The Vaccination Dilemma: Individual Rights vs. Public Health

Introduction: The Vaccination Dilemma

The rights of individuals to refuse vaccinations — and the rights of parents to refuse vaccinations on behalf of their children — have been increasingly called into question because of the way individual autonomy conflicts directly with the rights of the general public. Outbreaks of vaccine-preventable illnesses have increased, with serious measles outbreaks in the United States serving as a prime example. Although the Centers for Disease Control and Prevention declared the elimination of measles in 2000 due to effective vaccine penetration, a spike in measles cases in 2014 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 — and potentially deadly. The right of one person to refuse a vaccination in the name of patient autonomy may not outweigh the right of every other citizen to a disease-free environment. Yet the medical community generally remains committed to promoting and preserving patient autonomy, personal choice, and the right to self-determination. The primary dilemma regarding vaccines is therefore the conflict between individual or parental rights and the rights of the broader community.

Rights-Based Ethics and the Vaccine Debate

A rights-based ethical theory is best suited for addressing the complexities of the vaccination debate. On one hand, patient autonomy is firmly embedded 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 bodies without their express consent amounts to an infringement on rights, freedoms, and personal privacy (Gostin, 2015). Furthermore, healthcare workers have long 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 thorough treatment of each of these unique approaches to individual patient rights — including those asserted by persons 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 a person's right to refuse cancer treatment on personal grounds — a decision that does not impact friends or neighbors — vaccinations are different 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," a phenomenon known as herd immunity (Hendrix, Sturm, Zimet, et al., 2016, p. 274). A rights-based perspective illuminates why the issue of vaccinations is controversial by pinpointing the exact nature of the conflict. A rights-based society promotes both individual and collective rights: a person has the right to act, but only insofar as doing so does not harm others — which would amount to an infringement on the rights of others. It is also possible to frame the vaccination debate via the metaphor of the tragedy of the commons, in which individual rights frequently conflict with the public rights shared by all members of 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. This model provides healthcare workers with a reasonable framework for viewing an ethical dilemma clearly and logically, helping them avoid fallacies and emotional reasoning. The first step 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 individual rights and promote patient autonomy, it is equally critical to promote public health and safety through vaccination. After all, a host of deadly diseases have been eradicated through the proliferation of vaccines, and adverse effects from vaccinations are extremely rare — not significant enough to serve as a decisive factor in the debate (Gostin, 2015).

The second step in the ethical decision-making process is to check the facts. In this case, the facts clearly indicate that undervaccinated populations will have greater disease prevalence than vaccinated populations. The one complication is that some evidence suggests "anti-vaxxers" — those who outright refuse vaccines for themselves or their children — are not always the primary culprit in disease outbreaks. For example, Leask & Danchin (2017) note that in Australia, "rejection of vaccines is only one contributor to undervaccination, with inadvertent lateness or missed opportunities due to access issues being the larger contributor to undervaccination" (p. 439). To get the facts straight, healthcare workers would need to consult with epidemiologists in their area.

The subsequent steps ask the healthcare worker to identify the relevant factors involved, develop a list of options, test those options logically, and make a decision based on the results. Options may include a more aggressive public health awareness campaign rather than compulsory vaccination laws, or advocating for mandatory vaccinations on the grounds that a child has died in the community. The logical tests should also involve consultation with professional organizations to defer to their expertise and to scientific consensus ("A Seven Step Process for Making Ethical Decisions," n.d.). To resolve the dilemma, the seven-step process should be applied rigorously and, where possible, subject to peer review.

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 denied that right in practice 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 challenges related to vaccinations because of factors such as cost. Vaccine-preventable diseases like measles are costly and resource-draining. Nurses have an obligation to do whatever is within their power to reduce the prevalence of preventable diseases, including those preventable by vaccination. Treatment of preventable diseases is not only a drain on limited healthcare resources; it is also 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 ultimately harm another human being.