PIC Education Committee - Online Educational Modules
Ethical Aspects of Immunizations
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Recommendations are the populations, doses, and timing for each vaccine that is on the vaccine schedule. They are based on scientific studies and represent best health practices. They are determined by groups of experts at the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP).
Requirements, or mandates, are state-based laws that necessitate certain vaccines for subsets of the population. The best known mandates are those for school and daycare entry. Although decisions about mandates consider best health practices, they are also shaped by state finances, at-risk populations, and advocacy groups.
The first mandates were for smallpox vaccine and they began in 1805 in Massachusetts. School-entry requirements began in 1855, also in Massachusetts.
Herd immunity is a public health concept in which members of society who cannot get vaccines are protected because enough people around them are protected, so that disease spread is hampered. Herd immunity is one of the reasons that mandates are upheld.
Exemptions are state-based laws that allow individuals to forego a vaccine.
There are 3 types of exemptions:
- Medical exemptions – individuals are not required to get a vaccine because of a medical reason, such as an allergy or particular health issue. These types of exemptions are allowed in all 50 states.
- Religious exemptions – individuals that belong to certain religious sectors do not need to get a vaccine because vaccines or something about them is against their religious belief. Forty-eight of 50 states allow for this type of exemption. West Virginia and Mississippi are the exceptions.
- Philosophical exemptions – individuals are not required to get a vaccine because of their personal beliefs. Currently, 20 states allow for some type of philosophical exemption.
Concerns over vaccine mandates have increased as the quantity of mandates have increased, some vaccine-preventable diseases have all but disappeared, and newer vaccines have been developed against less contagious diseases.
Those against mandates have cited various concerns about vaccine safety; however, scientific studies have shown these concerns to be unfounded.
People who benefit from mandates, specifically those who cannot get vaccines because of their medical status or age, are not as organized or vocal as those who are against mandates. It is imperative that this group be remembered in vaccine decisions. Medical and public health personnel are usually thinking of these people as they speak in support of vaccines.
Mandates are also important because
- They necessitate financial programs to cover vaccine for those who could not otherwise afford it
- Private insurers are more likely to cover mandated vaccines
- Busy parents will be inclined to get the vaccines in a more timely manner
- Systems of education and vaccine delivery are put in place
Healthcare workers are recommended to get some vaccines because they are at increased risk of exposure and may transmit diseases to their patients who are particularly susceptible because of weakened immunity.
Recommendations versus requirements
The immunization schedule is based upon recommendations made by the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP). Recommendations include the populations, doses, and timing for each vaccine. They are based upon the best scientific information available. In essence, they represent the highest standard of healthcare.
Despite a vaccine recommendation, all people who should get a particular vaccine do not necessarily get one. This may occur for several reasons, including limited resources, lack of knowledge or the state in which someone lives. Where someone lives is important because of requirements. Requirements, or mandates, are state-based laws that necessitate certain vaccines for subsets of the population. The best-known requirements are those for school entry, which require certain vaccines at specific ages and intervals for children at particular entry points within the school system, such as kindergarten and 6th or 7th grade. Daycare entry requirements also exist in most states and may be a condition of licensing for the center. For example, in Pennsylvania, the Department of Public Welfare (DPW) requires that DPW-licensed childcare centers have all attendees up-to-date with all CDC-recommended vaccines.
Mandates vary from state-to-state because they are based upon laws made by politicians, not decisions by scientists, epidemiologists or medical personnel. Politicians make mandates based in part upon data, but they also consider state finances, at-risk populations and viewpoints of advocacy groups throughout the state. Some sectors of society are inherently opposed to vaccine mandates. In any state, loud enough opposition may lead to loose or nonexistent requirements or lack of enforcement, and unfortunately, without a requirement, vaccines may not be offered to people that could benefit. It is important to understand that these legal requirements are not determined based on best healthcare.
Mandates originated with an 1805 law in Massachusetts that required smallpox immunization; school entry requirements followed in that state in 1855. By the early 1900s, there were lawsuits challenging the legality of mandates. Courts upheld the rights of government to impose immunization requirements in part because vaccines benefit society as a whole. Specifically, when a disease is communicable, the greater number of immunized individuals, the lower the opportunity for disease spread to others. The decreased disease transmission protects people in the community who have not been immunized. This is called herd immunity and is particularly important for members of a community that are unable to get a vaccine for medical reasons, such as having allergies to vaccine components, being immuno-compromised, or because of their age.
As more vaccines were mandated, the need for exemptions grew. Exemptions are state-based laws that allow individuals to forego a vaccine. As mandate laws vary from state-to-state, so do exemption laws.
There are three types of exemptions:
- Medical exemptions – Individuals are not required to get a vaccine because of a medical reason, such as an allergy to a vaccine component or particular health issue (e.g., immuno-compromise). All 50 states allow medical exemptions.
- Religious exemptions – Individuals that belong to certain religious sectors do not need to get a vaccine because vaccines or something about them is against their religious belief. For example, many Amish people forego vaccines because of their belief that a healthy lifestyle will prevent infections. Forty-eight of 50 states allow for religious exemptions. The two exceptions are West Virginia and Mississippi.
- Philosophical exemptions – Individuals are not required to get a vaccine because of their personal beliefs. This is the most controversial type of exemption allowed. Currently, 20 states allow some type of philosophical exemption; however, the laws requiring what someone has to do to claim this type of exemption vary from simply signing a form to more in-depth requirements, such as education or notarized statements. Studies have shown that looser exemption policies correlate with higher disease rates among states or communities.
When people forego immunizations, they may be asked to stay out of school during an outbreak in order to protect them from the disease. Keeping unprotected people separate from the population is reminiscent of quarantines in the 1950s; however, in the past it meant keeping patients with measles separate from the rest of the population in order to control the spread of disease.
Societal benefits of herd immunity versus individual rights
As the legality of mandates has been questioned, so too has the ethics. Individual rights versus societal benefits have been the subjects of much debate. Concerns have grown as:
- The number of vaccine mandates has increased:
With the advent of new vaccines, new vaccine recommendations were made. Between 1980 and 2009, the vaccine schedule increased from seven vaccines to 14 vaccines for children by two years of age. As recommendations increased so did requirements.
- Some vaccine-preventable diseases have virtually disappeared:
Diseases rates have declined dramatically since the introduction of vaccines. In the U.S. smallpox, diphtheria, tetanus, polio, measles, mumps, rubella and Haemophilus influenzae type b have virtually disappeared. When people do not see these diseases, some do not understand why they must still use vaccines. However, other than smallpox, all other vaccine-preventable diseases still exist in other parts of the world and could easily be reintroduced into our communities.
- Newer vaccines protect against diseases that are not highly contagious:
Whereas many early vaccines were against diseases that were highly contagious, such as smallpox, diphtheria, polio, and measles, some newer vaccines are less easily spread through casual contact. These include meningococcus and human papillomavirus.
Several organized advocacy groups argue that individuals should have the right to choose whether or not to vaccinate, regardless of the impact on public health. In support of these efforts, some cite vaccine safety concerns, suggesting that vaccines cause chronic conditions, such as multiple sclerosis, neuro-developmental delays and tics, diabetes and autism. Scientific studies have disproven these theories as they have emerged; however, those arguing in support of individual rights cite the theoretical risk of getting these diseases as reasons to opt out of vaccines.
Mandates indirectly represent the rights of a different set of individuals—those who cannot receive vaccines for medical reasons or because of their age. This is because of herd immunity. For example, young infants are not eligible for influenza vaccine and require several doses of pertussis vaccine over several months to be protected. During the time that they are still susceptible to these diseases, we rely on immunity throughout the community to decrease their potential for exposure to these diseases. Because these individuals are not typically organized or vocal, public health officials and medical personnel are often thinking of them when they defend the importance of vaccines.
Mandates for newer vaccines that do not protect against highly contagious diseases have been criticized. However, these mandates are often sought because experience has shown that more people will be immunized when there is a mandate. This happens for a few reasons. First, a mandate necessitates financial programs to cover those who could not otherwise afford the vaccine. Second, private insurers are more likely to cover vaccines that are required than vaccines that are simply recommended. Third, busy parents may put off immunizations but a daycare or school-entry requirement prioritizes getting the vaccines. Finally, the legality of adhering to a mandate forces systems to be put in place to educate about and deliver the vaccine.
Special Focus: Healthcare Workers
The debate between individual rights and societal benefits is particularly interesting when considering healthcare workers. Several vaccines are recommended for healthcare workers because they are at increased risk of acquiring or transmitting disease due to exposure to blood or body fluids as well as close personal contact with patients. In most cases the vaccines can be required as a condition of employment; however, the influenza vaccine is an interesting study because it is required annually. Whether a healthcare worker gets immunized not only affects the individual worker, but also their employer and the patients and families that they will treat.
- Individual rights of the healthcare worker: Since there are no mandates, getting an influenza vaccine is the individual’s choice, and because it is required annually, it is difficult to make it a condition of employment. This group of individuals is at increased risk of coming into contact with influenza and could benefit directly from getting the vaccine. However, like society in general, some healthcare workers resist immunizations.
- Individual rights of the healthcare workers’ employer: Many hospitals and other settings for patient care provide free influenza vaccine for their employees. They do this for two main reasons: to protect their employees and to protect their patients. Because there is no mandate, they cannot make their employees get the vaccine; however, because they could potentially be liable if a patient acquires influenza while in their care, employers are beginning to determine ways to increase the number of employees that get the vaccine each year. Some of these efforts have included special activities during influenza season such as requiring un-immunized workers to wear masks when caring for patients or assigning them to non-patient care roles.
- Individual rights of patients and patient families: Many patients are at particular risk of getting influenza because their immune systems are weakened from illness; therefore, an infected healthcare worker is particularly dangerous to them. Currently, there are no individual rights allowing the patient or the patient’s family to require influenza vaccine for healthcare workers in contact with the patient. Unfortunately, cases of influenza transmission to patients by healthcare workers have been documented—calling into question the medical mantra, “first do no harm.”
To learn more about the ideas covered in this section, visit the following:
Recommendations versus requirements
Herd immunity and individual rights
UPDATED: June 2009