Ethical Analysis For Mandatory Mass Health Action
The personal beliefs exemption (PBE) which is legal in most states has been a problematic issue for public health officials, physicians, and parents alike. The main function of a PBE is to afford parents a legal means to opt out of mandated vaccination programs (Steve 2007). Specifically, PBE recognizes that there may be some parents who for deeply-held philosophical and religious reasons consider vaccination unnecessary. In the city of Tiburon in California, the situation is no different.
Many parents in Tiburon have opted not to vaccinate their children citing the philosophical beliefs. The parents’ choice not to vaccinate their children against measles would not be such a contentious decision were it not for the presence of immunocompromised students who attend Reed Elementary (Aliferis 2015).
The immunocompromised children have a legitimate reason not to be vaccinated because of their health status whereas that is not the case for non-immunocompromised students. The ethical concern in the case under consideration is how to get more non-immunocompromised children vaccinated for the good of public health. By banning non-immunocompromised children from attending school, parents will likely be forced to forego PBE and vaccinate thereby increasing herd immunity (Salathe 2015) to protect otherkids who may not be able to get the vaccine. Not unlike many public health ethics cases, the case study under consideration is a typical example of an ethical tension that needs to be resolved. The issue originates in Marin County California where a school superintendent is tasked with making a decision that is expected to increase vaccine uptake. The vaccine in question is for measles and there are some kids like Rhett Krawitt who for legitimate medical reasons cannot get the vaccine.
A close look at the ethical dilemma indicates that there are certain ethical frameworks that need to be considered to successfully recommend a course of action that is fair, just and accomplishes the aim of improving the health of the public. Some of the ethical frameworks thatare relevant to the case are elements within the five justificatory conditions (Childress et al., 2002), Mill’s harm principle and five step public health intervention framework as outlined by Gostin (Jennings et al 2003).
The relevant justificatory conditions needed to satisfactorily mandate the vaccination include its effectiveness in promoting public health, necessity, and impartiality. The effectiveness of mandating vaccination of non-immunocompromised children and making it a condition of school attendance can be considered effective. Effectiveness simply implies that the mandate’s goal of improving public health needs to be realized as a trade-off due to the possibility of violating such general moral considerations as privacy and autonomy (Childress et al 2002). If the aim of protecting public health is not feasible then the mandate will be unethical.
The gravity of the situation in Tiburon calls for a thorough examination of alternatives. For instance, due to the possibility of violating the autonomy and privacy of parents, will it be wiser to incentivize rather than merely coercing them to comply? Since education is deemed a basic right in the state of California, a coerced vaccination program can be legally challenged in a court of law. In the event of a lawsuit the proponents will then have the burden of moral proof (Childress et al., 2002) that indeed the mandate is necessary for the health of the public.
Impartiality is a justificatory principle that is very relevant to the case in Marin County, California. The principle of impartiality emphasizes fairness which in a sense can be interpreted as non-discrimination. By mandating the measles vaccine for just non-immunocompromised children, opponents of the measure can cite an instance of partiality and discrimination to some extent. Once again, proponents of the measure must show that the mandate as applied to kids with no medical reason for non-compliance is indeed in the interest of public health.
In the case of Rhett Krawitt, physicians have concluded that his immunocompromised state is enough reason to exclude him from the immunization exercise (Aliferis 2015).
Mill’s Harm Principle holds that the only condition under which the state can rightfully infringe upon the right of any individual is if it benefits the health and well-being of the many (Upshur 2002). The Reed Elementary school parents who opt to not have their children vaccinated against measles indirectly place other kids at risk. Children with legitimate medical reasons not to get vaccinated likely will suffer from morbidity and mortality associated with contracting the measles virus. Since minors are generally not able to make medically sound decisions for themselves, Mill’s position on the state’s duty to protect the vulnerable – in this case children - is quite sound. The key question, however, for the superintendent’s recommendation is that kids with no medical reason not to vaccinate far outnumber the immunocompromised children. In view of this, there could be a situation where Mill’s principle is challenged based solely on numbers even though it probably will be a weak argument. In that case, high lethality and contagiousness of the disease could be used as the main factor in deciding the appropriate course of action which is to mandate immunization for those with no medically justifiable reason. Furthermore, the precedent set by Jacobson v. Massachusetts could also be used to facilitate the ethical basis of a mandate. Parents often are not medical experts capable of determining what is or is not harmful to their kids. Therefore, Mill’s principle, in a bid to preserve individuality, personal autonomy, and privacy advocates education for the public. In a case such as the one in Tiburon, California, a comprehensive awareness program can be created for parents who have doubts about the immunization intervention. By so doing, they can make an informed decision as to what is in the best interest of their children which will be the ideal ethical route. Even with a comprehensive awareness creation campaign, there is no sure
way to predict the final position that vaccine hesitant parents will possibly take especially in a situation where the philosophical beliefs of a parent is held much deeper than the trust of science.
In order to make an appropriate decision as to whether to intervene in a public health crisis, Lawrence Gostin identifies five main steps for consideration. They are: a demonstration of effectiveness, risk, economic cost, burdens on human rights, and the fairness of the intervention (Jennings et al., 2003). The proposed intervention needs to be fair and just. The implication of fairness is based on two things, namely need and risk (Jennings et al., 2003). The most at-risk population deserve to enjoy the privilege of the intervention because the virus can be deadly to them. In the case of Tiburon, children of school-going age are the main means of demonstrating need with the exception of those who are immunocompromised. Excluding the immunocompromised takes risks associated with the intervention into account as a vaccination of a child such as Rhett Krawitt essentially defeats the purpose of preserving health.
For the town of Tiburon and their school districts to reach herd immunity, there needs to be an exemption but only for those who have valid medical reasons. Although mandating a mass immunization exercise and making it a condition of school attendance is laudable, it places parental autonomy under undue stress. Additionally, it disregards the value of personal beliefs held by parents as well as the basic rights of non-immunocompromised children to be educated both of which must be taken into account (Jennings et al., 2003).
Another factor Gostin discusses is the issue of economic cost of the potential mandate in the case under consideration. It is no secret that the measles vaccine is efficacious and that it does prevent morbidity and mortality associated with the disease – which demonstrates its effectiveness (Jennings et al., 2003). The monetary cost associated with a potential mandate will likely be justified; but considering the fact that the government provides funding for children to attend schools, denying education access to a child whose parents opt not to comply with the mandate in a way represents a loss to the government. The potential legal costs that could be incurred in case a parents chooses to sue the government based on invasion of privacy also must be taken into consideration.
The risk(s) associated with not vaccinating could be catastrophic. The most disconcerting perhaps has to do with the ultimate loss of lives due to a mass transmission. Children have immune systems that are susceptible to disease unlike those of adults. It is therefore imperative to increase herd immunity by vaccinating non-immunocompromised children. Without good herd immunity, there is a possibility that the virus could mutate thereby resulting in vaccine resistant strains which represents new and complex challenges for the medical experts.