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Tuesday, December 12th 2006

By The Whip

Should the HPV (or any other vaccine) be compulsory?

Laws making vaccination compulsory raise unique ethical and policy issues. High levels of herd immunity protect all members of the community, including those who cannot receive vaccines because of medical contraindications. This protection provides a justification for compulsion. The availability of religious or philosophical exemptions mitigates concern about governmental intrusion on individual decision making.

So there are two arguments. The state’s role as a protector of public health.

Data show that schools with exemption rates as low as 2 to 4% are at increased risk for disease outbreaks and that children who have been exempted from vaccine requirements have a much greater risk of acquiring infectious diseases than their vaccinated peers.

I refute this role. Defining this “obligation” of the state (I don’t like speaking of positive “rights” of the state) is dangerous. This sort of paternalism has no reasonable end.

Let’s look out at compulsory immunization and forcing residence in sanatoriums for AIDS patients. Is there a major difference? “Oh, it is okay to deny personal liberty to the extent we have to stick you with a needle but not okay to violate personal liberty by forcibly holding you.”

But limiting paternal public health laws on the extent of liberty violated is a completely subjective and ridiculous way of trying to define the limit of the government’s “rights” (there’s that bad term again, speaking of “rights” for the government). The safest thing, the right thing, is to protect personal liberty above all else.

I say all this with absolute certainty, but ask me about quarantining in the case of say some future superbug outbreak and my answer is everyone elses – of course! So tear away at the holes in my philosophy. It boils down that I think personal liberty is too precious to sacrifice for much, if anything. It is unquantifiable in my little blinder view of the situation. Sacrificing even something as simple as refusing a needle stick is dangerous, and such a liberty should be denied only under situations were the need is more dramatic, more obvious than in the case of compulsory vaccinations.

Keep reading for more on how/why I define parental rights as ‘personal liberty.’

The second defense of compulsory vaccination is the state’s role in protecting the welfare of children.

Minors have a right to be protected against vaccine-preventable illness, and society has an interest in safeguarding the welfare of children who may be harmed by the choices of their parents or guardians.

A better argument. Clearly parents have positive obligations to their children. Clearly this sort of mandate borders on the government’s role to protect one individual (child) from the decisions/actions of another (parent).

I am a firm believer, as any, that when the child’s life and death is on the line the physician’s legal and moral responsibility is to provide care even at the objection of the parents. I do believe the judicial system, when the evidence is available, needs to take a long look, on an individual basis, at the maturity of older “children” refusing care (even at the proding of their parents) and not to define the right of consent merely as one belonging to someone of a hard and fast age.

That being said, we aren’t mandating a transfusion for a four year old with an internal bleed. The child might get chicken pox. The child might get HPV and might develop cervical cancer later in life.

Playing the odds is necessary in enacting preemptive protections for the populace. And it is reasonable. In fact I even support the speed limit (“Oh, thank God,” you say).

It sounds kinda ridiculous, I understand, to be standing here saying I support speed limit laws while everyone else goes, “No, duh.”

But, back to the topic at hand, you’re legislating to protect against what might happen. And when doing that you attempt to weight the odds and the severity of consequence against personal liberty. I encourage legislatures to be as objective and dutiful in data collection as possible before implementing protection laws. The scale, when weighing these laws, needs to favor liberty. The consequences multiplied by the odds need to be dramatic.

And while that definition of when these laws are appropriate is subjective (for which I criticized efforts in trying to define an “acceptable” level of paternalism above), I maintain that the bar needs to be set high. The burden of maintaining personal liberty needs to be viewed as a significant thing to overcome.

Clearly that isn’t the case when you have things like seat belt laws.

There are other issues when mandating parent’s positive obligations to their children. What sort of natural rights do parents have over offspring? Is this really an issue of personal liberty for the parents? Certainly we wouldn’t grant young children the capacity of autonomous personal choice. And more. They’re for another discussion though.

I don’t know. Clearly, I feel the argument that compulsory vaccines meet an obligation for child welfare is a sounder one than the state’s role in protecting public health. I’m not sure that I truly feel that the consequences of not vaccinating, and the odds of those consequences, rise up to a level where it is acceptable for the government to deny parental choice.

From the article:

Bioethicists, who generally hold the values of patient autonomy and informed consent to be preeminent, tend to be skeptical about compulsory vaccination laws. Not surprisingly, some have expressed wariness about or opposition to mandating HPV vaccination. Because HPV is not casually transmissible, they argue, there is a less compelling rationale for requiring protection against it than against measles or pertussis, for instance; in the absence of potential harm to a third party, such laws may be considered unacceptably paternalistic. Similar concerns have been raised about school-based requirements for vaccination against hepatitis B: because the virus spreads primarily among sexually active people and injection-drug users, some parents argued that the vaccine should be given only to those groups rather than to all children. Such targeting of the vaccine, however, proved to be less effective than universal vaccination in reducing the incidence of the disease.

Finally, let me just say that there is no evidence tying vaccines to developmental deficits and people who spout that line are still complete crack pots. In no way is this post in line with those who truly believe that vaccinations are tied to autism or other disease.

I think that fictional belief is a terribly poor reason not a vaccinate your child. It is sad to see it so prevalent. And while I concede that no amount of education or proof can effectively lower the incidence of anti-vaxers, I do not buy this as an argument for compulsion.

Orac is feeling for Flea who is battling a horde of anti-vaccine commenters.