The current project has the goal of adding substantially to the discourse on the ethics of MMR vaccination in children to prevent measles infection. The goal is to provide ethical recommendations regarding vaccination with MMR that can guide individual decision-making in the medical context, as well as societal and government policy. To do so, I will structure this project in a way that will address the main deficiencies identified in the existing literature.
I shall perform a thorough analysis of the relevant medical facts surrounding measles infection and MMR vaccination. In chapter 2 I shall consider measles infection, including the epidemiology, complications, cost of measles infection to the health system, the concept of herd immunity, and measles virus characteristics of note. In chapter 3 I shall analyze measles vaccination with the focus on MMR, the most widely used vaccine to prevent measles infection. Here I shall address questions such as vaccine efficacy, vaccine cost, potential adverse effects, the autism controversy, vaccine history, vaccine opposition and refusal, and the anti-vaccine movement. I shall also present a comparison between the complications of measles and the potential adverse effects of MMR vaccination. The medical facts regarding measles and MMR vaccination will provide the necessary empirical background for the consideration of normative ethical arguments.
Next, I shall turn to the process of analyzing ethical considerations involved and advance ethical arguments. In the literature on the ethics of MMR vaccination, the following important ethical issues are addressed:
(1) Ethical considerations of the individual case of MMR vaccination. To my mind this is an appropriate ethical question, as vaccination surrounds a (usually) healthy and (usually) young child. Looking at this situation, ethical questions of justification for providing an intervention which can have adverse effects to a child who cannot provide consent arise. Although these questions are addressed in the existing literature, they have not been substantively answered due to the defects I previously identified.
(2) Individual freedom/autonomy versus responsibility to others/justice. This is a central question within MMR vaccination, and every author attempts to come to terms with this tension.
However, invariably the author assumes a communitarian justice perspective. Nowhere do we find a serious analysis of the implications of other theories of justice for this question, which is strange since communitarianism does not enjoy universal appeal. Furthermore, I argued before that the way in which authors engage with the tension is highly unsystematic and unsubstantive, meaning that the tension is never satisfactorily dealt with through grounded ethical arguments that stay within a consistent ethical paradigm.
(3) Are coercive vaccination policies, using state power, ethically justified? This is another central ethical issue that virtually all the authors address. Again, it is addressed in a very unsystematic and haphazard way. Often times it is not clear how preceding arguments and stated ethical paradigms are connected with arguments offered when considering the issue of coercive
36 vaccination. Consequently, the recommendations offered do not appear to be substantively grounded in ethical justifications.
I shall address all three of these central ethical questions with the goal of reaching ethically justifiable and ethically grounded recommendations for vaccination practice and policy. During this process, it would be important to analyze the ethical aspects of the individual case of MMR vaccination, the implications of different theories of justice, and to bring the conclusions of these arguments to bear on vaccination policy considerations.
I aim to make recommendations that are widely applicable and widely accepted, and not restricted to a specific country, community or context. Rather than writing a set of recommendations for the ‘American’ context, the ‘South African’ context, or the ‘European’
context, I aim to provide analysis and recommendations that can guide ethical decision-making for a variety of communities, countries, and individuals. Therefore, when I cite different countries in the empirical or policy section, it should be seen as examples of specific disease and vaccination trends or examples of different types of policy. These considerations function as premises in an ongoing argument throughout this dissertation, aimed at providing a set of ethical recommendations that can be used to formulate policy in the just society, and guide medical decision-making for the individual child.
To engage in ethical analysis, I shall make use of the principlist paradigm of Beauchamp and Childress. Principlism has arguably become the most popular approach to resolving knotty bioethical questions, and can arguably be considered the lingua franca of bioethics. One of its strong points is that it relies on widely shared moral judgments; conclusions reached through the application of principlism would appeal to persons of different ethical theoretical persuasion. For example, the four principles can be at home within both a utilitarian and a Kantian paradigm.
This is not to say that they are relativistic: instead, they rely on those moral convictions that persons from such competing theories share. After all, there is a large amount of agreement about which actions are morally right between Kantians, utilitarians, contractarians, and so forth.
They all know that it is wrong to steal, murder, torture innocents, and the like. The strength of the principlist approach is that the four principles appeal to adherents of the different theories in the same way these shared moral judgments do. Thus, in using the principlist paradigm I expect to reach conclusions that will enjoy wide appeal to persons all over the spectrum of ethical theory. If I were to ground arguments in a specific classical theory – say, for example, utilitarianism – the conclusions reached would only be persuasive to those who share the theoretical background. Using the principlist paradigm has the advantage of providing normative ethical justifications that would appeal to all people who see the sense of our shared moral judgments.
More importantly, the principlist paradigm is ideally situated to engage with the three central ethical questions identified in the MMR vaccination ethics literature. All four of the principles are engaged – autonomy speaks to the issue of respecting individual freedom and the individual case of MMR vaccination; beneficence and non-maleficence are relevant to the individual case; justice is relevant to the tension between individual freedom and what people owe each other. The four principles show themselves to be excellent starting points for the consideration of the main ethical questions at hand. The method of principlism requires application of the four principles
37 to the issue at hand, and then through a process of specifying to arrive at specified action guides.
Through a process of balancing one then brings these action guides into equilibrium with one another, so that it is clear what the actual moral obligations in the given scenario is. Thus, the principlist paradigm offers the tools and methods necessary to bring all three central ethical questions in MMR vaccination into balance with one another, leading to clarity on ethical conclusions and obligations.
I shall therefore proceed as follows. In chapter 4 I shall examine the principlist paradigm, its method, some objections against it, and eventually endorse it as the paradigm of choice for the task at hand.
In chapter 5 I shall analyze the individual case of vaccination, bringing the principles of autonomy, beneficence and non-maleficence to bear on the empirical facts. I shall ground a best interests approach firmly in these principles, and indicate how parental choices guided by best interests meet the requirements of these three principles. I shall also consider and defeat the argument that in a highly vaccinated society a child’s best interests may be to forego MMR vaccination. In conclusion I shall offer two ethical action guides, two principles derived from the analysis of the individual case of vaccination.
In chapter 6 I shall consider MMR vaccination from the perspective of five different theories of justice. I shall demonstrate how each theory of justice leads us to adopt two ethical action guides, delineating the ethical obligations of the just society. The goal of this chapter will not be to provide a comprehensive analysis of a specific theory of justice, such as libertarianism or Rawls’
egalitarian contractarianism. Instead, I will briefly introduce the main points of each theory of justice to the extent that is necessary to engage in meaningful ethical argumentation around MMR vaccination. The aim of this chapter is to show how each different theory of justice supports the same two ethical action guides. In terms of the overall principlist framework, the principle of justice would then endorse these two action guides derived from the different, competing theories of justice.
In chapter 7, the concluding chapter, I shall point out that the two action guides from chapter 5 are similar to the two action guides from chapter 6. Therefore, we are able to bring all four principles into balance by stating two ethical action guides. These action guides are:
(1) All children eligible for measles vaccination should be vaccinated against measles, at least to the point of sustained measles elimination.
(2) Respect for parental decision-making and the parent-child relationship guide the response to parental vaccine refusals.
These two action guides of principles can be used to derive ethical obligations and to regulate policy. In chapter 7 I shall engage in this process, and offer recommendations as to ethically justifiable MMR vaccination policies.
38
Chapter 1 References
Adetunji, Y, Macklin, D, Patel, R, & Kinsinger L 2003, ‘American College of Preventive Medicine Practice policy statement - childhood immunizations’, American Journal of Preventive
Medicine, vol. 25, no. 2, pp. 169-175.
Allen A 2007, Vaccine: The controversial story of medicine’s greatest lifesaver, Norton, New York.
American Academy of Pediatrics: Committee on Practice and Ambulatory Medicine and Council on Community Pediatrics 2010, ‘Policy statement – increasing immunization coverage’,
Pediatrics, vol. 125, no. 6, pp. 1295-1304.
Beauchamp, TL, & Childress, JF 2013, Principles of Biomedical Ethics, 7th edn, Oxford University Press, New York.
Buchanan, AE, & Brock, W 1990, Deciding for others: The ethics of surrogate decision-making, Cambridge University Press, Cambridge.
Centers for Disease Control and Prevention (CDC) 1999, ‘Achievements in public health, 1900–1999 Impact of vaccines universally recommended for children – United States, 1990–
1998’, Morbity Mortality Weekly Report, vol. 48, no. 12, pp. 243–248.
Centers for Diseases Control and Prevention (CDC) 2008, ‘Update: Measles- United States, January-July 2008’, MMWR Weekly, vol. 57, no. 33, pp. 893-896.
Children’s Act 38 of 2005. Available from:
https://www.capetown.gov.za/en/CityHealth/Documentation/Documents/Act_Childrens_Act_
38_of_2005_%28as_amended_march_2010%29.pdf [13 Aril 2016].
Clouser, KD, & Gert, B 1990, ‘A critique of principlism’, The Journal of Medicine and Philosophy, vol. 15, pp. 219-236.
Dare, T 1998, ‘Mass immunization programmes: some philosophical issues’, Bioethics, vol. 12, no.2, pp. 125-149.
Dawson, A 2004, ‘Vaccination and the prevention problem’, Bioethics, vol. 18, no. 6, pp. 515-530.
Dawson, A 2005, ‘The determination of the best interests in relation to childhood immunization’, Bioethics, vol. 19, no. 1, pp. 72-89.
Dawson, A 2011, ‘The moral case for the routine vaccination of children in developed and developing countries’, Health Affairs, vol. 30, no. 6, pp. 1029-1033.
39 Dawson, A 2014, ‘Vaccination ethics’, Vaccine, vol. 32, pp. 7161-7162.
Demicheli, V, Rivetti, A, Debalini, MG, & Di Pietrantonj, C 2012, ‘Vaccines for measles, mumps and rubella in children’, Cochrane Database of Systematic Reviews, Issue 2, Art. No.: CD004407.
DOI: 10.1002/14651858.CD004407.pub3.
Diekema, DS 2005, ‘Responding to parental refusals of immunization of children’, Pediatrics, vol. 115, no. 5, pp. 1428-1431.
Diekema, DS 2004, ‘Parental refusals of medical treatment: the harm principle as threshold for state intervention’, Theoretical Medicine and Bioethics, vol. 25, no. 4, pp. 243-264.
Diekema, DS 2011, ‘Revisiting the best interest standard: uses and misuses’, Journal of Clinical Ethics, vol. 22, no. 2, pp. 128-133.
Diekema, DS, & Marcuse, EK 2007, ‘Ethical Issues in the Vaccination of Children’, in R Bayer, LO Gostin, B Jennings, & B Steinbock, (eds), Public Health Ethics, pp. 279-288. Oxford University Press, New York.
The Editors of the Lancet 2010, ‘Retraction – Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children’, Lancet, vol. 375, no. 9713, p. 445.
El Amin, AN, Parra, MT, Kim-Farley, R, & Fielding, JE 2012, ‘Ethical issues concerning vaccination requirements’, Public Health Reviews, vol. 34, no.1, pp. 1-20.
Euro Surveillance Editorial Team 2008, ‘Measles once again endemic in the United Kingdom’, Euro Surveillance, vol. 13, no. 27, pii=18919.
Gay, NJ 2004, ‘The Theory of Measles Elimination: Implications for the Design of Elimination Strategies’, The Journal of Infectious Diseases, vol. 189, Suppl. 1, pp. S27-35.
Godlee, F, Smith, J, & Marcovitch, H 2011, ‘Wakefield’s article linking MMR vaccine and autism was fraudulent’, British Medical Journal, vol. 342, p. c7452.
Goldacre, B 2008, ‘The media’s MMR hoax,’ (Chapter 12) in B. Goldacre, Bad Science, pp. 208-252. McClelland & Stewart, Toronto.
Goldstein, BD 2001, ‘The precautionary principle also applies to public health actions’, American Journal of Public Health, vol. 91, no. 9, pp. 1358-1361.
Gostin, LO, Bayer, R, & Fairchild, A 2003, ‘Ethical and legal challenges posed by Severe Acute Respiratory Syndrome: Implications for the control of severe infectious disease threats’, JAMA vol. 290, no. 4, pp. 3229-3237.
40 Gostin, LO 2015, ‘Law, ethics, and public health in the vaccination debates: Politics of the
measles outbreak’, JAMA, vol. 313, no.11, pp. 1099-1100.
Heller, T, Heller, D, & Pattison S 2001 ‘Vaccination against mumps, measles, and rubella: is there a case for deepening the debate?’, BMJ, vol.323, p. 838.
Isaacs, D 2012, ‘An ethical framework for public health immunization programs’, NSW Public Health Bulletin, vol.23, no.5-6, pp. 111-115.
Kata, A 2010, ‘A Postmodern Pandora's Box: Anti-vaccination misinformation on the Internet’, Vaccine, vol. 28, pp. 1709-1716.
Krantz, I, Sachs, L, & Nilstun, T 2004, ‘Ethics and Vaccination’, Scandinavian Journal of Public Health, vol. 32, pp. 172-178.
Knol, MJ, Urbanus, AT, Swart, EM, Mollema, L, Ruijs, WL, van Binnedijk, RS, Wierik, MJ, de Melker, HE, Timen, A, & Hahne SJ 2013, ‘Large ongoing measles outbreak in a religious
community in the Netherlands since May 2013’, Euro Surveillance, vol. 18, no. (36), pii=20580.
Mill, JS 2010a, ‘On Liberty’, in On Liberty and Other Essays, pp. 5-74. Digireads.com, Breinigsville, PA.
Moss, WJ, Griffin, DE 2012, ‘Measles’, Lancet vol. 379, pp. 153-164.
Omer, SB, Salmon, D, Orenstein, WA, deHart, P, & Halsey, N 2009, ‘Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases’, New England Journal of Medicine, vol. 360, no. 19, pp. 1981–1988.
Pierik, R 2014, ‘The return of measles to the low countries: A legal-philosophical exploration’, Netherlands Journal of Legal Philosophy, vol. 43, no.2, pp. 103-107.
Pierik, R 2016, ‘Mandatory vaccination: an unqualified defense’, Journal of Applied Philosophy, doi:10.1111/japp.12215
Ross, WD 1930, The Right and the Good, Oxford University Press (Reprinted copy: Hackett, Indianapolis, IN).
Sheather, J 2013, ‘Should childhood MMR vaccination be compulsory? Rights, duties and the public interest’, Human Vaccines & Immunotherapeutics, vol. 9, no. 6, pp. 1389-1391.
van den Hoven, M 2012, ‘Why one should do one’s bit: Thinking about free riding in the context of public health ethics’, Public Health Ethics, vol. 5, no. 2, pp. 154-160.
Verweij, M, & Dawson, A 2004, ‘Ethical principles for collective immunisation programmes’, Vaccine, vol. 22, pp. 3122-3126.
41 Walsh, TJ 2013, ‘Advancing the interests of South Africa’s children: a look at the best interests of children under South Africa’s Children’s Act’, Michigan State International Law Review, vol.
19, no. 2, pp. 201-250.
Wood-Harper, J 2005, ‘Informing education policy on MMR: balancing individual freedoms and collective responsibilities for the promotion of public health’, Nursing Ethics, vol.12, no. 1, pp.
43-58.
Woolley, S 2005, ‘Children of Jehovah’s Witnesses and adolescent Jehovah’s Witnesses: what are their rights?’, Archives of Disease in Childhood, vol. 90, no. 7, pp. 715-719.
42
Chapter 2: Scientific review of measles disease and epidemiology
In this chapter the scientific data regarding measles disease will be reviewed and discussed.
Measles illness, complications and transmission will be considered as well as the historical and present-day epidemiology of measles. As important examples of the impact and spread of measles and the feasibility for eradication, the epidemiology of measles within the United States, Canada, South Africa and selected European countries will be examined. At the end of the chapter the most important aspects of measles as pertains to the ethics of measles vaccination will be summarized.