nursing ethics and vaccination debate

The Vaccination Dilemma
The rights of individuals to refuse vaccinations, and the rights of parents to refuse their children vaccinations, has been increasingly called into question because of the way individual autonomy conflicts directly with the rights of the general public. For example, outbreaks of vaccine-preventable illnesses have increased, with serious outbreaks of measles in the United States being a prime example. Although the United States Centers for Disease Control and Prevention declared the elimination of measles in 2000 due to effective vaccine penetration, in 2014 a spike in measles cases raised the possibility of a “public health crisis” that also “reignited a historic controversy” in medical ethics (Gostin, 2015, p. 1099). Essentially, unvaccinated persons spread diseases that are preventable, as well as possibly deadly. The rights of one person to refuse a vaccination in the interests of patient autonomy might not outweigh the right of every other citizen to a disease-free environment. Yet the medical community generally remains committed to the promotion and preservation of patient autonomy, personal choice, and the right to self-determination. Therefore, the primary dilemma regarding vaccines is the conflict between parent or individual rights, and between the rights of the community.
Rights-Based Ethics
A rights-based ethical theory is the one best suited for addressing the complexities of the vaccination debate. On the one hand, patient autonomy is embedded firmly in the American medical tradition, as well as in medical practice in similar countries with strong support for individual rights and freedoms (Leask & Danchin, 2017). Compelling persons to do anything to their body without their express consent amounts to an infringement on rights, freedoms, and personal privacy (Gostin, 2015). Furthermore, healthcare workers have grappled with the rights of individuals to refuse medical treatments, interventions, or vaccines on religious grounds. Some parents have also expressed concern that vaccinations will have adverse effects on their children, and claim the right to refuse vaccinations on those grounds (Gostin, 2015). The rights-based ethical theory allows for a full treatment of each of these unique approaches to the individual rights of patients, or for those who speak on behalf of patients, such as parents and guardians.
Another reason why the vaccine controversy is best viewed from a rights-based perspective is that it highlights the rights of the community. While it is easy to imagine the rights of a person to refuse cancer treatment on personal grounds, their refusal for treatment does not impact the rights of their friends and neighbors. On the other hand, vaccinations can and often do impact other people because an unvaccinated individual can spread disease. “It does not take many unvaccinated individuals to approach the tipping point at which vaccine coverage levels are too low and are thus ineffective in preventing disease spread,” which is known as herd immunity (Hendrix, Sturm, Zimet, et al., 2016, p. 274). A rights-based perspective shows why the issue of vaccinations is controversial, by pinpointing the exact nature of the conflict. Essentially, a rights-based society promotes both individual and collective rights. A person has the right to act, but only insofar as it does not harm others—which amounts to an infringement on the rights of others. It is also possible to frame the vaccination debate from a rights-based point of view via the metaphor of the tragedy of the commons, in which the rights of individuals does frequently conflict with the public rights shared in common by all members of the society (Gostin 2015)
The Seven-Step Process for Ethical Decisions
One of the better models for ethical decision making is the seven-step process outlined in the Fremgen text. The seven step model provides healthcare workers with a reasonable framework to view the ethical dilemma clearly and logically, avoiding fallacies and emotional reasoning. The first step in the seven step model is to state the problem outright. In this case, the problem is that most healthcare workers support both the rights of individuals and the rights of communities to public health and safety. While it is important to protect the rights of individuals and promote patient autonomy, it is also critical to promote public health and safety through the vaccination process. After all, a litany of deadly diseases have been eradicated due to the proliferation of vaccinations. Adverse effects from vaccinations are extremely rare, and not significant enough of an issue to incorporate into the debate (Gostin, 2015).
The second step in the ethical decision making process is to check the facts, In this case, the facts are abundantly clear that undervaccinated populations will have greater disease prevalence than vaccinated populations. The only wrench in the issue is that some evidence seems to suggest that “anti-vaccers,” those who outright refuse their or their children the privilege for the vaccine, are not the main culprit in disease outbreaks. For example, Leask & Danchin (2017) claim that in Australia, “Rejection of vaccines is only one contributor to under?vaccination, with inadvertent lateness or missed opportunities due to access issues being the larger contributor to under?vaccination,” (p. 439). To get the facts straight, healthcare workers would need to consult with epidemiologists in their area. Next, the healthcare worker identifies the relevant factors involved, develops a list of options to take, tests those options logically, and then makes a decision based on the results of those logical tests. Options may involve a more aggressive public health awareness campaign instead of compulsory vaccination laws, or to argue in favor of mandatory vaccinations on the grounds that a child died in the community. The logical tests should also involve consultation with professional organizations to defer to their expertise or to scientific consensus (“A Seven Step Process for Making Ethical Decisions,” n.d.). To resolve the dilemma, the seven-step process should be applied with scrutiny, and if possible, with peer review.
Resolving the Dilemma
It is never easy to resolve a genuine ethical dilemma like the one posed by vaccinations. While many healthcare workers will immediately come out in favor of compulsory vaccinations on multiple ethical grounds, all of which are sound, it is equally as logical to point out the rights of parents to refuse their children the vaccination if and only if the consequences of getting the disease are mild. In the case of most vaccinations that are either compulsory or being strongly recommended, such as for measles, the adverse health consequences of refusing the vaccination tend to outweigh the slim to no chance that the child will suffer harmful outcomes. As Gostin (2015) points out, research does show that many parents are simply ill-informed when it comes to the potential harms of vaccinations. If misinformation is the real problem, identified by using the seven-step ethical decision making model, then nurses need to focus more on improving health education, public awareness, and outreach. Partnering with public health organizations, nurses can take steps to educate the community instead of resorting to coercive tactics that parents and any other patients may find offensive.
In fact, the medical community and healthcare ethicists do seem to agree that a balanced approach is best in the case of the vaccination dilemma. “States would be unwise to overreact to the current measles outbreak by fining or imprisoning parents, or subjecting them to tort litigation, if they fail to vaccinate their children,” not least of which is that such tactics might increase the public outcry against vaccinations and thus defeat the purpose the vaccination programs are designed to serve (Gostin, 2015, p. 1100). Leask & Danchin (2017) also caution against imposing penalties or using the justice system to prosecute parents who are exercising their rights as autonomous patients. Healthcare workers have been faced with the vaccination dilemma for years, allowing for sensible options for resolution to evolve. Hendrix, Sturm, Zimet, et al. (2016) advocate improving communication with patients and adopting a “non-adversarial” approach,” (p. 276). Yet the non-adversarial approach should still come with some strings attached for those who would choose to opt out of a life-saving vaccination. Persons who are not vaccinated are in fact potentially dangerous members of the community. Without unnecessary alarmism, nurses know that they need to tell schools which students have not been vaccinated, or to have some way of keeping track of the problem.
Conclusion
A rights-based ethical theory reveals multiple points of view in the vaccination debate, which is not a clear cut problem. All patients have the right to self-determination. Children are often bereft of the right to self-determination because their parents are legally in charge of their medical decisions. Nurses need to consider the vaccination debate from a rights-based perspective, keeping in mind the needs of their communities as well as the needs of their individual patients.
Healthcare workers also face additional ethical dilemmas with regard to vaccinations because of factors like cost. Vaccination-preventable diseases like measles costly and resource draining. Nurses have an obligation to do whatever it is in their power to reduce the prevalence of preventable diseases, including those that are preventable via vaccinations. Not only is treatment of preventable diseases a drain to limited healthcare resources; it can also be a drain on public health and epidemiology research resources. Finally, preventable diseases do kill. People who refuse vaccinations should remain aware that their decision could actually harm another human being.
References
“A Seven Step Process for Making Ethical Decisions,” (n.d.). https://www.e-education.psu.edu/emsc302/node/170
Gostin, L. O. (2015). Law, Ethics, and Public Health in the Vaccination Debates. JAMA, 313(11), 1099. doi:10.1001/jama.2015.1518
Hendrix, K. S., Sturm, L. A., Zimet, G. D., & Meslin, E. M. (2016). Ethics and Childhood Vaccination Policy in the United States. American Journal of Public Health, 106(2), 273–278. doi:10.2105/ajph.2015.302952
Leask, J. & Danchin, M. (2017). Imposing penalties for vaccine rejection requires strong scrutiny. Journal of Pediatrics and Child Health 53(5): 439-444.
Tomkins, A., Duff, J., Fitzgibbon, A., Karam, A., Mills, E. J., Munnings, K., … Yugi, P. (2015). Controversies in faith and health care. The Lancet, 386(10005), 1776–1785. doi:10.1016/s0140-6736(15)60252-5