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COUNTERPOINT: Should Childhood Vaccination Against Measles Be a Mandatory Requirement for Attending School? NoMandatory Measles Vaccination. No FREE TO VIEW

Peter Schröder-Bäck, PhD; Kyriakos Martakis, MD
Author and Funding Information

From the Department of International Health (Drs Schröder-Bäck and Martakis), CAPHRI—School of Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University; the Faculty for Human and Health Sciences (Dr Schröder-Bäck), University of Bremen, Bremen, Germany; and the Children’s and Adolescents’ Hospital, University Hospital of Cologne (Dr Martakis), Cologne, Germany.

CORRESPONDENCE TO: Peter Schröder-Bäck, PhD, Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care (CAPHRI), Department of International Health, Postbox 616, 6200 MD Maastricht, The Netherlands; e-mail: Peter.Schroder@maastrichtuniversity.nl


CONFLICT OF INTEREST: None declared.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(4):854-856. doi:10.1378/chest.15-1162
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We have no doubt that childhood measles immunization programs aimed at achieving or maintaining herd immunity are justified from both a public health and an ethical perspective. The minor risks that may be associated with the vaccination far outweigh the burden of disease that measles outbreaks produce.1

Although the effectiveness of a policy imposing a mandatory childhood vaccination prior to enrollment in school (usually including exemptions because of religious or so-called philosophical reasons)2 may look self-evident, we would doubt that this measure is necessary or sufficient for herd immunity. In fact, the vaccination coverage of local populations where measles outbreaks have occurred is as low as 50%3 and is often the result of nonvaccinated adults.4 Thus, it is reasonable to develop or strengthen policies to approach every unvaccinated candidate, including adults.

Here, we have considered mandatory vaccination at school entry from an ethical perspective. In our ethical analysis we have taken into account values such as avoiding harm, autonomy, social justice, and health maximization.5 We are convinced that it is essential to use as little compulsion as possible for successful and justifiable immunization programs.6 Allowing school enrollment only if the child is immunized is a form of compulsion. It is de facto compulsion for many parents, because private alternatives to school like home schooling might be difficult to afford or to accomplish for many parents. Pragmatically, many parents need supervision of their children while they go to work. Thus, not allowing children to attend school is, for many parents, no option.

What are the most relevant ethical arguments from our point of view in the context of this issue? It may be argued that the decision of not having one’s child immunized against measles is a matter of liberty or autonomy.7 Our arguments are in fact a clear departure from this perception. John Stuart Mill said that the liberty of individuals shall be protected as long as the exercise of their liberty does not pose harm to others.7 This classic “harm principle” points out that parents who deliberately do not immunize their own child put the community at risk. Potential victims include the parents’ children themselves, nonvaccinated children (including infants too young to be immunized), immigrant children from countries with no access to measles vaccine, and individuals for whom measles vaccination is contraindicated, such as patients with immune deficiencies. Thus, the libertarian argument of self-responsibility—that prevention is one’s individual decision and infection would be one’s own fault—is not convincing.

Similarly, the autonomy argument that deciding against immunization is an autonomous act worthy of protection is flawed. It is at least flawed if we understand “autonomy” in the tradition of Immanuel Kant. Immanuel Kant describes acting autonomously as acting on a maxim on which everyone else could act as well. Yet, if the actual goal of a parent was to free ride on the positive immunization status of others, this would not work out if nobody immunized.8 If a parent were to argue for an autonomous decision of accepting the risk of a measles infection rather than immunizing their child, this decision could be argued to be in conflict with the child’s developing autonomy.9

If we are convinced one should immunize oneself and one’s children against measles, why are we arguing against a positive mandatory measles immunization status for attending school? Such a policy would also seemingly find support from a social ethics perspective: One could argue for forcing all children to be immunized out of fairness, because the benefits and burden of immunization would be equally distributed. In turn, free riders—who are often people of high socioeconomic status who manage to receive exemptions2—would be eradicated. Such fairness is certainly appealing.

Yet, along with other authors,2,10 we prefer that incentives and nudges be used to achieve herd immunity to avoid compulsion. Our societies can afford incentives and should explore these possibilities first before turning to compulsion. Examples for incentives could be financial: incentive payments for immunization, lower (health) insurance premiums, or tax exemptions.2 Among the possible “nudges” could be a choice architecture that makes measles immunization the default option (eg, in the pediatrician or family practitioner’s consultations).10 These incentives and nudges could also focus on nonimmunized adults. Although this might entail substantial financial investment, it is certainly affordable for the society.

Our main argument against a mandatory positive vaccination status for school and in favor of incentives and nudges is derived from our understanding of social justice. The aim of social justice is to protect the well-being of everyone in our societies. We agree with Powers and Faden11 that well-being has certain morally significant, irreducible dimensions (irreducible meaning one dimension may not be traded off or compensated against another). Among these are health and development of capacities for reasoning. In our understanding, the latter is best achieved through state-controlled school education, which offers children equal opportunities to participate in society. Thus, to exclude children from decent school education for health would violate the convincing postulate that both dimensions—education and health—should be irreducible. Although in liberal societies adults may choose to do tradeoffs between dimensions of well-being or other goods, in this context we are talking about the state and parents making an ethically unconvincing tradeoff with the well-being of children. Such a tradeoff would be intended by the policy if school can only be attended when vaccinated. This tradeoff would be a burden to a particularly vulnerable group that needs any society’s best attention: children. Rather than allowing tradeoffs of essential dimensions of well-being by policy design, more energy and resources have to be spent so that children get both: measles immunization and decent school education.

No doubt, during a local measles outbreak it may be necessary to close schools temporarily or, arguably, exclude nonimmunized children. Such eventualities must be followed by efforts to limit the resulting educational setback. Also, access to cinemas, amusement parks, or concert halls could be limited for nonimmunized people. Yet, to prevent children from attending school is ethically questionable, potentially discriminating against those of lower sociodemographic status who cannot organize adequate alternative education or receive exemptions.

From an ethical perspective, we conclude that herd immunity to protect against measles outbreaks is the right public health goal. However, when it comes to achieving herd immunity we are doubtful that immunization should be a prerequisite for attending school. We remain unconvinced that this is a necessary or a sufficiently effective intervention; it may be more effective to focus on other interventions that include all nonimmunized individuals, including adults. We also see ethical reasons against this unjust policy—not only because wealthier parents might de facto still be able to receive exemptions from immunization. With such a policy the state trades off, in principle, the right to decent education with the right to health. Yet both education and health present irreducible dimensions of well-being. Instead, we should strive to realize both—the right to health and the right to decent education—for everyone.

References

Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2012;2(2):CD004407. [PubMed]
 
Constable C, Blank NR, Caplan AL. Rising rates of vaccine exemptions: problems with current policy and more promising remedies. Vaccine. 2014;32(16):1793-1797. [CrossRef] [PubMed]
 
Majumder MS, Cohn EL, Mekaru SR, Huston JE, Brownstein JS. Substandard vaccination compliance and the 2015 measles outbreak. JAMA Pediatr. 2015;169(5):494-495. [CrossRef] [PubMed]
 
Robert Koch Institute. Measles: on the measles outbreaks in Berlin and Bosnia Herzegovina [in German]. Epidemiologisches Bulletin. 2015;5:37.
 
Schröder-Bäck P, Duncan P, Sherlaw W, Brall C, Czabanowska K. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Med Ethics. 2014;15:73. [CrossRef] [PubMed]
 
Schröder-Bäck P, Brand H, Escamilla I, et al. Ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the European Union. Cent Eur J Public Health. 2009;17(4):183-186. [PubMed]
 
Nuffield Council on Bioethics. Public Health: Ethical Issues. London, England: Nuffield Council on Bioethics; 2007.
 
O’Neill O. Public health or clinical ethics: thinking beyond borders. Ethics Int Aff. 2002;16(2):35-45. [CrossRef] [PubMed]
 
Komrad MS. A defence of medical paternalism: maximising patients’ autonomy. J Med Ethics. 1983;9(1):38-44. [CrossRef] [PubMed]
 
Gostin LO. Law, ethics, and public health in the vaccination debates: politics of the measles outbreak. JAMA. 2015;313(11):1099-1100. [CrossRef] [PubMed]
 
Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York, NY: Oxford University Press; 2006.
 

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References

Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2012;2(2):CD004407. [PubMed]
 
Constable C, Blank NR, Caplan AL. Rising rates of vaccine exemptions: problems with current policy and more promising remedies. Vaccine. 2014;32(16):1793-1797. [CrossRef] [PubMed]
 
Majumder MS, Cohn EL, Mekaru SR, Huston JE, Brownstein JS. Substandard vaccination compliance and the 2015 measles outbreak. JAMA Pediatr. 2015;169(5):494-495. [CrossRef] [PubMed]
 
Robert Koch Institute. Measles: on the measles outbreaks in Berlin and Bosnia Herzegovina [in German]. Epidemiologisches Bulletin. 2015;5:37.
 
Schröder-Bäck P, Duncan P, Sherlaw W, Brall C, Czabanowska K. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Med Ethics. 2014;15:73. [CrossRef] [PubMed]
 
Schröder-Bäck P, Brand H, Escamilla I, et al. Ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the European Union. Cent Eur J Public Health. 2009;17(4):183-186. [PubMed]
 
Nuffield Council on Bioethics. Public Health: Ethical Issues. London, England: Nuffield Council on Bioethics; 2007.
 
O’Neill O. Public health or clinical ethics: thinking beyond borders. Ethics Int Aff. 2002;16(2):35-45. [CrossRef] [PubMed]
 
Komrad MS. A defence of medical paternalism: maximising patients’ autonomy. J Med Ethics. 1983;9(1):38-44. [CrossRef] [PubMed]
 
Gostin LO. Law, ethics, and public health in the vaccination debates: politics of the measles outbreak. JAMA. 2015;313(11):1099-1100. [CrossRef] [PubMed]
 
Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York, NY: Oxford University Press; 2006.
 
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