Vaccination policy: what role for ethical values?

Jeroen Luyten

Jeroen Luyten

January 16th, 2012

Jeroen Luyten

‘In evaluating vaccination programmes, considerations about medical effectiveness and economic efficiency should be complemented with ethical values such as respect for individual autonomy, protection of privacy, non-discrimination and protection of the worst-off.’

Because vaccination is a matter of collective importance that at the same time reaches into the most private sphere of citizens, these different values may often prove difficult to reconcile. The following three issues require a careful balancing of values.

(1) What is the ethical significance of adverse herd immunity effects?

    Occasionally herd immunity may have negative consequences, namely when the severity of disease symptoms increases with age.

    Introducing vaccination programmes against certain infectious diseases at suboptimal uptake levels will increase the average time to acquiring infection in unvaccinated groups potentially resulting in catching the disease at an older age and therefore with an increased risk of severe morbidity and mortality.

    These groups are presumably the worst-off groups in society, be it medically (when they cannot receive vaccines for health reasons), socio-economically (when they are limited in their access to vaccination), or both. These herd immunity effects are an important consequence of vaccination policy that requires more ethical discussion.   

(2) Is it ethical to target vaccination programmes at certain risk-groups?

    And which characteristics may be used to define these risk-groups? In vaccination policy individuals are often differentiated according to age, gender or occupation. However, research indicates that a differentiation between individuals according to other, more controversial characteristics may also be an efficient use of resources such as ethnicity, sexual activity, religion or (illicit) drug use. 

    In justifying targeted vaccination policies for these subgroups, several values need to be balanced: efficiency, non-discrimination and protection of privacy.

    If the efficiency gains of such targeted policies cannot be neglected, then policy makers will have to decide which is more important to uphold: protection of privacy or non-discrimination.

    The former will direct vaccination policy away from individually relevant characteristics while the latter will do the opposite and guides vaccination policy to group characteristics that could sometimes be discriminatory.

(3) Ethically, which policy measures should be addressed when vaccination coverage is
      insufficient in a population?

    Aiming for an improved public understanding of immunisation through educational campaigns is an obvious first step, but the benefits of detailed information on ‘who-acquires-infection-from-whom’ need to be balanced against the potentially stigmatising effects on minority groups.

    When voluntary measures have failed, legal compulsion could be an effective though drastic and ethically controversial policy option because it fails to respect the autonomy of individuals.

    A justification for a vaccine mandate largely depends on two considerations. Are vaccine refusers to be considered as autonomous decision makers? And to what extent does the harm that is caused by not being vaccinated exceed the normal risks of participating in society?
    Although it may raise equity concerns, the use of financial incentives to increase vaccine uptake could be an alternative worth investigating.

    Perhaps individuals could somehow be held accountable for the consequences of not being vaccinated, or financial rewards could be offered to individuals that choose to become vaccinated (especially when vaccination is done for altruistic reasons).


  1. Robert Schecter

    Robert Schecter

    January 21st, 2012

    And to what extent does the harm that is caused by not being vaccinated exceed the normal risks of participating in society?

    Not getting a vaccination causes no harm. Infectious agents, in certain circumstances, cause harm. But these infectious agents have been transmitted between people since the beginning of civilization. As such, “harm” has always existed and is not a creation of the unvaccinated.

    • Gary Finnegan

      Gary Finnegan

      January 23rd, 2012

      I have a colleague whose daughter has problems with her immune system. As a result, she cannot be vaccinated so she relies on others to be vaccinated. For that reason, I would dispute what you say about not getting a vaccination causing ‘no harm’. It increases your risk of illness and the risk that others will become ill. For people who cannot be vaccinated for health reasons (perhaps they have immune system disorders, cancer and so on) infections can be more serious than they would be for healthier people.

      Regarding the fact that infectious agents have been around since the beginning of civilization – and long before, of course – the death rates from these diseases were much higher before vaccination. Life expectancy was shorter and infant mortality was higher. Immunisation (along with improved sanitation, clean drinking water, education and so on) played an important role in reducing the risk of infection. Personally, I wouldn’t want to go back to the pre-vaccination era.