Mass immunisation programmes: Some philosophical issues

Bioethics

Volumn 12, Issue 2, 1998, Pages 125-149

  Dare, Tim ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ANALYTICAL APPROACH; ARTICLE; CHILD; COMPARATIVE STUDY; DECISION MAKING; ETHICAL THEORY; ETHICS; HEALTH CARE AND PUBLIC HEALTH; HEALTH PROMOTION; HUMAN; IMMUNIZATION; INTERNATIONAL COOPERATION; MANAGEMENT; MANDATORY PROGRAM; NEW ZEALAND; PARENT; PERSUASIVE COMMUNICATION; PHILOSOPHICAL APPROACH; POLICY; PROBABILITY; RISK; RISK ASSESSMENT; SCHOOL; TIME; UNCERTAINTY; UNITED STATES; VOLUNTARY PROGRAM;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH; PHILOSOPHICAL APPROACH;

CHILD; COERCION; DECISION MAKING; ETHICAL THEORY; ETHICS; HEALTH PROMOTION; HUMANS; IMMUNIZATION; INTERNATIONAL COOPERATION; INTERNATIONALITY; MANDATORY PROGRAMS; NEW ZEALAND; PARENTS; POLICY MAKING; PROBABILITY; PUBLIC POLICY; RISK; RISK ASSESSMENT; SCHOOLS; TIME FACTORS; UNCERTAINTY; UNITED STATES; VOLUNTARY PROGRAMS;

EID: 85044702177     PISSN: 02699702     EISSN: None     Source Type: Journal    
DOI: 10.1111/1467-8519.00100     Document Type: Article

References (36)

1. Susan and Stanley Protkin 'A Short History of Vaccination', in Vaccines 2nd edn, eds Stanley Protkin & Edward Mortimer (WB Saunders & Co, Philadelphia, 1994) 1.
2. J. Clark-Nelson and J. Rogers, 'The Right to Die? Anti-Vaccination Activity and the 1874 Smallpox Epidemic in Stockholm', in Social History of Medicine, 23, (1992), pp. 370-381. Emile Roux, one of Louis Pasteur's closest colleagues, resigned from Pasteur's laboratory over the first human vaccinations, of Joseph Miester and Jean Baptiste Jupille against rabies in 1885. Forty-five years earlier variolation had been made a felony in England.
3. I know of only two explicitly philosophical treatments: Heta Hayry & Meta Hayry, 'Utilitarianism, Human Rights and the Redistribution of Health through Preventive Medical Measures', Journal of Applied Philosophy, 6, (1989), pp. 43-51 and Paul Menzel 'Non-Compliance: Fair or Free-Riding' Health Care Analysis, 3, (1995), pp. 113-115 . Menzel's piece is a contribution to symposium on immunisation: 'The Pros and Cons of Immunisation' Health Care Analysis, 3, (1995), pp. 99-115.
4. I know of only two explicitly philosophical treatments: Heta Hayry & Meta Hayry, 'Utilitarianism, Human Rights and the Redistribution of Health through Preventive Medical Measures', Journal of Applied Philosophy, 6, (1989), pp. 43-51 and Paul Menzel 'Non-Compliance: Fair or Free-Riding' Health Care Analysis, 3, (1995), pp. 113-115 . Menzel's piece is a contribution to symposium on immunisation: 'The Pros and Cons of Immunisation' Health Care Analysis, 3, (1995), pp. 99-115.
5. I know of only two explicitly philosophical treatments: Heta Hayry & Meta Hayry, 'Utilitarianism, Human Rights and the Redistribution of Health through Preventive Medical Measures', Journal of Applied Philosophy, 6, (1989), pp. 43-51 and Paul Menzel 'Non-Compliance: Fair or Free-Riding' Health Care Analysis, 3, (1995), pp. 113-115 . Menzel's piece is a contribution to symposium on immunisation: 'The Pros and Cons of Immunisation' Health Care Analysis, 3, (1995), pp. 99-115.
6. The leading case is Jacobson v Massachusetts 197 US 11 (1905). A recent case upholding the requirement is Hanzel v Arter, 625 F Supp. 1259 (SD Ohio 1985). Some states do not require all of the standard paediatric vaccines: twenty do not require mumps vaccination and nine do not require pertussis (whooping cough).
7. The contrast may seem independently interesting, since the United States is in general far more individualist than New Zealand. New Zealand's immunisation programme targets nine diseases: Haemophilus influenzae type b (hib), hepatitis b, mumps, rubella, measles, pertussis (whooping cough), tetanus, polio and diphtheria.
8. "[T]he cot death rate would be halved if vaccination were to be suspended." Sheibner and Karlsson, 'Cot Death Linked to Vaccinations', Nexus (Australia), October/November, 1991.
9. From a letter by S.L. Tonkin of the New Zealand National Children's Health Research Foundation, Cot-Death Division, dated July 8 1992, responding to the Sheibner and Karlsson article quoted in the previous footnote.
10. This remark assumes a certain view about the supposed distinction between acts and omissions. I will return to the issue briefly below.
11. The point has an august pedigree. Aristotle has it in mind when he proposes that "[i]t is the mark of an educated man to look for precision in each class of things just so far as the nature of the subject admits; it is evidently equally foolish to accept probable reasoning from a mathematician and to demand from a rhetorician scientific proofs". Nichomachean Ethics 1.1, 1094b24-28. (trans WD Ross)
12. One specific implication of these positive duties is the obligation to consider vaccines individually. Even if, in general, it seems that immunisation is desirable, scientists and policy-makers ought not to be blind to evidence that some vaccines - the pertussis vaccine for instance - seems to be less efficient and more prone to side effects than other common vaccines.
13. See, for instance, the papers collected in Judgment Under Uncertainty: Heuristics and Biases, eds. Daniel Kahneman, Paul Slovic, and Amos Tversky (Cambridge University Press, Cambridge, 1982).
14. Amos Tversky and Daniel Kahneman, 'Availability: A Heuristic for Judging Frequency and Probability', Cognitive Psychology, 5, (1973), pp. 207-232.
15. Noting that availability is offered only as an example. Immunisation choices seem likely to be vulnerable to various other sources of cognitive dissonance.
16. Paul Slovic, Baruch Fischhoff and Sarah Lichtenstein, 'Facts Versus Fears: Understanding Perceived Risk', in Kahneman, Slovic, and Tversky, Judgment Under Uncertainty: Heuristics and Biases, pp. 463-489, 488-489.
17. Ibid 465
18. We will return to this issue in the next section.
19. Consequently there have been literally hundreds of cost-benefit studies of vaccination programmes and of particular vaccines, all of which, one study concludes, "have shown that immunisation represents a remarkably efficient use of resources ....". Alan Hinman & Walter Orenstein, 'Public Health Considerations', in Protkin & Mortimer, Vaccines, pp. 903-932, 919. The authors reference some ninety-eight cost-benefit studies of immunisation programmes and specific vaccines.
20. John M. Last, Public Health and Human Ecology (Appleton and Lange, Ottawa, 1987), pp. 353-354. Emphasis added.
21. Ibid
22. See Hayry & Hayry 'Utilitarianism, Human Rights and the Redistribution of Health', for this very conclusion about the New York case.
23. See Donald Henderson & Frank Fenner, 'Smallpox and Vaccinia', in Protkin & Mortimer, Vaccines, pp. 13-39, 19.
24. R.E. Gooden, 'Ethical Principles for Environmental Protection' in Environmental Philosophy eds Robert Elliot & Arran Gare (1983), 6, pp. 3-20.
25. See eg R.M. Anderson and R.M. May 'Vaccination against Rubella and Measles: Quantitative Investigations of Different Policies', Journal of Hygiene, 90, (1983), pp. 259-325, and H.W. Heathcote, 'Measles and Rubella in the United States', American Journal of Epidemiology, 117, (1983), pp. 2-13.
26. See eg R.M. Anderson and R.M. May 'Vaccination against Rubella and Measles: Quantitative Investigations of Different Policies', Journal of Hygiene, 90, (1983), pp. 259-325, and H.W. Heathcote, 'Measles and Rubella in the United States', American Journal of Epidemiology, 117, (1983), pp. 2-13.
27. There have been attempts to identify this figure. One notes that voluntary immunisation has reached a coverage rate of 80% by the second birthday and suggests that the improvement of 15% to the coverage figure of 95% is therefore attributable to the school laws. This is problematic in both directions. It is surely likely that at least some of those who immunise their children before their second birthday do so in anticipation of the requirement that all immunisations be completed by school entrance age, and that at least some of those who complete immunisation programmes after their second birthday but prior to school entrance are voluntarily following a schedule to that effect. Alternatively, a 1978 study compared low and high measles incidence areas with similar demographic characteristics, vaccine uptake in children under two, and surveillance systems concluding that the only relevant difference between the two areas was the vigour with which school immunisation laws were enforced; more strictly and comprehensively in low incidence areas. Norman D. Noah reports both approaches in 'Immunisation before School Entry: Should there be a Law? British Medical Journal, 16 May 1987, pp. 270-271.
28. See Noah, ibid, for details.
29. Lester Calder, Central Auckland Community Medicine Registrar, 'What is the Best Way to Inform High risk Groups About Hepatitis B Immunisation?: A Survey by Polynesian Community Health Workers' Unpublished, 1988.
30. It might be argued, though, that it is worse to drown knowing someone could have rescued you if they could been bothered, than it is to drown simpliciter.
31. Joel Feinberg, Harm to Others: The Moral Limits of the Criminal Law, (Oxford University Press, New York, 1984), p. 136.
32. The latin maxim translates roughly as 'no harm is done to one who consents'.
33. Lester Calder, 'What is the Best Way ...'.
34. Of the nine diseases targeted by New Zealand's immunisation programme, Hib, hepatitis b, mumps, and rubella could be eliminated. Measles, pertussis (whooping cough), and tetanus can be controlled, but are thought unlikely to be eliminated. Polio and diphtheria have been eliminated in New Zealand but not everywhere else - immunisation for these in New Zealand is intended to protect against occasional imports and contact abroad.
35. John Stuart Mill On Liberty, (1859), Introduction.
36. For a fuller discussion to similar effect see Robert Nozick Anarchy, State and Utopia (Basil Blackwell, Oxford, 1974) pp. 90-95.