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).