Ethical Issues Surrounding Mass Preventative Immunisation Despite numerous breakthroughs in healthcare in the 20th and early 21st

century, human health remains threatened by infectious disease, both in the developed and developing worlds. Vaccination remains one of the very few medical interventions which grants health benefits not only to the individual (through preventing that individual getting the disease), but also on a wider scale to the community through Herd Immunity1. This means that once enough people are vaccinated it becomes much more difficult for the disease to pass between those who are not immunized2. However vaccination does carry risks, like any other medical intervention, ranging from mild (general malaise) to severe (even death). Thus, the decision whether or not to immunize raises many ethical issues, including those from a public health standpoint, and those from an individual standpoint, usually governed by general medical ethics. These points of view can appear to oppose one another. This places particular pressure on the public health physician, who must balance the risk and needs of the individual with those of the community on a much wider scale3. Even within general medical ethics, immunization raises ethical issues, like those between respecting a patients autonomy in wanting to decline immunization when the practitioner believes that benefits far outweigh risks to the individual. Both the issues between public health ethics and general health ethics, as well as issues within general medical ethics itself, will be discussed in this essay. Within medical ethics, there is a well known subset of common themes, being: autonomy, nonmaleficence, beneficence and justice4. By keeping these in mind, practitioners can make practical decisions about what is the best action to be taken in each case, and what strategies to adopt. In public health ethics, it is often believed that justice is the prevailing theme.

Justice Justice is a concept of fair and equal treatment, offered to every individual. It is not necessarily wrong for someone to be unjustly treated, but any discrimination must be properly justified.4 More than one approach has been taken, by different philosophers. They aim not to give answers, but to inform judgements about issues of right and wrong, and about which action ought4 to be taken. There are two prevailing schools of thought, Deontology and Teleology. Deontologists strongly believe that we are all bound by certain universal rules, such as beneficence, non-maleficence, and veracity, and we must act by them, despite the consequences.5 Teleology not only concern itself with means, but also ends, believing the individual must always act in a way which produces the most utility, or good. Both branches have their advantages and disadvantages, and will be discussed with mass immunization in mind. Deontology Deontology was inspired by the work of Immanuel Kant, who believed the means, never the consequences or outcome of an act, determined its intrinsic morality. Therefore, the motives of the person performing the act are paramount to determining whether an action is right or wrong. Deontologists believe in a set of universal moral duties which should be followed to produce moral acts6. Kants work states firstly, that individuals must act as if their actions should become law for everyone. If everyone acted the way you chose to act, would the outcome, overall, be good? If the answer was yes, then the way in which you acted could be applied to all similar situations. Secondly, individuals must never be used by others as merely a means to an end, but respected as an end in themselves, and, one must never harm others. A rule which respects all peoples would be deemed moral7. The first idea sets out that decisions must be universalizable, and the second states the requirement of respect for those around us. In the case of immunization, Deontology raises a few issues. Immunization, as previously stated, has dual intentions. It sets out to protect the individual from a disease, but also to create herd immunity. If immunization was to be taken as a moral universal rule, it would need to produce benefit in everyone who received it. However, all vaccinations carry a risk of side effects, (the risk of side effects in some populations may even outweigh the chances of the disease being contracted, i.e., polio), and in some people do not evoke an immune response at all, especially in the elderly. In this way, compulsory immunization would be seen as immoral, as it puts every individual undergoing it at some form of risk, and in some, has no immediate beneficial effects. Even if chances of side effects are minimized, and certain people exempt (immunosuppressed), some individuals would still suffer side effects, causing both harm and good to the individual (they would still gain immunity, if they survive). The physician does not set out to do harm, but knows his actions may bring harm in some cases.

From a deontological perspective, achieving herd immunity is also immoral, as it reduces the individual to a means of meeting the public health objective of herd immunity and reducing spread of infection through the community,. You are also exposing them to a known danger, for a larger purpose. During mass immunization, a number of individuals would suffer side effects or die; compulsory immunization would not meet deontological criteria for morality. Later, it is discussed whether herd immunity can be viewed as a public and individual good. Kants theory states that all individuals must be respected as having their own goals and purposes7. In a way, vaccination could be seen as empowering an individuals autonomy, by furthering their abilities to achieve their goals. However, Kant goes on to imply we must never harm others, so minimizing risk in how and who we immunise becomes paramount7. Taken together, a deontologist could accept that the individual is useful in producing herd immunity, but they are also being respected as an end in themselves by gaining an individual immunity to the disease. To conclude, I believe making information about risks and benefits of vaccinations widely available, and thoroughly and consistently informing patients about risks and acquiring informed consent from patients would avoid coercion or deception, and would improve autonomy. This, whilst leaving immunization optional, would move closer to ethical action by deontological criteria7, by fully respecting the individual as an end in themselves6. Teleology Teleology is the second major branch of philosophy shaping western ethics, often known as consequentialism. Its best known branch is utilitarianism. It differs greatly from deontology, as it is much more concerned with the outcome of a situation than the means of how it is achieved5. It holds that the means are completely justified by the consequences. A pioneer in the concept of utility was Jeremy Bentham, who claimed the morally best alternative is that which produced the greatest net utility, where utility is determined in terms of happiness/pleasure8. John Stuart Mill took it a step further, saying We ought to do that which produces the greatest happiness for the greatest number of people8. Again, applying immunization to this moral framework allows us to analyze it and discover any problems that arise. For instance, how do we measure the outcome? The outcome or benefit in this case would be the number of people who did not contract the disease who would have, without vaccination. It is, of course, impossible to tell who has been spared exposure to a disease, as the intervention is carried out on asymptomatic individuals9, leaving us to attempt to quantify utility by more inaccurate methods, such as the number of people vaccinated, etc . At a high enough percentage coverage, due to herd immunity, almost everyone would be protected from disease transmission, so almost the entire population, not just those immunized could be considered to be benefiting from immunization. This includes people who couldnt be immunized (immunosuppressed), those who chose not to be or those in whom the vaccine was not sufficient to produce immunity. As shown, it is not as simple as counting the number of people vaccinated, to measure utility.

Furthermore, this approach dismisses the risk that the individual takes in getting the vaccination. It can potentially belittle the aforementioned concepts of beneficence and non-maleficence to the individual, by justifying the small number of people who suffer side effects by the number of people who benefit. In this way, it is an approach often criticized for ignoring a minority suffering for the greater good (utility), displaying the so called tyranny of the majority8. A utilitarian would argue that a minority of individuals suffering side effects, even death, is justifiable by the majority of the population who do not, and achievement of herd immunity5. The physician must weigh the chance of doing harm to the individual against the benefit that they and the community will receive3. One issue that deontologists argue is that we can never truly predict the outcomes of our actions6. This raises the question of how one weighs happiness against misery8. If misery is equal to happiness (utility), then more people would have to suffer side effects from the vaccination than those who benefited for it to be immoral, under utilitarian argument. However, severity must be considered; most communities would deem severe side effects, in a substantial minority unjustifiable, especially if the disease is one that is rarely seen today. Most people would agree that misery in this context, is not equal to happiness, and deem the vaccine immoral. However, a vaccination that produced very minor side effects in a small minority of people would be seen from a utilitarian point of view as morally justifiable. It should be noted that it is not just the fact that a means causes misery in people, but how severe it is in relation to the utility produced, and on what scale8. How a vaccine is morally viewed, is summarized by the risk-benefit ratio. A vaccine with frequent side effects for a common, dangerous disease will be tolerated more than the same vaccine for an uncommon, less serious disease.

Autonomy and Consent Autonomy refers to the capacity of an individual to independently direct their own life, and make their own choices6. It may be summarized as the capacity to think and decide independently, the capacity to act on the basis of that decision3. An individuals autonomy becomes limited when their choices begin to affect others in negative ways6. Since immunization is not required for school entry in the UK, nor is it compulsory, autonomy in this situation refers to the choice of (usually) parents to get their child immunized, before the age that they are deemed to be autonomous/have capacity. Like with any other medical intervention, informed consent is required (from the parents in the case of infants). The precise definition of informed consent is complex, and is the topic of much debate4. For the purposes of this essay, we will consider consent as the permission to do something he would not have the right to do without such permission.4. Informed consent enhances a patients autonomy, and their ability to be self-governing and selfdetermining, both of which are paramount when deciding if an intervention being carried out is ethical. Within this we see benevolence and non-maleficence becoming relevant, as the only way these concepts can be satisfied is working with the patients consent. If obtained correctly, it avoids coercion and ensures the patients decision is informed and of their own free will4. The patient understands the benefits and implications of treatments, and the practitioner avoids doing harm via misinformation. An issue arising whilst obtaining informed consent is just how much information should be disclosed to the patient/parents4. The physician knows that the intervention will protect the individual, and benefit society, with small chances of side effects. However, informing patients/parents of side effects can cause them to be cautious, especially in the wake of media stories questioning the safety of many known, safe vaccinations6. They may even deny treatment, causing the individual to go unprotected and herd immunity compromised. This is a clash of the physicians duties beneficence/non-maleficence, with respect for the patients autonomy; as they are being paternalistic about the patients treatment. The decision should be respected, if the risks and benefits of the procedure are fully understood by the patient. However, often the physician is committed to promoting health, and may try to persuade the patient; especially in cases where their decision affects others (herd immunity). Withholding information about risks or trying to persuade the individual is paternalistic, and counterproductive to enhancing autonomy. Patients may have (often misinformed) ideas about vaccine-associated risks from the mass media, or other sources. If they are not fully informed on risks or believe a practitioner is withholding information, the patient:doctor relationship could be damaged, with loss of trust, and is a failure of the practitioner to enhance autonomy, and to beneficence/non-maleficence. The patient could also then deny treatment, and the child will go unvaccinated, and herd immunity can be compromised. Yet, if the practitioner does not persuade the patient, whilst respecting their autonomy, by omission he may be doing harm to not only the individual in question, but to society as a whole. In short, a practitioners duty to veracity and the patients right to be fully informed can conflict with a duty to beneficence3.

In the face of media stories that can contain unproven claims about vaccine safety, and sometimes panic inducing scare-stories, many practitioners may feel pressured not to raise issues of risks, feeling they cannot answer to parents expectations, or they may accept parents refusal of vaccination without attempting to persuade them. The only way to ethically combat such stories is increasing education about interventions like immunization, and making sure the public understand fully the benefits/risks involved, like that whilst vaccination has intrinsic risk, declining vaccination is not risk free, either. Individuals could also be informed of such concepts as herd immunity. This could encourage them into themselves working towards the greater good out of choice rather than being coerced into vaccination. However such education could also place unreasonable psychological pressure on the individual by making them feel that they are doing their children/community wrong by not vaccinating. Also, healthcare professionals must be up to date with information so they can educate on risk, to enhance autonomy, meet the criteria of informed consent, and do good, and avoid doing harm by ignorance or omission6. Government must be open with the public about the information that it has and make it widely accessible, to improve trust and autonomy, allowing patients to fully make up their own minds about vaccination10. Campbell (1990) argues that all forms of education contain a form of persuasion from the person educating, and that therefore an intention to empower and to create autonomy cannot completely rule out persuasion as a contributor to the aforementioned intention6. This however implies that the patient seeks out education and advice, and that it is not given against their will. One way to encourage this kind of behaviour would be to work with media sources, and advertise/inform the public on things like vaccination (as stated), along with other common, everyday interventions that are taken for granted, not only to enhance autonomy, but to prompt them to question practitioners or health promoters. This however could raise further arguments about who is to say what is healthy or best for the population, or that this kind of education can prioritize the greater good over individual good, in a utilitarian manner, which as previously seen contains its flaws. Also, autonomy of the community and public as a whole must be taken into consideration, and such campaigns or policies may be not even be justified by public opinion8, yet again proving to be paternalistic. A note on beneficence and non-maleficence; Many activists, as stated under Justice, argue that the risk imposed on asymptomatic individuals when they may receive little to no benefit, is ethically unacceptable, arguing the benefit is to the community and not to the individual. Dawson9 argues that vaccination has potential benefit for the individual, and the individual contributes to a collective utility, from which everyone benefits, once herd immunity exists in the community. These two benefits can be considered as private and public goods, respectively. Klosko11 characterised public goods as being comprised of nonexcludability, and the requirement of positive contributions by a large group of people, as is often required in health promotion. Nonexcludability means that even if the individual did not take part in the vaccination (immunosuppressed/religious reasons), they receive benefit (herd immunity), and this good cannot be achieved without co-operation of many people. Dawson then concludes a public good is nothing more than many individuals receiving the same equal share of one larger

benefit, so that even things done contributing to the greater good can be seen on an individual level, undermining the argument that risk outweighs benefit to the individual9. In conclusion, this provides a potential argument for justifying herd immunity as an individual and public benefit, as well as the benefit of individual protection from disease, over the (often) small risk of side effects to the individual. Conclusion Through the course of this essay, I have highlighted many ethical issues surrounding mass immunization, particularly those concerned with its effects on not only the individual, but society as a whole, and how these may conflict or be balanced. I feel the major conclusions to be drawn are as follows; Whilst all medical interventions, including vaccinations, carry some level of risk, these occur in a very small subset of those immunized with modern vaccinations. Very few again suffer serious side effects, and they survive to enjoy the benefits of individual and public good conferred from the vaccination. For this reason I believe Teleological argument is more applicable than Kantian theory, which can be too narrow minded to be apply to individual and public good simultaneously. Teleology allows for flexibility/adaption to the changing ethics and laws of modern medicine, and takes changing societal values into consideration7. Often, those who would suffer side effects are the ones who are advised against vaccination, like immunosuppressed patients who will enjoy the protection of herd immunization. By identifying such at-risk groups, we can continue to maximize benefit and minimize risk in modern vaccination programs, for the most ethical procedures. By working with the media, and making information on vaccination, and its benefits and risk as widely available as possible in the community, we can allow people to make their own choices. This enhances their autonomy, enhancing how informed consent is to make it as valid as possible, whilst leaving the population free to inquire for more information. This helps combat damaging press stories about immunization risks, whilst hopefully convincing the public that benefits far outweigh risks. Beneficence is maximized, and maleficence done by omission or ignorance is reduced. To the argument that the individual rarely benefits, I conclude that we can never know if he/she benefits individually, as its impossible to tell if they would have contracted the disease. However, I feel I have given evidence on how a share of the public good of herd immunity can be seen as an individual good, whilst they contribute to furthering herd protection. Of course, other issues exist surrounding immunization, such as varying risk;benefit ratios in different populations12, distributive justice, and the complex societal issues surrounding compulsory vaccination13. These were seen as outside the scope of this essay, and contained merely variations/combinations of the issues seen here. I attempted to deal with the issues in their simplest form in order to tackle as many theoretical scenarios as possible. On a final note; I feel that mass preventative immunization presents society and the physician with a complex range of ethical issues, and will continue to as long as such programs continue.

Pressure groups against them will always exist, and new vaccines will continue to bring new dilemmas and controversy. Proper education and openness about risks and benefits will properly empower the individual to make their own rational decision, which will hopefully be to their own, and societies, benefit.