journal of Public Health 91: 1776–1782.
Kjaer, S., C. Munk, J.F. Winther, H.O. Jorgensen, C.J. Meijer, and A.J. van den Brule. 2005. Acquisition and persistence of human papillomavirus infection in younger men: A prospective follow-up study among Danish men. Cancer Epidemiology, Biomarkers and Prevention 6: 1528–1533.
Kulasingam, S.H. 2007. Implementation of an HPV-vaccination program. Disease Management & Health Outcomes 15: 141–149.
Lehtinen, M., K. French, J. Dillner, J. Paavonen, and G. Garnett. 2008. Sound implementation of HPV vaccination. Future Medicine (Therapy) 5: 289–294.
Lenselink, C.H., M.M.J.G. Gerrits, W.J.G. Melchers, L.F.A.G. Massuger, D. van Hamonta, and R.L.M. Bekkers. 2008. Parental acceptance of Human papillomavirus vaccines. European Journal of Obstetrics and Gynecology and Reproductive Biology 137: 103–107.
Lo, B. 2006. HPV vaccine and adolescents’ sexual activity. British Medical Journal 332: 1106–1107.
Marra, F., K. Cloutier, B. Oteng, C. Marra, and G. Ogilvie. 2009. Effectiveness and cost effectiveness of human papillomavirus vaccine: A systematic review. Pharmacoeconomics 27: 127–147.
Näsman, A., P. Attner, L. Hammarstedt, J. Du, M. Eriksson, G. Giraud, S. Ahrlund-Richter, L. Marklund, M. Romanitan, D. Lindquist, T. Ramqvist, J. Lindholm, P. Sparén, W. Ye, H. Dahlstrand, E. Munck-Wikland, and T. Dalianis. 2009. Incidence of human papillomavirus (HPV) positive tonsillar carcinoma in Stockholm, Sweden: An epidemic of viral-induced carcinoma? International Journal of Cancer 125: 362–366.
Ogilvie, G.S., V.P. Remple, F. Marra, S.A. McNeil, M. Naus, K.L. Pielak, T.G. Ehlen, S.R. Dobson, D.M. Money, and D.M. Patrick. 2007. Parental intention to have daughters receive the human papillomavirus vaccine. Canadian Medical Association Journal 177: 1506–1512.
Paavonen, J., and the HPV PATRICIA Study Group. 2009. Efficacy of human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): Final analysis of a double-blind, randomised study in young women. Lancet 374: 310–314.
Parkin, D.M. 2006. The global health burden of infection-associated cancers in the year 2002. International Journal of Cancer 118: 3030–3044.
Rawls, J. 1971. A theory of justice. Cambridge, Mass: Belknap.
Regan, D.G., D.J. Philip, J.S. Hocking, and M.G. Law. 2007. Modelling the population-level impact of vaccination on the transmission of human papillomavirus type 16 in Australia. Sexual Health 4: 147–163.
Ross, L.F. 2002. Adolescent autonomy in health care? APA Newsletter: Philosophy and Medicine 2: 193–200.
Taira, A.V., P. Neukermans, and G.D. Sanders. 2004. Evaluating human papillomavirus vaccination programs. Emerging Infectious Diseases 10: 1915–1923.
Trottier, H., and A.N. Burchell. 2009. Epidemiology of mucosal human papillomavirus infection and associated diseases. Public Health Genomics 12: 291–307.
WHO (World Health Organization). 2010. Viral cancer. Human papillomavirus. Available: http://www.who.int/vaccine_research/diseases/viral_cancers/en/index3.html. Accessed 04 Feb 2010.
Winer, R.L., J.P. Hughes, Q. Feng, S. O’Reilly, N.B. Kiviat, K.K. Holmes, and L.A. Koutsky. 2006. Condom use and the risk of genital human papillomavirus infection in young women. New England Journal of Medicine 354: 2645–2654.
Woodhall, S., M. Lehtinen, T. Verho, H. Huhtala, M. Hokkanen, and E. Kosunen. 2007. Anticipated acceptance of HPV vaccination at the baseline of implementation: A survey of parental and adolescent knowledge and attitudes in Finland. Journal of Adolescent Health 40: 466–469.
Zimmerman, R.K. 2006. Ethical analysis of HPV vaccine policy options. Vaccine 24: 4112–4120.
This work was supported by the Swedish Cancer Society.
Conflicts of interest
ML has received grants for phase II-IV vaccination research from Merck & Co Inc. and GSK Biologicals through his employers: University of Tampere and National Institute for Health and Welfare.
About this article
Cite this article
Malmqvist, E., Helgesson, G., Lehtinen, J. et al. The ethics of implementing human papillomavirus vaccination in developed countries. Med Health Care and Philos 14, 19–27 (2011). https://doi.org/10.1007/s11019-010-9285-9
- Cervical cancer
- Herd immunity
- Human papillomavirus