The determination of the best interests in relation to childhood immunisation

Bioethics

Volumn 19, Issue 1, 2005, Pages 72-89

  Dawson, Angus ^a  

^a KEELE UNIVERSITY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

MEASLES MUMPS RUBELLA VACCINE; YELLOW FEVER VACCINE;

ACTIVE IMMUNIZATION; CHILD PARENT RELATION; HERD IMMUNITY; HUMAN; IMMUNE DEFICIENCY; INFECTION PREVENTION; INFECTION RISK; MEASLES; MEDICAL DECISION MAKING; PASSIVE IMMUNIZATION; PATIENT CARE; REVIEW; RISK ASSESSMENT; RISK REDUCTION; YELLOW FEVER;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH;

BENEFICENCE; CHILD; CHILD ADVOCACY; DECISION MAKING; ETHICAL ANALYSIS; HUMANS; IMMUNIZATION PROGRAMS; INFANT; PARENTAL CONSENT; PARENTS; PATERNALISM; REFUSAL TO PARTICIPATE; RISK ASSESSMENT; THIRD-PARTY CONSENT; TREATMENT REFUSAL; VACCINATION;

EID: 13444288169     PISSN: 02699702     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2005.00425.x     Document Type: Review

References (48)

1. If we are talking about an older child then they may be competent, in which case, we should treat them in the same way as we would a competent adult (although the latter issue is not discussed in this paper).
2. I will use the term 'parents' throughout. This term is to be read as a shorthand form to include anyone holding the appropriate legal relationship of parent or guardian. Of course 'parents', where there is more than one, can disagree amongst themselves. I will ignore this issue here, and will assume for the purposes of argument that parents agree as to what is in fact in their child's best interest in relation to vaccinations.
3. That is justified in the appropriate sense, for example, by being bound by a relevant legal duty of care or statutory duty.
4. See, for example, M. Evans, M. Stoddart, H. Condon, L.M. Grizzell, M. Mullen & R. Mullen. 2001. 'Parents' perspectives on the MMR immunisation: a focus group study' British Journal of General Practice. 2001; 51: 904-910.
5. See T. Heller, D. Heller & S. Pattison. 2001. 'Ethical debate: Vaccination against mumps, measles & rubella: is there a case for deepening the debate?' BMJ. 323. 838-840. R. Fry. 2002. 'Debate crystallises dilemma facing many medical disciplines' BMJ. 324. 733; P. English. 'General practitioners' two roles are not in conflict with MMR immunisation. BMJ. 324. 733.
6. See T. Heller, D. Heller & S. Pattison. 2001. 'Ethical debate: Vaccination against mumps, measles & rubella: is there a case for deepening the debate?' BMJ. 323. 838-840. R. Fry. 2002. 'Debate crystallises dilemma facing many medical disciplines' BMJ. 324. 733; P. English. 'General practitioners' two roles are not in conflict with MMR immunisation. BMJ. 324. 733.
7. See T. Heller, D. Heller & S. Pattison. 2001. 'Ethical debate: Vaccination against mumps, measles & rubella: is there a case for deepening the debate?' BMJ. 323. 838-840. R. Fry. 2002. 'Debate crystallises dilemma facing many medical disciplines' BMJ. 324. 733; P. English. 'General practitioners' two roles are not in conflict with MMR immunisation. BMJ. 324. 733.
8. See A & D and B & E [2003] EWHC 1376 (Fam) and the appeal of the same case B (Child) [2003] EWCA Civ 1148.
9. This paper is one in a series that seeks to explore all of the different possible arguments that there might be about childhood vaccination. I will therefore not be discussing other possible arguments in favour of vaccination of children based upon such things as the good of the community or harm to others etc in this paper. However, for some discussion of these other arguments see A. Dawson. 'Therapeutic vaccines and the prevention problem', Bioethics 2004; 18 (6): 515-530; M. Verweij, & A. Dawson. 'Ethical principles for collective immunisation programmes'. Vaccine. A. Dawson. 2004; 22: 3122-3126. 'Herd protection as a public good: vaccination and our obligations to others' (ms).
10. This paper is one in a series that seeks to explore all of the different possible arguments that there might be about childhood vaccination. I will therefore not be discussing other possible arguments in favour of vaccination of children based upon such things as the good of the community or harm to others etc in this paper. However, for some discussion of these other arguments see A. Dawson. 'Therapeutic vaccines and the prevention problem', Bioethics 2004; 18 (6): 515-530; M. Verweij, & A. Dawson. 'Ethical principles for collective immunisation programmes'. Vaccine. A. Dawson. 2004; 22: 3122-3126. 'Herd protection as a public good: vaccination and our obligations to others' (ms).
11. This should be acceptable even to the advocates of the greater participation of children within decision-making about their health care sure as P. Alderson & J. Montgomery. 1996. Health Care Choices: Making Decisions with Children. London. Institute for Public Policy Research.
12. This is the standard age for many existing vaccination programmes. See, for example, the suggested ages in Health Education Authority. 1997. A Guide to Childhood Immunisations. London. HEA
13. There is here a general theory of obligation at work in the background. In short, I would argue that we all have moral obligations to each other arising from the fact we are sentient beings, but that parents are given a special set of obligations by society in relation to their children. However, these are revocable, and they should be revoked where the parents do not carry out the particular obligations (whether positive or negative) that we expect someone in a parental role to perform; for example, where a child is abused or neglected.
14. This general claim can be accepted even if we don't actually know, or cannot agree upon, what is in that child's best interests.
15. This is, of course, a simplification of very complicated issues. I say much more about this in 'What are "best interests"?' (ms).
16. A. Buchanan & D. Brock. 1989. Deciding For Others: The Ethics of Surrogate Decision Making, Cambridge. Cambridge University Press: p. 94.
17. Clearly, in relation to infants these future-orientated interests are very important. They are the type of thing Feinberg calls attention to in: J. Feinberg 'The Child's Right to an Open Future', in Freedom & Fulfillment: Philosophical Essays, Princeton, NJ: Princeton University Press.
18. This is, of course, true of adults as well. However, the difference lies in the fact that some decisions made on behalf of children will close oft various options in later life in a way not true of adults. This is because children have various non-actualised developmental interests that need to be protected.
19. It is worth noting that in cases involving the serious risk of such harms it is no good merely to state that the child can review the situation themselves once they have obtained a suitable threshold of competence, since as a result of a parental decision the potential harm might already have occurred.
20. I am very grateful for the comments of an anonymous referee for prompting improvements in this section.
21. 'Harm', here, is used in Feinberg's sense of 'set back to interests'. See J. Feinberg. 1984. Harm to Others. Oxford University Press; chapter 1. Such an account is also employed by P. Allmark, S. Mason, A. Gill & C. Megone. Is it in a neonate's best interest to enter a randomised controlled trial? J Med Ethics. 2001; 27: 110-113.
22. 'Harm', here, is used in Feinberg's sense of 'set back to interests'. See J. Feinberg. 1984. Harm to Others. Oxford University Press; chapter 1. Such an account is also employed by P. Allmark, S. Mason, A. Gill & C. Megone. Is it in a neonate's best interest to enter a randomised controlled trial? J Med Ethics. 2001; 27: 110-113.
23. There is no good reason to do this, of course, because the assessment should be done in terms of both harms and benefits, not merely on harms. Personally, I see no reason to justify prioritising either harms or benefits in decision-making.
24. It might be argued that the assessment of such risks necessarily involves some evaluative element. To some extent this is true. However, I would argue that we should not give up on the importance of the distinction between the likelihood of a harm occurring (the probability of the harm) and what such an occurrence might mean to me (the meaning of the harm). The idea, here, is that the likelihood of a risk occurring might be very low but I choose to prevent that risk occurring because the consequence would be significant to me.
25. th edition). Oxford. Oxford University Press: pp. 199-200.
26. See D. Salisbury & N. Begg, N. (eds.). 1996. Immunisation Against Infectious Disease. London. HMSO, p. 263.
27. See D. Salisbury & Begg, N. eds. 1996, Immunisation Against Infectious Disease. London. HMSO. Complication rates from the disease can be as high as one in fifteen cases (p. 125).
28. Remember that for the purposes of this paper, I'm ignoring the 'harm to others' considerations.
29. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
30. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
31. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
32. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
33. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
34. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
35. Relevant evidence in relation to MMR vaccine, though not of equal value might include: A. Wakefield et al. Ileal-lyrnphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children, Lancet 1998; 351: 637-641. & A. Wakefield & S. Montgomery. Measles, mumps and rubella vaccine: through a glass, darkly. Adverse Drug React Toxicol Rev 2000; 19: 265-283. D. Elliman & H. Bedford. MMR vaccine: the continuing saga. BMJ 2001; 322: 183-184; A. Patja et al. Serious adverse events after measles-mumps-rubella vaccination during a fourteen-year prospective follow-up. Pediatr Infect Dis J 2000; 19: 1127-1134. H. Peltola & O. Heinonen. Frequency of true adverse reactions in measles-mumps-rubella vaccine. A double-blind placebo-controlled trial in twins. Lancet 1986; 1: 939-942. & K. Madsen et al. A population-based study of measles, mumps and rubella vaccination and autism. NEJM 2002; 347: 1477-1482. L. Smeeth et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet 2004; 364: 963-969.
36. See Department of Health. 1998. Communicating About Risks to Public Health. London. Department of Health, for a discussion of some of these issues.
37. See, for example, Camden London Borough Council v A, B, C (By her Guardian ad Litem) [2000] 2 WLR 270, and Re A (Children) [2001] 4 all ER 961.
38. See Education Act 1996, s.8.
39. See H. La Follette. Licensing parents. Philosophy and Public Affairs 1980: 9: 183-197.
40. A good example of the way these considerations are weighted in a real case is provided by the previously cited A, B, Cease [2000], which involved the risk of transmission of HIV through breast-feeding.
41. I assume there is no relevant moral difference between the two when assessing what outcome is in the best interests of an incompetent individual.
42. Or insist the infant is not vaccinated in such cases as blue spot disease perhaps.
43. This point is likely to be strengthened once the 'harm to others' considerations are added in.
44. Not just about the effectiveness of the vaccination and the risk of side effects, but also about other considerations I've chosen to ignore to simplify the argument such as what the percentage uptake for a particular vaccination is within a population might be etc.
45. However, see the legal case, mentioned earlier, in footnote 6, where this was the relevant legal test.
46. Certainly J. Mill. 1859. On Liberty & J. Feinberg. 1973 Social Philosophy Prentice-Hall: 45-52 do so.
47. Certainly J. Mill. 1859. On Liberty & J. Feinberg. 1973 Social Philosophy Prentice-Hall: 45-52 do so.
48. As an anonymous referee suggested it might be possible to argue that the state is, here, acting paternalistically upon or through the parents. If this is the case the justification for the action might switch from an appeal to paternalism to a more general 'harm prevention' principle in the light of the perceived negligent decision of the parents.