How should liberal-democratic governments deal with emerging vaccination hesitancy when that leads to the resurgence of diseases that for decades were under control? This article argues that vaccination policies should be justified in terms of a proper weighing of the rights of children to be protected against vaccine-preventable diseases and the rights of parents to raise their children in ways that they see fit. The argument starts from the concept of the ‘best interests of the child involved’. The concept (...) is elaborated for this context into the dual regime structure in which parents have fiduciary authority over what they consider to be best for their child, and the state has fiduciary authority over a child’s basic interests. This argument leads to conditional mandatory vaccination programs that should be informed by a correct balancing of the two legal principles of proportionality and precaution. This results in contextual childhood vaccination policies of upscaling interference: a three-tiered approach of increased intrusion, from voluntary program when possible and mandatory or even compulsory programs when necessary to protect the child’s basic interests. (shrink)

Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of (...) the interdependence of humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society. (shrink)

The purpose of the paper is to use analytical method and optimization tool to suggest a vaccination program intensity for a basic SIR epidemic model with limited resources for vaccination. We show that there are two different scenarios for optimal vaccination strategies, and obtain analytical solutions for the optimal control problem that minimizes the total cost of disease under the assumption of daily vaccine supply being limited. These solutions and their corresponding optimal control policies are derived explicitly in terms (...) of initial conditions, model parameters and resources for vaccination. With sufficient resources, the optimal control strategy is the normal Bang–Bang control. However, with limited resources, the optimal control strategy requires to switch to time-variant vaccination. (shrink)

Vaccination involves priming the immune system with an antigenic agent that mimics a virus or bacterium, which results in immunity against the “real” microorganism. Collective vaccination policies have played an important role in the control of infectious disease worldwide. They can serve the utilitarian aim to protect public health – hence welfare – and also promote fairness: making essential vaccines accessible to all members of the public. Yet as more and more vaccines are developed, societies face the question of how (...) far to go in expanding public programs. Decisions about adopting new vaccines in the program will require combining scientific evidence about the disease and the vaccine, with value judgments about, for example, the extent to which a disease poses a threat to public health. It makes sense to promote transparency of such deliberations because one cannot expect that citizens simply accept every government vaccination policy. (shrink)

BackgroundAt the start of 2021, oncologists lacked the necessary scientific knowledge to adapt their clinical practices optimally when faced with cancer patients refusing or reluctant to be vaccinated against COVID-19, despite the marked vulnerability of these patients to severe, and even fatal forms of this new viral infectious disease. Oncologists at Foch Hospital were confronted with this phenomenon, which was observed worldwide, in both the general population and the population of cancer patients.MethodsBetween April and November 2021, the Ethics and Oncology (...) Departments of Foch Hospital decided to investigate this subject, through an empirical and interdisciplinary study in bioethics. Our scientific objective was to try to identify and resolve the principal bio-ethical issues, with a view to improving clinical practices in oncology during future major pandemics of this kind, from a highly specific bio-ethical standpoint. We used a mainly qualitative methodological approach based on questionnaires and interviews.ResultsIn April 2021, 29 cancer patients refused or were reluctant to be vaccinated. Seventeen of these patients said that making vaccination mandatory would have helped them to accept vaccination. In October 2021, only 10 cancer patients continued to maintain their refusal. One of the main reasons for the decrease in refusals was probably the introduction of the “pass sanitaire” in July 2021, which rendered vaccination indispensable for many activities. However, even this was not sufficient to convince these 10 cancer patients.ConclusionWe identified a key bio-ethical issue, which we then tried to resolve: vaccination policy. We characterized a major tension between “the recommendation of anti-COVID-19 vaccination” and “free will”, and the duty to “protect each other”. Mandatory vaccination, at least in France, could resolve this tension, with positive effects on quality of life, or survival, in cancer patients initially refusing or reluctant to be vaccinated, but only if collective and individual scales are clearly distinguished. (shrink)

Most literature about vaccine hesitancy has been focused on parental attitudes. Less attention has been devoted to both scientists and experts who raise criticism about immunization policies and intervene in the public debate. This consideration aims to balance the current emphasis in the literature on parents’ attitudes about vaccination, offering a complementary angle to reframe and widen the controversy. Focusing on scientists and experts, an unattended complex picture of multiple attitudes towards vaccines and vaccinations has been discovered through a (...) qualitative content analysis of texts related to the harsh public debate, held between March 2017 and November 2018, triggered by the legislative proposal of making ten vaccinations mandatory for children. Unlike oversemplications that misleading dichotomies reproduce, the analysis reveals nine different positions along the continuum of immunisation attitudes, ranging from radical acceptance of vaccinations to radical rejection, which constitute a fuzzy set. Consequently, a twofold reality emerges: on the surface, the conflict seems between pro-vaxxers versus hesitant, pro-choice and anti-vaxxers; beneath it is amid standardized versus a varieties of contextual and personalised approaches to health. (shrink)

The ethical tension in childhood vaccination policies is often framed as one of balancing the value of choice with the duty to protect. Because infectious diseases spread from person to person, unvaccinated children are usually described as putting others around them at risk, violating a perceived right to be protected from harm. Editors of Lancet Infectious Diseases recently argued against mandatory vaccination, reminding us that the resort to mandatory vaccination as a means of achieving high vaccination rates is still very (...) much a topic of Western vaccine debates. The nation of Japan offers an interesting case study in childhood vaccination policy, as it has an entirely voluntary system that achieves high vaccination rates. In this paper, we offer an overview of Japanese childhood vaccine policy, suggest some ways to contextualize and understand how a voluntary system achieves high vaccination rates, and speculate on what the future of Japanese vaccination policymaking and government–public relations may hold. (shrink)

SARS-CoV-2 vaccines are indispensable allies in the fight against COVID-19. Behavioral and cognitive scientists have argued for taking advantage of insights from their fields of investigations in shaping anti-COVID policies. B&C scientists extensively discussed the methodological and practical issues that arise in translating B&C research results into policy interventions aimed to boost vaccination, Nevertheless, the same cannot be said for the ethical aspects. In the present work, we discuss the ethics of nudging vaccination in light of the “alien control” (...) objection, a kind of control whereby an agent has the power to influence the choice of another agent, and the latter cannot control such power. We proceed as follows. We begin by presenting several cases of mandatory policies avaiable to policymakers to boost the vaccine rate. Next, we point out that insights from B&C sciences can inform mandatory policies and open up ways to enhance them. In section 3, we focus on untraditional policy tools, viz. nudges. In the second part of the article, we introduce the debate on the ethics of nudges, focusing on the “alien control” objection and its relevance for the citizens’ freedom and autonomy. We therefore discuss the original point of the paper. We argue that, referring to nudging vaccination, a somehow neglected ethical issue posed by nudges emerges. Our point is that nudges do not exert exclusively an influence over a targeted behavior. Indeed, nudges impose as well a political influence by which citizens are treated as means to succeed in achieving a peculiar, and potentially controversial, political aim. We argue that, due to what we propose to call the “political multi-justifiability" of nudges, their political influence cannot be detected by citizens. This leads to the threat of alien control. In the last section, we draw some tentative conclusions, suggest a possible solution and its practical advantages. (shrink)

This paper discusses recent changes to state legal frameworks for mandatory vaccination in the context of school and healthcare worker vaccination. It then discusses state laws that allow pharmacists the authority to vaccinate.

Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity (...) if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This ‘conditional’ policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers’ established professional, legal and ethical obligations to their patients and to society at large. (shrink)

A vaccine for hepatitis B became available in the UK from 1982, but it did not solve the public health dilemmas presented by the disease. In the decade that followed, epidemiologically important groups such as intravenous drug users and gay men were not targetted, while the groups of health workers at the centre of policy concern received little vaccine. This paper draws on models of diffusion, the pattern of the disease, and previous policies on screening, to explain (...) the restricted vaccine policy which was a field for contention through the 1980s and into the 1990s. (shrink)

Increasing vaccine hesitancy among parents in high income countries and the resulting drop in early childhood immunisation constitute an important public health problem, and raise the issue of what policies might be taken to promote higher rates of vaccination. This article first outlines the background of the problem of increasing vaccine hesitancy. It then explores the pros and cons of three types of policy: 1) Interventions focused on increasing awareness of the benefits of vaccination while eliminating mistaken (...) perceptions of risks. 2) “Nudges”, which make certain choices more likely to be voluntarily chosen by manipulating the decision environment. 3) Policies that impose costs to make non-vaccination undesirable even for parents who are hesitant. It argues that a wide range of policies, including coercive policies, is desirable from a public health perspective, as the least intrusive policies alone are unlikely to achieve and sustain the important public good of herd immunity. (shrink)

Background Policy decisions about childhood vaccination require consideration of multiple, sometimes conflicting, public health and ethical imperatives. Examples of these decisions are whether vaccination should be mandatory and, if so, whether to allow for non-medical exemptions. In this article we argue that these policy decisions go beyond typical public health mandates and therefore require democratic input.Methods We report on the design, implementation, and results of a deliberative public forum convened over four days in Ontario, Canada, on the topic (...) of childhood vaccination.Results 25 participants completed all four days of deliberation and collectively developed 20 policy recommendations on issues relating to mandatory vaccinations and exemptions, communication about vaccines and vaccination, and AEFI (adverse events following immunization) compensation and reporting. Notable recommendations include unanimous support for mandatory childhood vaccination in Ontario, the need for broad educational communication about vaccination, and the development of a no-fault compensation scheme for AEFIs. There was persistent disagreement among deliberants about the form of exemptions from vaccination (conscience, religious beliefs) that should be permissible, as well as appropriate consequences if parents do not vaccinate their children.Conclusions We conclude that conducting deliberative democratic processes on topics that are polarizing and controversial is viable and should be further developed and implemented to support democratically legitimate and trustworthy policy about childhood vaccination. (shrink)

Cameron et al ’s1 ethical considerations about the ‘Dualism of Values’ in pandemic response emphasise the need to strike a fair balance between the interests of the less vulnerable to COVID-19 and the interests of the more vulnerable. Those considerations are at the basis of ethical defences of focused protection strategies.2 One example is the proposal put forward in the Great Barrington Declaration. It presented focused protection strategies as more ethical alternatives to lockdowns which would prevent lockdowns’ ‘irreparable damage, with (...) the underprivileged disproportionately harmed’.3 Here we want to suggest that a version of Cameron et al ’s analysis can be applied to the case of vaccines to support a focused protection vaccination strategy. At this stage, we should limit vaccination to the vulnerable and not target children in COVID-19 vaccination strategies. We argue that, given the current state of knowledge about COVID-19, immunity and vaccines, it would be wrong to pose the costs and risks of vaccines on children for three reasons. First, they are unlikely to benefit from COVID-19 vaccination …. (shrink)

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage or at the development stage. The Catholic Church’s position is that, if there are (...) alternatives, Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies. (shrink)

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or (...) abstract away from the diverse values that are relevant to the ethical justifications of particular political communities’ vaccine‐mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine‐mandate policies implicate various values. (shrink)

Experimental vaccines are being developed for the treatment of ‘unhealthy lifestyles’ and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of ‘lifestyle vaccines’ for public health. Based on findings from a (...) qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The ‘vaccinization’ of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future. (shrink)

This case (Wilfond, Duenas, and Johnson 2023) asks us to consider the ongoing obligations, if any, for researchers who have enrolled people into clinical trials. This issue can be particularly chal...

Marshall and O’Leary’s thoughtful response to our article suggests that dismissal policies are ethically justifiable because they might induce parents to immunize their children. This outcome is conceivable, but we have only anecdotes about how often it occurs. Such evidence became the thin reed on which the American Academy of Pediatrics rested its new policy of tolerating the practice of dismissing vaccine-hesitant parents. It seems likely that relatively few parents would agree to vaccinate because they were threatened with (...) dismissal. Other heavy-handed interventions have failed to move most such parents. When Washington state made nonmedical exemptions more difficult to obtain, nearly two-thirds of vaccine refusers were unmoved and their children remained unvaccinated. Even if dismissal threats led some parents to accept vaccines, this alone would not justify a dismissal policy. The benefits would still have to be weighed against the risks of dismissing those families who do not change their minds. (shrink)

The current UK policy for the distribution of scarce vaccination in an influenza pandemic is ethically dubious. It is based on the planned outcome of the maximum health benefit in terms of the saving of lives and the reduction of illness. To that end, the population is classified in terms of particular priority groups. An alternative policy with a non-consequentialist rationale is proposed in the present work. The state should give the vaccination, in the first instance, to those (...) who are at risk of catching the pandemic flu in the line of their duties of public employment. Thereafter, if there is not sufficient vaccine to give all citizens equally an effective dose, the state should give all citizens an equal chance of receiving an effective dose. This would be the just thing to do because the state has a duty to treat each and all of its citizens impartially and they have a corresponding right to such impartial treatment. Although this article specifically refers to the UK, it is considered that the suggested alternative policy would be applicable generally. The duty to act justly is not merely a local one. (shrink)

The COVID-19 vaccine has been a miraculous, life-saving advance, offering staggering efficacy in adults, and was developed with astonishing speed. The time from sequencing the virus to authorizing the first COVID-19 vaccine was so brisk even the optimists appear close-minded. Yet, simultaneously, United States’ COVID-19 vaccination roll-out and related policies have contained missed opportunities, errors, run counter to evidence-based medicine, and revealed limitations in the judgment of public policymakers. Misplaced utilization, contradictory messaging, and poor deployment in those who (...) would benefit most—the elderly and high-risk—alongside unrealistic messaging, exaggeration, and coercion in those who benefit least—young, healthy Americans—is at the heart. It is important to consider the history of COVID-19 vaccines to identify where we succeeded and where we failed, and the effects that these errors may have more broadly on vaccination hesitancy and routine childhood immunization programs in the decades to come. (shrink)

In 2022, students at North American universities with third-dose COVID-19 vaccine mandates risk disenrolment if unvaccinated. To assess the appropriateness of booster mandates in this age group, we combine empirical risk-benefit assessment and ethical analysis. To prevent one COVID-19 hospitalisation over a 6-month period, we estimate that 31 207–42 836 young adults aged 18–29 years must receive a third mRNA vaccine. Booster mandates in young adults are expected to cause a net harm: per COVID-19 hospitalisation prevented, we anticipate (...) at least 18.5 serious adverse events from mRNA vaccines, including 1.5–4.6 booster-associated myopericarditis cases in males (typically requiring hospitalisation). We also anticipate 1430–4626 cases of grade ≥3 reactogenicity interfering with daily activities (although typically not requiring hospitalisation). University booster mandates are unethical because they: (1) are not based on an updated (Omicron era) stratified risk-benefit assessment for this age group; (2) may result in a net harm to healthy young adults; (3) are not proportionate: expected harms are not outweighed by public health benefits given modest and transient effectiveness of vaccines against transmission; (4) violate the reciprocity principle because serious vaccine-related harms are not reliably compensated due to gaps in vaccine injury schemes; and (5) may result in wider social harms. We consider counterarguments including efforts to increase safety on campus but find these are fraught with limitations and little scientific support. Finally, we discuss the policy relevance of our analysis for primary series COVID-19 vaccine mandates. (shrink)

While the unprecedented lockdown measures were at the heart of the debate in the first year of the pandemic, the focus since then has shifted to vaccination issues. The reason, of course, is that vaccines and vaccinations have become available by now. All experts agree: If mankind had failed to develop vaccines against SARS-CoV-2, the death toll would have been much higher. This issue seeks to explore what could be described as a “generational approach to vaccinations”. The question “What can (...) we do to avoid future pandemics?” is related to different aspects of the failures and successes of humanity’s vaccination strategy against SARS-CoV-2. Pathogens are among the existential risks to humanity that could potentially kill a large part of it in a very short time. For all the tragedy and horror it has brought upon the world, the Corona virus has not been lethal on such a large, all-encompassing scale. But it could serve as a wake-up call for more and better prevention in the future, put differently: as a call to build a “preventive society”. When people look back to the year 2022 from the year 2200, will they think of the absence of mandatory vaccination as a dangerous anachronism? And will the unequal global distribution of vaccines be seen as an unbearable vice of our epoch? And will “human infection studies” still be dismissed as unethical if a dangerous new virus boards human bodies? If intergenerational justice means improving the life chances and living conditions of future generations to the largest possible extent, then its link to (the avoidance) of infectious diseases is obvious. We should protect future generations from foreseeable damage if we have the power to do so. “We” is humankind in its entirety. Politically, humanity is divided into many single nations. But biologically, as members of the same species, we share the same vulnerability regardless of ethnicity. The regular reader of this journal might wonder why this issue of IGJR has a different structure. An unprecedented pandemic calls for an unprecedented reaction and therefore IGJR 1/2021 and 2/2021 are special issues that deal with this disruptive event. We have invited several health experts, politicians and scholars alike to share their perspectives in short opinion pieces (instead of regular peer-reviewed articles). And we are exploring something new: the publication of a FRFG policy paper. This policy paper starts off with a historical overview on how pandemics have afflicted humanity in the past. It separates moral from legal duties and formulates “epidemiological imperatives” – the way of thinking of a responsible and solidary individual facing the task of preventing an outbreak of epidemics in a community. With the discovery of vaccines, and their availability, the catalogue of duties is increased by one more: to get the jabs as an act of solidarity with others, including future generations. This would prevent states from being forced to take disease control measures that bring about drastic collateral damage. During the first two years of the Corona pandemic, states have imposed lockdowns. The closure of schools has put a special burden on the youngest members of society. This could have been prevented during the second and the further waves. The policy paper also calls for more government funding for prophylactic vaccine research and for the designation of vaccines as “global public goods”. The issue then moves on to a section dedicated to opinion papers by various different authors. The first paper, written by Agnes Binagwaho and Kedest Mathewos (both from University of Global Health Equity, Rwanda), focuses on the issue of health inequity, a concern which has gained more and more traction during the Covid-19 pandemic. The paper examines how vaccine distribution during the pandemic was mainly focused on the global north and how such actions might affect future generations’ perception of what is just, fair and morally correct. The second paper, by Samantha Vanderslott (University of Oxford), focuses on the right and wrongdoings connected to pandemic preparedness and response. The third paper, authored by Rajeev Sadanandan (Health Systems Transformation Platform, India), talks about the lessons that can and should be drawn from child immunisations. The fourth paper, by Adriano Mannino (LMU and Parmenides Foundation, Munich), delves into the question how future generations will assess our actions and our response to the current pandemic. The fifth and final paper, written by Jörg Tremmel (FRFG and University Tübingen), is centered around the question whether human infection studies could have been implemented during the early stages of the pandemic to minimise deaths and severe infections. The issue concludes with two reviews on recent books by Alberto Giubilini and Katie Wright. In his review of Giubilini’s The Ethics of Vaccination, Marius Kunte notes that it contains a “thought-provoking plea” for individual, collective and institutional obligations to reach high vaccination rates. Judith Kausch-Zongo concludes her review of Wright’s Gender, Migration and the Intergenerational Transfer of Human Wellbeing with a special emphasis on the book’s empirical findings, and praises it in its entirety as “undoubtedly important”. Both books serve as poignant reminders of how sustainable societies can only emerge once the challenges revolving around its most vulnerable members have been properly addressed. (shrink)

The issues and problems of mandatory vaccination policy and roll out in First Nations communities are unique and do not concern the safety and effectiveness of vaccines. These issues are also independent of more specific arguments of mandatory vaccination of healthcare workers as a condition of employment. As important as these issues are, they do not consider the complex politics of ongoing settler colonialism and First Nations community relations. In this paper, we also set aside the very real problems (...) of disinformation, hesitancy, scientific and health illiteracy, and other concerns that drive vaccine hesitancy and refusal. These affect all communities, including First Nations communities. We, instead describe the dominant arguments in favour of mandatory vaccination and critique them in terms of the disputed legitimacy of Settler-Colonial decision-making as it impacts First Nations communities. We contend cultural responsiveness and safety—not state compulsion—must remain the first principles of any engagement—including vaccination—with First Nations Peoples, families, and communities. (shrink)

In this article, I apply a policy-oriented applied Islamic bioethics lens to two verdicts on the permissibility of using vaccines with porcine components. I begin by reviewing the decrees and then proceed to describe how they were used by health policy stakeholders. Subsequently, My analysis will highlight aspects of the verdict's ethico-legal arguments in order to illustrate salient legal concepts that must be accounted for when using Islamic verdicts as the basis for health policy. I will conclude (...) with several suggestions for facilitating a more judicious use of verdicts in policy-relevant discourse. My analysis is meant to contribute to the dialogue between science and religion, and aims to further efforts at developing health policies that value health while accommodating religious values. In the encounter between the Islamic tradition and global public health, a multidisciplinary dialogue, where Islamic legists become aware of the health policy implications of their ethico-legal pronouncements, and where health policy actors gain a literate understanding of Islamic ethico-legal theory, will lead to verdicts that better meet the needs of patients, health workers, and religious leaders. (shrink)

Using 2021 data and information related to COVID‐19, this paper discusses the contribution of colonization, medical mistrust and racism to vaccine hesitancy. Vaccine hesitancy is defined as ‘delay in acceptance or refusal of vaccines despite availability’. Colonization is described as the ‘way the extractive economic system of capitalism came to the United States, supported by systems of supremacy and domination, which are a necessary part of keeping the wealth and power accumulated in the hands of the colonizers and (...) ultimately their financiers’. The system of colonization results in policies and practices, including those related to health, that continue to create oppression and support racism. Persons experience trauma as the byproduct of colonization. Chronic stress and trauma create chronic inflammation and all diseases, whether genetic or lifestyle, have a common pathogenesis that is a component of inflammation. Medical mistrust is the absence of trust that healthcare providers and organizations genuinely care for patients' interests, are honest, practice confidentiality and have the competence to produce the best possible results. Finally, racism is described as everyday racism and perceived racism in healthcare. (shrink)

Preventive vaccination can protect not just vaccinated individuals, but also others, which is often a central point in discussions about vaccination. To date, there has been no systematic study of self- and other-directed motives behind vaccination. This article has two major goals: first, to examine and distinguish between self- and other-directed motives behind vaccination, especially with regard to vaccinating for the sake of third parties, and second, to explore some ways in which this approach can help to clarify and guide (...) vaccination debates and policy. I propose conceiving of vaccination in terms of three basic elements: the vaccination decision-maker, the vaccine recipient and the primary beneficiary. I develop a taxonomy based on the relations between these elements to distinguish four kinds of vaccination: self-protective, paternalistic, altruistic and indirect. I finally discuss the case of human papillomavirus vaccine regulation for men and women to show how each kind of vaccination is associated with and raises specific ethical questions. (shrink)

Laws and policies are vital tools in preventing outbreaks and limiting the further spread of disease, but they can vary in content and implementation. This manuscript provides insight into challenges in responding to recent vaccine-preventable disease outbreaks by examining legislative changes in California, policy changes on certain university campuses, and the laws implicated in a measles outbreak in Minnesota.

Although vaccines are considered an efficient public health tool by medical experts, in different countries, people’s confidence in them has been decreasing. COVID-19 has elevated medical scientists’ and practitioners’ social reputation, and it may have reduced global vaccination hesitancy. Still, this alone will not altogether remove the existent frictions that prevent people from complying with vaccination schedules. This paper will review the common causes behind vaccination hesitancy. It will also explore different types of public policy interventions that health experts (...) in governments and institutions employ to fight vaccine hesitancy and non-compliance. The main objective of this article is to argue that, considering the nature of the issue (vaccine hesitancy and its causes), among the various possibilities, policies based on behavioral insights can provide an effective instrument to remove those frictions. Among them, special attention will be devoted to nudges which promise efficiency while avoiding some of the ethical and political costs of other interventions, thanks to their libertarian paternalistic frame. The article concludes by suggesting that public health policymakers should consider the libertarian paternalistic approach of nudges when deploying interventions that aim at changing people’s attitudes and behavior. (shrink)

In a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and Savulescu give (...) insufficient weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally. (shrink)

The Covid‐19 pandemic needs to be considered from two perspectives simultaneously. First, there are questions about which policies are most effective and fair in the here and now, as the pandemic unfolds. These polices concern, for example, who should receive priority in being tested, how to implement contact tracing, or how to decide who should get ventilators or vaccines when not all can. Second, it is imperative to anticipate the medium‐ and longer‐term consequences that these policies have. The case of (...) vaccine rationing is particularly instructive. Ethical, epidemiological, and economic reasons demand that rationing approaches give priority to groups who have been structurally and historically disadvantaged, even if this means that overall life years gained may be lower. (shrink)

We argue that, from the point of view public health ethics, vaccination is significantly analogous to seat belt use in motor vehicles and that coercive vaccination policies are ethically justified for the same reasons why coercive seat belt laws are ethically justified. We start by taking seriously the small risk of vaccines’ side effects and the fact that such risks might need to be coercively imposed on individuals. If millions of individuals are vaccinated, even a very small risk of serious (...) side effects implies that, statistically, at some point side effects will occur. Imposing such risks raises issues about individual freedom to decide what risks to take on oneself or on one’s children and about attribution of responsibility in case of adverse side effects. Seat belt requirements raise many of the same ethical issues as vaccination requirements, and seat belt laws initially encountered some opposition from the public that is very similar to some of the current opposition to vaccine mandates. The analogy suggests that the risks of vaccines do not constitute strong enough reasons against coercive vaccination policies and that the same reasons that justify compulsory seat belt use—a measure now widely accepted and endorsed—also justify coercive vaccination policies. (shrink)

In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to policies (...) that do not allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility. (shrink)

We discuss the relationship between expertise, expert authority, and trust in the case of vaccine research and policy, with a particular focus on COVID-19 vaccines. We argue that expert authority is not merely an epistemic notion, but entails being trusted by the relevant public and is valuable if it is accompanied by expert trustworthiness. Trustworthiness requires, among other things, being transparent, acknowledging uncertainty and expert disagreement (e.g., around vaccines’ effectiveness and safety), being willing to revise views in response (...) to new evidence, and being clear about the values that underpin expert recommendations. We explore how failure to acknowledge expert disagreement and uncertainty can undermine trust in vaccination and public health experts, using expert recommendations around COVID-19 vaccines as a case study. (shrink)

Australian states exclude unvaccinated children from early education and care via ‘No Jab No Play’ policies, but some offer exemptions for the socially disadvantaged. Such mandatory vaccination policies provoke heated arguments about morality and potential downstream impacts, and the politics of which kinds of people get exempted from mandates are often fraught. Synthesising existing frameworks for considering the role of moral principles and rational-technical justifications in policymaking, we show how the same values can be the focus of both ‘rational-instrumental’ and (...) ‘morality’ frames, while ‘pragmatic’ approaches are crowded out by high epistemic or moral certainty. (shrink)

Vaccination can protect vaccinated individuals and often also prevent them from spreading disease to other people. This opens up the possibility of getting vaccinated for the sake of others. In fact, altruistic vaccination has recently been conceptualized as a kind of vaccination that is undertaken primary for the benefit of others. In order to better understand the potential role of altruistic motives in people’s vaccination decisions, we conducted two focus group studies with a total of 37 participants. Study 1 included (...) three focus groups on the subject of HPV vaccination for boys. Study 2 included three focus groups on the subject of pertussis and measles vaccination for childcare workers. We found substantial evidence of other-regarding motives across all focus groups, which suggests that altruistic motives could be an important factor when it comes to people’s vaccination decisions. We address the significance of these findings for vaccination policy surrounding HPV vaccination for boys and vaccination for childcare workers. We also extend the findings to normative work on vaccination for the sake of others more generally. (shrink)

In attempting to provide protection to individuals and communities, childhood immunization has benefits that far outweigh disease risks. However, some parents decide not to immunize their children with some or all vaccines for reasons including lack of trust in governments, health professionals, and vaccine manufacturers. This article employs a theoretical analysis of trust and distrust to explore how twenty-seven parents with a history of vaccine rejection in two Australian cities view the expert systems central to vaccination policy (...) and practice. Our data show how perceptions of the profit motive generate distrust in the expert systems pertaining to vaccination. Our participants perceived that pharmaceutical companies had a pernicious influence over the systems driving vaccination: research, health professionals, and government. Accordingly, they saw vaccine recommendations in conflict with the interests of their child and “the system” underscored by malign intent, even if individual representatives of this system were not equally tainted. This perspective was common to parents who declined all vaccines and those who accepted some. We regard the differences between these parents—and indeed the differences between vaccine decliners and those whose Western medical epistemology informs reflexive trust—as arising from the internalization of countering views, which facilitates nuance. (shrink)

There is an enigma that plagues the modern world. On the one hand, access to information is more abundant than ever. On the other, knowledge seems all the more difficult to come by. The world is divided on numerous fact-based questions regarding nutrition, exercise, public policy impact, sickness prevention, mental wellness, and more. What accounts for this phenomenon? Likely, these disagreements and difficulties cannot be accounted for by a single factor, and the elements in play vary from question to (...) question and subject to subject. This paper will focus on one possible factor: eroding trust in subject matter experts. (shrink)

Context In response to outbreaks of vaccine‐preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as “vaccine mandates.” However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context‐specific instruments. Their (...) legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. Methods In this paper, we introduce a taxonomy for classifying real‐world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). Findings A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute—salience —which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. Conclusion Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments. (shrink)

Health behaviors such as tobacco use contribute significantly to poor health. It is widely recognized that efforts to prevent poor health outcomes should begin in early childhood. Biomedical enhancements, such as a nicotine vaccine, are now emerging and have potential to be used for primary prevention of common diseases. In anticipation of such enhancements, it is important that we begin to consider the ethical and policy appropriateness of their use with children. The main ethical concerns raised by enhancing (...) children relate to their impact on children’s well-being and autonomy. These concerns are significant, however they do not appear to apply in the case of the nicotine vaccine; indeed the vaccine could even further these goals for children. Nevertheless, concerns about broadly applying this enhancement may be more challenging. The vaccine may be less cost-effective than alternative public efforts to prevent tobacco use, utilizing it could distract from addressing the foundational causes of smoking and it might not be publically acceptable. Empirical research about these concerns is needed to ascertain their likelihood and impact as well as how they could be minimized. This research could help determine whether behavior-related enhancements hold promise for improving children’s health. (shrink)

Vaccine refusal is not a free rider problem. The claim that vaccine refusers are free riders is inconsistent with the beliefs and motivations of most vaccine refusers. This claim also inaccurately depicts the relationship between an individual’s immunization choice, their ability to enjoy the benefits of community protection, and the costs and benefits that individuals experience from immunization and community protection. Modeling vaccine refusers as free riders also likely distorts the ethical analysis of vaccine refusal (...) and may lead to unsuccessful policy interventions. (shrink)

This open access book discusses individual, collective, and institutional responsibilities with regard to vaccination from the perspective of philosophy and public health ethics. It addresses the issue of what it means for a collective to be morally responsible for the realisation of herd immunity and what the implications of collective responsibility are for individual and institutional responsibilities. The first chapter introduces some key concepts in the vaccination debate, such as ‘herd immunity’, ‘public goods’, and ‘vaccine refusal’; and explains why (...) failure to vaccinate raises certain ethical issues. The second chapter analyses, from a philosophical perspective, the relationship between individual, collective, and institutional responsibilities with regard to the realisation of herd immunity. The third chapter is about the principle of least restrictive alternative in public health ethics and its implications for vaccination policies. Finally, the fourth chapter presents an ethical argument for unqualified compulsory vaccination, i.e. for compulsory vaccination that does not allow for any conscientious objection. The book will appeal to philosophers interested in public health ethics and the general public interested in the philosophical underpinning of different arguments about our moral obligations with regard to vaccination. (shrink)

This paper argues that vice-charging, the practice of charging other persons with epistemic vice, can itself be epistemically vicious. It identifies some potential vices of vice-charging and identifies knowledge of other people as a type of knowledge that is obstructed by epistemically vicious attributions of epistemic vice. The hazards of vice-charging are illustrated by reference to the accusation that parents who hesitate to give their children the MMR triple vaccine are guilty of gullibility and dogmatism. Ethnographic and sociological research (...) is used to make the case that this charge is, in a significant range of cases, epistemically unjust and hinders attempts to make sense of vaccine hesitancy. This epistemic injustice consists in the representation of vaccine hesitant parents as less than full epistemic agents. A case is made for a more tolerant and inclusive approach, not only to vaccine hesitancy but also to other forms of unorthodoxy or non-compliance. The primary objective in these cases should be to achieve Verstehen of seemingly alien outlooks and practices so that policy makers and practitioners in public services can more effectively educate a sceptical public about the risks of vaccine hesitancy. (shrink)