Ethics of Vaccination in Childhood: Comparison
View Latest Version
Please note this is a comparison between Version 3 by Nora Tang and Version 2 by Meta Rus.

Although vaccination is recognised as the top public health achievement of the twentieth century, unequivocal consensus about its beneficence does not exist among the general population. In countries with well-established immunisation programmes, vaccines are “victims of their own success”, because low incidences of diseases now prevented with vaccines diminished the experience of their historical burdens. Increasing number of vaccine-hesitant people in recent years threatens, or even effectively disables, herd immunity levels of the population and results in outbreaks of previously already controlled diseases. We aimed to apply a framework for ethical analysis of vaccination in childhood based on the four principles of biomedical ethics (respect for autonomy, nonmaleficence, beneficence and justice) to provide a comprehensive and applicable model on how to address the ethical aspects of vaccination at both individual and societal levels. We suggest finding an “ethical equilibrium”, which means that the degree of respect for parents’ autonomy is not constant, but variable; it shall depend on the level of established herd immunity and it is specific for every society. When the moral obligation of individuals to contribute to herd immunity is not fulfilled, mandatory vaccination policies are ethically justified, because states bear responsibility to protect herd immunity as a common good.

  • vaccination
  • children
  • bioethics
  • principles of biomedical ethics
  • autonomy
  • nonmaleficence
Please wait, diff process is still running!

References

  1. Centers for Disease Control and Prevention. Ten Great Public Health Achievements—United States, 1900–1999. MMWR Morb. Mortal. Wkly. Rep. 1999, 48, 241–243.
  2. Dubé, E.; Vivion, M.; MacDonald, N.E. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: Influence, impact and implications. Expert Rev. Vaccines 2015, 14, 99–117.
  3. Salmon, D.A.; Dudley, M.Z.; Glanz, J.M.; Omer, S.B. Vaccine hesitancy: Causes, consequences, and a call to action. Vaccine 2015, 33 (Suppl. 4), D66–D71.
  4. Olson, O.; Berry, C.; Kumar, N. Addressing Parental Vaccine Hesitancy towards Childhood Vaccines in the United States: A Systematic Literature Review of Communication Interventions and Strategies. Vaccines 2020, 8, 590.
  5. Giubilini, A.; Douglas, T.; Savulescu, J. The moral obligation to be vaccinated: Utilitarianism, contractualism, and collective easy rescue. Med. Health Care Philos. 2018, 21, 547–560.
  6. Giubilini, A. The Ethics of Vaccination, 1st ed.; Palgrave Pivot: Cham, Switzerland, 2019.
  7. Williamson, L.; Glaab, H. Addressing vaccine hesitancy requires an ethically consistent health strategy. BMC Med. Ethics 2018, 19, 84.
  8. McIntosh, E.D.; Janda, J.; Ehrich, J.H.; Pettoello-Mantovani, M.; Somekh, E. Vaccine Hesitancy and Refusal. J. Pediatr. 2016, 175, 248–249.e1.
  9. Peretti-Watel, P.; Larson, H.J.; Ward, J.K.; Schulz, W.S.; Verger, P. Vaccine hesitancy: Clarifying a theoretical framework for an ambiguous notion. PLoS Curr. 2015, 7.
  10. Bedford, H.; Attwell, K.; Danchin, M.; Marshall, H.; Corben, P.; Leask, J. Vaccine hesitancy, refusal and access barriers: The need for clarity in terminology. Vaccine 2018, 36, 6556–6558.
  11. Schwartz, J.L.; Caplan, A.L. Vaccination refusal: Ethics, individual rights, and the common good. Prim. Care 2011, 38, 717–728.
  12. Larson, H.J.; Jarrett, C.; Eckersberger, E.; Smith, D.M.; Paterson, P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine 2014, 32, 2150–2159.
  13. Lane, S.; MacDonald, N.E.; Marti, M.; Dumolard, L. Vaccine hesitancy around the globe: Analysis of three years of WHO/UNICEF Joint Reporting Form data-2015–2017. Vaccine 2018, 36, 3861–3867.
  14. Wagner, A.L.; Masters, N.B.; Domek, G.J.; Mathew, J.L.; Sun, X.; Asturias, E.J.; Ren, J.; Huang, Z.; Contreras-Roldan, I.L.; Gebremeskel, B.; et al. Comparisons of Vaccine Hesitancy across Five Low- and Middle-Income Countries. Vaccines 2019, 7, 155.
  15. Opel, D.J.; Schwartz, J.L.; Omer, S.B.; Silverman, R.; Duchin, J.; Kodish, E.; Diekema, D.S.; Marcuse, E.K.; Orenstein, W. Achieving an Optimal Childhood Vaccine Policy. JAMA Pediatr. 2017, 171, 893–896.
  16. de Figueiredo, A.; Simas, C.; Karafillakis, E.; Paterson, P.; Larson, H.J. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: A large-scale retrospective temporal modelling study. Lancet 2020, 396, 898–908.
  17. Luyten, J.; Bruyneel, L.; van Hoek, A.J. Assessing vaccine hesitancy in the UK population using a generalized vaccine hesitancy survey instrument. Vaccine 2019, 37, 2494–2501.
  18. Hanna, J.N.; Symons, D.J.; Lyon, M.J. A measles outbreak in the Whitsundays, Queensland: The shape of things to come? Commun. Dis. Intell. Q. Rep. 2002, 26, 589–592.
  19. Bechini, A.; Boccalini, S.; Ninci, A.; Zanobini, P.; Sartor, G.; Bonaccorsi, G.; Grazzini, M.; Bonanni, P. Childhood vaccination coverage in Europe: Impact of different public health policies. Expert Rev. Vaccines 2019, 18, 693–701.
  20. Phadke, V.K.; Bednarczyk, R.A.; Salmon, D.A.; Omer, S.B. Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis. JAMA 2016, 315, 1149–1158.
  21. Angelo, K.M.; Gastañaduy, P.A.; Walker, A.T.; Patel, M.; Reef, S.; Lee, C.V.; Nemhauser, J. Spread of Measles in Europe and Implications for US Travelers. Pediatrics 2019, 144.
  22. World Health Organisation. Ten Threats to Global Health in 2019. Available online: (accessed on 20 October 2020).
  23. Iserson, K.V. SARS-CoV-2 (COVID-19) Vaccine Development and Production: An Ethical Way Forward. Camb. Q. Healthc. Ethics 2021, 30, 59–68.
  24. Folayan, M.O.; Yakubu, A.; Haire, B.; Peterson, K. Ebola vaccine development plan: Ethics, concerns and proposed measures. BMC Med. Ethics 2016, 17, 10.
  25. Schaefer, G.O.; Tam, C.C.; Savulescu, J.; Voo, T.C. COVID-19 vaccine development: Time to consider SARS-CoV-2 challenge studies? Vaccine 2020, 38, 5085–5088.
  26. Venkatramanan, S.; Chen, J.; Fadikar, A.; Gupta, S.; Higdon, D.; Lewis, B.; Marathe, M.; Mortveit, H.; Vullikanti, A. Optimizing spatial allocation of seasonal influenza vaccine under temporal constraints. PLoS Comput. Biol. 2019, 15, e1007111.
  27. Freedman, D.O.; Chen, L.H. Vaccines for International Travel. Mayo Clin. Proc. 2019, 94, 2314–2339.
  28. Haviari, S.; Bénet, T.; Saadatian-Elahi, M.; André, P.; Loulergue, P.; Vanhems, P. Vaccination of healthcare workers: A review. Hum. Vaccines Immunother. 2015, 11, 2522–2537.
  29. Krantz, I.; Sachs, L.; Nilstun, T. Ethics and vaccination. Scand. J. Public Health 2004, 32, 172–178.
  30. Greenberg, J.; Dubé, E.; Driedger, M. Vaccine Hesitancy: In Search of the Risk Communication Comfort Zone. PLoS Curr. 2017, 9.
  31. Fernbach, A. Parental rights and decision making regarding vaccinations: Ethical dilemmas for the primary care provider. J. Am. Acad. Nurse Pract. 2011, 23, 336–345.
  32. Chadwick, R.; Wilson, D. The Emergence and Development of Bioethics in the Uk. Med. Law Rev. 2018, 26, 183–201.
  33. Evans, J.H. A sociological account of the growth of principlism. Hastings Center Rep. 2000, 30, 31–38.
  34. Herissone-Kelly, P. Determining the common morality’s norms in the sixth edition of Principles of Biomedical Ethics. J. Med. Ethics 2011, 37, 584–587.
  35. Shea, M. Principlism’s Balancing Act: Why the Principles of Biomedical Ethics Need a Theory of the Good. J. Med. Philos. 2020, 45, 441–470.
  36. Beauchamp, T.L.; Childress, J.F. Response to Commentaries. J. Med. Philos. 2020, 45, 560–579.
  37. Harris, J. In praise of unprincipled ethics. J. Med. Ethics 2003, 29, 303–306.
  38. Gillon, R. Ethics needs principles—Four can encompass the rest—And respect for autonomy should be “first among equals”. J. Med. Ethics 2003, 29, 307–312.
  39. Beauchamp, T.; Childress, J. Principles of Biomedical Ethics: Marking Its Fortieth Anniversary. Am. J. Bioeth. AJOB 2019, 19, 9–12.
  40. Hine, K. What is the outcome of applying principlism? Theor. Med. Bioeth. 2011, 32, 375–388.
  41. Beauchamp TL, C.J. The Principles of Biomedical Ethics, 6th ed.; Oxford University Press: New York, NY, USA, 2009.
  42. Stammers, T. The Evolution of Autonomy. New Bioeth. Multidiscip. J. Biotechnol. Body 2015, 21, 155–163.
  43. Saad, T.C. The history of autonomy in medicine from antiquity to principlism. Med. Health Care Philos. 2018, 21, 125–137.
  44. Stirrat, G.M.; Gill, R. Autonomy in medical ethics after O’Neill. J. Med. Ethics 2005, 31, 127–130.
  45. Cocanour, C.S. Informed consent-It’s more than a signature on a piece of paper. Am. J. Surg. 2017, 214, 993–997.
  46. Sugarman, J. Ethics of Primary Care; McGraw-Hill: New York, NY, USA, 2000.
  47. Katz, A.L.; Webb, S.A. Informed Consent in Decision-Making in Pediatric Practice. Pediatrics 2016, 138.
  48. Groselj, U. The concepts of assent and parental permission in pediatrics. World J. Pediatr. WJP 2014, 10, 89.
  49. Chantler, T.; Letley, L.; Paterson, P.; Yarwood, J.; Saliba, V.; Mounier-Jack, S. Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis. Vaccine 2019, 37, 5218–5224.
  50. Centers for Disease Control and Prevention. Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger, United States. 2020. Available online: (accessed on 5 November 2020).
  51. Jones, A.M.; Omer, S.B.; Bednarczyk, R.A.; Halsey, N.A.; Moulton, L.H.; Salmon, D.A. Parents’ source of vaccine information and impact on vaccine attitudes, beliefs, and nonmedical exemptions. Adv. Prev. Med. 2012, 2012, 932741.
  52. Bedford, H.E.; Elliman, D.A.C. Fifteen-minute consultation: Vaccine-hesitant parents. Arch. Dis. Child. Educ. Pract. Ed. 2020, 105, 194–199.
  53. Storr, C.; Sanftenberg, L.; Schelling, J.; Heininger, U.; Schneider, A. Measles Status-Barriers to Vaccination and Strategies for Overcoming Them. Dtsch. Arztebl. Int. 2018, 115, 723–730.
  54. McKee, C.; Bohannon, K. Exploring the Reasons Behind Parental Refusal of Vaccines. J. Pediatr. Pharmacol. Ther. 2016, 21, 104–109.
  55. Swaney, S.E.; Burns, S. Exploring reasons for vaccine-hesitancy among higher-SES parents in Perth, Western Australia. Health Promot. J. Aust. 2019, 30, 143–152.
  56. Nihlén Fahlquist, J. Vaccine hesitancy and trust. Ethical aspects of risk communication. Scand. J. Public Health 2018, 46, 182–188.
  57. Danchin, M.; Nolan, T. A positive approach to parents with concerns about vaccination for the family physician. Aust. Fam. Physician 2014, 43, 690–694.
  58. Ahlin Marceta, J. A non-ideal authenticity-based conceptualization of personal autonomy. Med. Health Care Philos. 2019, 22, 387–395.
  59. Salmon, D.A.; Siegel, A.W. Religious and philosophical exemptions from vaccination requirements and lessons learned from conscientious objectors from conscription. Public Health Rep. 2001, 116, 289–295.
  60. Clarke, S.; Giubilini, A.; Walker, M.J. Conscientious Objection to Vaccination. Bioethics 2017, 31, 155–161.
  61. Gostin, L.O.; Hodge, J.G., Jr.; Bloom, B.R.; El-Mohandes, A.; Fielding, J.; Hotez, P.; Kurth, A.; Larson, H.J.; Orenstein, W.A.; Rabin, K.; et al. The public health crisis of underimmunisation: A global plan of action. Lancet Infect. Dis. 2020, 20, e11–e16.
  62. National Conference on State Legislatures. States with Religious and Philosophical Exemptions from School Immunization Requirements. Available online: (accessed on 6 November 2020).
  63. Vaz, O.M.; Ellingson, M.K.; Weiss, P.; Jenness, S.M.; Bardají, A.; Bednarczyk, R.A.; Omer, S.B. Mandatory Vaccination in Europe. Pediatrics 2020, 145.
  64. Rhodes, R. Conscience, conscientious objections, and medicine. Theor. Med. Bioeth. 2019, 40, 487–506.
  65. McAndrew, S. Internal morality of medicine and physician autonomy. J. Med. Ethics 2019, 45, 198–203.
  66. Eberl, J.T. Conscientious objection in health care. Theor. Med. Bioeth. 2019, 40, 483–486.
  67. Forster, M. Ethical position of medical practitioners who refuse to treat unvaccinated children. J. Med. Ethics 2019, 45, 552–555.
  68. Shanawani, H. The Challenges of Conscientious Objection in Health care. J. Relig. Health 2016, 55, 384–393.
  69. Gillon, R. “Primum non nocere” and the principle of non-maleficence. Br. Med. J. (Clin. Res. Ed.) 1985, 291, 130–131.
  70. Spencer, J.P.; Trondsen Pawlowski, R.H.; Thomas, S. Vaccine Adverse Events: Separating Myth from Reality. Am. Fam. Physician 2017, 95, 786–794.
  71. Smith, M. Vaccine safety: Medical contraindications, myths, and risk communication. Pediatr. Rev. 2015, 36, 227–238.
  72. Fisman, D.N.; Laupland, K.B. The sounds of silence: Public goods, externalities, and the value of infectious disease control programs. Can. J. Infect. Dis. Med. Microbiol. J. Can. Mal. Infect. Microbiol. Med. 2009, 20, 39–41.
  73. Committee to Review Adverse Effects of Vaccines; Institute of Medicine. Adverse Effects of Vaccines: Evidence and Causality; Stratton, K., Ford, A., Rusch, E., Clayton, E.W., Eds.; National Academies Press (US): Washington, DC, USA, 2011.
  74. Grignolio, A. Kdo se Boji Cepiv; *Cf.: Ljubljana, Slovenia, 2018.
  75. Hviid, A.; Hansen, J.V.; Frisch, M.; Melbye, M. Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Ann. Intern. Med. 2019, 170, 513–520.
  76. Opri, R.; Zanoni, G.; Caffarelli, C.; Bottau, P.; Caimmi, S.; Crisafulli, G.; Franceschini, F.; Liotti, L.; Saretta, F.; Vernich, M.; et al. True and false contraindications to vaccines. Allergol. Immunopathol. 2018, 46, 99–104.
  77. Jacobson, R.M.; Ovsyannikova, I.G.; Poland, G.A. Testing vaccines in pediatric research subjects. Vaccine 2009, 27, 3291–3294.
  78. Giubilini, A. Vaccination ethics. Br. Med. Bull. 2020.
  79. Davidson, A.J.; O’Brien, M. Ethics and medical research in children. Paediatr. Anaesth. 2009, 19, 994–1004.
  80. Mintz, K.; Jardas, E.; Shah, S.; Grady, C.; Danis, M.; Wendler, D. Enrolling Minors in COVID-19 Vaccine Trials. Pediatrics 2020.
  81. Taylor, R.M. Ethical principles and concepts in medicine. Handb. Clin. Neurol. 2013, 118, 1–9.
  82. Haire, B.; Komesaroff, P.; Leontini, R.; Raina MacIntyre, C. Raising Rates of Childhood Vaccination: The Trade-off Between Coercion and Trust. J. Bioethical Inq. 2018, 15, 199–209.
  83. Doherty, M.; Buchy, P.; Standaert, B.; Giaquinto, C.; Prado-Cohrs, D. Vaccine impact: Benefits for human health. Vaccine 2016, 34, 6707–6714.
  84. Jennings, B.; Arras, J.D.; Drue, H.B.; Barbara, A.E. (Eds.) Emergency Ethics: Public Health Preparedness and Response; Oxford University Press: Oxford, UK, 2016.
  85. Bester, J.C. Not a matter of parental choice but of social justice obligation: Children are owed measles vaccination. Bioethics 2018, 32, 611–619.
  86. Hendrix, K.S.; Sturm, L.A.; Zimet, G.D.; Meslin, E.M. Ethics and Childhood Vaccination Policy in the United States. Am. J. Public Health 2016, 106, 273–278.
  87. Verweij, M.F.; Houweling, H. What is the responsibility of national government with respect to vaccination? Vaccine 2014, 32, 7163–7166.
  88. Ter Meulen, R. Solidarity, justice, and recognition of the other. Theor. Med. Bioeth. 2016, 37, 517–529.
  89. Davies, B.; Savulescu, J. Solidarity and Responsibility in Health Care. Public Health Ethics 2019, 12, 133–144.
  90. Browne, K. The Measles and Free Riders. Camb. Q. Healthc. Ethics CQ Int. J. Healthc. Ethics Comm. 2016, 25, 472–478.
  91. Rakar, I.; Tičar, B.; Sever, T. Water Protection in Slovenia: Constitutional and Administrative Law Perspectives. In Water, Governance, and Crime Issues; Eman, K., Meško, G., Segato, L., Migliorini, M., Eds.; Springer International Publishing: Cham, Switzerland, 2020; pp. 129–155.
  92. Grzybowski, A.; Patryn, R.K.; Sak, J.; Zagaja, A. Vaccination refusal. Autonomy and permitted coercion. Pathog. Glob. Health 2017, 111, 200–205.
  93. Flanigan, J. A defense of compulsory vaccination. HEC Forum Interdiscip. J. Hosp. Ethical Legal Issues 2014, 26, 5–25.
  94. Navin, M.C.; Attwell, K. Vaccine mandates, value pluralism, and policy diversity. Bioethics 2019, 33, 1042–1049.
  95. Blunden, C.T. Libertarianism and collective action: Is there a libertarian case for mandatory vaccination? J. Med. Ethics 2019, 45, 71–74.
  96. Gostin, L.O. Public Health Law: Power, Duty, Restraint; University of California Press: Berkeley, CA, USA, 2008.
  97. Cohen, R.; Gaudelus, J.; Leboucher, B.; Stahl, J.P.; Denis, F.; Subtil, D.; Pujol, P.; Lepetit, H.; Longfier, L.; Martinot, A. Impact of mandatory vaccination extension on infant vaccine coverages: Promising preliminary results. Med. Mal. Infect. 2019, 49, 34–37.
  98. Giubilini, A.; Savulescu, J. Vaccination, Risks, and Freedom: The Seat Belt Analogy. Public Health Ethics 2019, 12, 237–249.
  99. Odone, A.; Fara, G.M.; Giammaco, G.; Blangiardi, F.; Signorelli, C. The future of immunization policies in Italy and in the European Union: The Declaration of Erice. Hum. Vaccines Immunother. 2015, 11, 1268–1271.
  100. Field, R.I.; Caplan, A.L. A proposed ethical framework for vaccine mandates: Competing values and the case of HPV. Kennedy Inst. Ethics J. 2008, 18, 111–124.
  101. Bennett, B.; Cohen, I.G.; Davies, S.E.; Gostin, L.O.; Hill, P.S.; Mankad, A.; Phelan, A.L. Future-proofing global health: Governance of priorities. Glob. Public Health 2018, 13, 519–527.
  102. Spielthenner, G. The Principle-Based Method of Practical Ethics. Health Care Anal. HCA J. Health Philos. Policy 2017, 25, 275–289.
  103. Braun, C.; O’Leary, S.T. Recent advances in addressing vaccine hesitancy. Curr. Opin. Pediatr. 2020, 32, 601–609.
  104. Dubé, E. Addressing vaccine hesitancy: The crucial role of healthcare providers. Clin. Microbiol. Infect. 2017, 23, 279–280.
  105. Gagneur, A.; Battista, M.C.; Boucher, F.D.; Tapiero, B.; Quach, C.; De Wals, P.; Lemaitre, T.; Farrands, A.; Boulianne, N.; Sauvageau, C.; et al. Promoting vaccination in maternity wards—Motivational interview technique reduces hesitancy and enhances intention to vaccinate, results from a multicentre non-controlled pre- and post-intervention RCT-nested study, Quebec, March 2014 to February 2015. Euro Surveill. Bull. Eur. Mal. Transm. Eur. Commun. Dis. Bull. 2019, 24.
  106. Jarrett, C.; Wilson, R.; O’Leary, M.; Eckersberger, E.; Larson, H.J. Strategies for addressing vaccine hesitancy—A systematic review. Vaccine 2015, 33, 4180–4190.
  107. Gagneur, A. Motivational interviewing: A powerful tool to address vaccine hesitancy. Can. Commun. Dis. Rep. Relev. Mal. Transm. Can. 2020, 46, 93–97.
  108. Dzansi, D.Y. Finding an Equilibrium Ethical Framework in a Heterogeneous Society: The Role of Rules and Values. J. Sociol. Soc. Anthropol. 2013, 4.
More
© Text is available under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)
Feedback