Ethics of Public Health Policies: Vaccines and Justice

Introduction

Public health concerns necessarily introduce a tension between the individual and the greater good, which may have different resolutions depending on the ethical perspective used to assess them. As a society, the United States has determined that certain public health policies so strongly promote the greater good that they should be pursued even if they infringe upon private liberties or, in some cases, pose a threat to individual health or welfare. One widely discussed example of this type of policy is universal or affordable healthcare for the impoverished; others are effectively compelled to subsidize healthcare costs for those who can least afford it because doing so is believed to serve the best interests of overall public health.

However, some public health policies are even more controversial. Vaccinations to prevent the spread of communicable illnesses, particularly childhood vaccinations, may represent one of the most contentious areas of public health policy. Although childhood vaccinations have been demonstrated to reduce childhood mortality, there are health risks associated with vaccines that can make requiring them a difficult ethical issue. What type of vaccination policy a country should adopt may depend on whether the country approaches the issue from a utilitarian, distributive justice, or paternalistic perspective.

Childhood Vaccinations

Childhood vaccinations consist of a series of vaccines given on a defined schedule to prevent certain childhood illnesses, so that by the time a child enters the public school system, he or she is fully vaccinated. There are some risks associated with vaccines, and a small percentage of children experience adverse reactions. Moreover, for children who are considered high risk, vaccines may not be recommended or may be postponed from the usual schedule. The result is that, in order to provide maximum effectiveness, most children should be vaccinated, which confers herd immunity even to children who are unable to receive the vaccines. Vaccines have been proven to be an effective and life-saving preventative health measure.

However, falsified research linking childhood vaccinations to autism resulted in a substantial portion of the population refusing to vaccinate their children and contributed to the resurgence of childhood diseases — such as measles — that had been virtually eradicated in the United States. While the risk from vaccinations may have been grossly overstated, the reality is that some degree of risk does exist. This risk appears to conflict directly with the principles of autonomy. Autonomy refers to the right to self-determination regarding health decisions and discourages conduct that would prevent people from taking autonomous action (Anonymous, 2011). As a result, whether it is acceptable to force or compel people to vaccinate their children in order to promote overall public health remains one of the most controversial ethical issues in the field.

Utilitarianism and Vaccination Policy

The utilitarian perspective supports not only a vaccination policy, but also compulsory vaccinations with very few exceptions. In utilitarianism, "the morally justifiable act is that which produces the greatest amount of value over disvalue" (Anonymous, 2011). Furthermore, the relative worth of an action is determined by its consequences rather than by the intentions behind it. Because vaccinations provide herd immunity in addition to individual immunity and do result in lower death rates from communicable diseases, they clearly produce the greatest amount of value over disvalue for the community as a whole. Moreover, the individual risk from vaccinations is relatively small while the potential reward can literally be life-saving, suggesting that promoting a vaccination policy — even at the individual level — fits comfortably within the utilitarian framework.

Conclusion

Selgelid wrote, "while public health ethicists often claim that the least restrictive alternative should be used to achieve the public health goal in question, I argue that a plausible but under-recognized idea is that the least restrictive alternative might sometimes involve improvement of global health via redistributive taxation — i.e., rather than coercive social distancing measures" (2009). Selgelid seems to suggest that health improvement can be achieved through a social justice approach. It is certainly true that health improvement can be achieved through some degree of financial redistribution. For example, looking specifically at the issue of vaccinations, providing free or reduced-cost vaccines to low-income people — funded through redistributive taxation — increases the likelihood that more people will be vaccinated.

However, Selgelid's argument overlooks the relationship between ignorance and the poverty that redistributive justice seeks to address. Ignorance and poverty are correlated; people with less education are more likely to be financially vulnerable and may also be more susceptible to misinformation about health topics. Furthermore, limited education may prevent individuals from being able to evaluate health research and make truly autonomous decisions. It is nearly impossible to consider any type of health policy without examining the relationship between poverty and health risk. Although vaccinations improve health outcomes for children across all income brackets, impoverished children face a greater risk of contracting communicable diseases due to the living conditions that typically accompany poverty.

A redistributive approach that focuses only on a particular health condition may be insufficient to address the underlying social issues that generate healthcare disparities. Therefore, it seems clear that — as with vaccination policy — a combination of redistributive taxation to make healthcare affordable and appropriately targeted coercive policies may be the most effective means of enacting broader public health measures.