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Ethics and Childhood Vaccination Policy in the

United States
Childhood immunization in- Kristin S. Hendrix, PhD, Lynne A. Sturm, PhD, Gregory D. Zimet, PhD, and Eric M. Meslin, PhD, FCAHS
volves a balance between par-
ents’ autonomy in deciding
whether to immunize their chil-
dren and the benefits to public
F ollowing the December
2014 measles outbreak at
a popular amusement park in
the developed world is witness-
ing a resurgence of vaccine-
preventable illnesses.7–9 Although
underlying vaccine-hesitant atti-
tudes about vaccination may be
driven by religious reasons,
health from mandating vaccines.
California,1,2 which spread to the spread of antivaccine and skepticism about science, or the
Ethical concerns about pediatric
other states, Canada, and Mex- vaccine-fear sentiments has be- influence of personalities she
vaccination span several public ico, there has been increased come common through social trusts on other matters.
health domains, including those attention to US childhood im- networks, both online and in A different mother may hold
of policymakers, clinicians, and munization practices. A recent person,10,11 a growing body of provaccination attitudes, but may
other professionals. study attributed the outbreak research argues that such senti- not vaccinate herself or her
In light of ongoing develop- to underimmunization,3 and ments are multidimensional and children because of access barriers
ments and debates, we discuss several policymakers have called nuanced.12,13 such as difficulties securing
several key ethical issues con- for an end to religious and phil- Although sensible public transportation to a health care
cerning childhood immunization osophical (i.e., personal-belief) policy is often consistent with provider or inability to pay for
in the United States and de- exemptions altogether, with the public sentiment, there are in- vaccination. Moreover, some
state of California passing legis- stances in which empirical data parents may resist particular
scribe how they affect policy
lation removing the option of can give conflicting input about vaccines rather than all vac-
development and clinical prac-
personal-belief exemptions.4,5 the ethical acceptability of policy. cines.14 They may mistakenly
tice. We focus on ethical con-
Political candidates have In vaccine policy, this is especially believe that vaccination is ap-
siderations pertaining to herd expressed various viewpoints on true when one distinguishes be- propriate for others but not for
immunity as a community good, vaccination.6 In light of these haviors from attitudes. Although their children or family, perhaps
vaccine communication, dis- developments, we discuss several related to one another, attitudes believing that they are in-
missal of vaccine-refusing fam- key ethical issues concerning about vaccination may differ vulnerable to an illness.15,16
ilies from practice, and vaccine childhood immunization in the from actual behaviors; indeed, Thus, studies that capture either
mandates. United States and describe how they can at times be orthogonal attitudes or behaviors, but not
Clinicians and policymakers they affect policy development constructs that interact uniquely both, provide an incomplete
need to consider the nature and clinical practice. There are depending on individual and portrait of the larger vaccination
and timing of vaccine-related a myriad of ethical issues re- contextual factors. For example, landscape. It is the group of
garding such topics as vaccination a mother who seeks vaccination parents who both hold
discussions and invoke delib-
development, administration, for herself and her children is vaccine-opposing (or vaccine-
erative approaches to policy-
communication, and safety exhibiting provaccine behavior, hesitant) attitudes and exhibit
making. (Am J Public Health.
monitoring. We focus on a few but may nonetheless feel hesitant nonvaccinating behavior that are
2016;106:273–278. doi:10.2105/ key ethical issues concerning or uncertain about vaccines. In the primary focus of this essay.
AJPH.2015.302952) childhood immunization in the this case, her behavior may be This is the group that is at the
United States—what we refer to a response to school-entry re- center of the “public health vs
as a “vaccine ethics” approach— quirements and employer poli- personal choice” debate.
and describe how such an cies. In contrast to her provaccine Some may believe that a few
approach affects policy develop- behavior, however, her nonvaccinating parents will have
ment and clinical immunization
Kristin S. Hendrix, Lynne A. Sturm, and Gregory D. Zimet are with the Department of
Pediatrics and Eric M. Meslin is with the Center for Bioethics, Indiana University School of
VACCINE ATTITUDES Medicine, Indianapolis.
AND BEHAVIORS Correspondence should be sent to Kristin S. Hendrix, PhD, Children’s Health Services
In a time of growing hesita- Research, 410 W 10th St, HITS Suite 1000, Indianapolis, IN 46202 (e-mail: kshendri@iu.
edu). Reprints can be ordered at by clicking the “Reprints” link.
tion, uncertainty, and opposition This article was accepted October 12, 2015.
concerning childhood vaccines, doi: 10.2105/AJPH.2015.302952

February 2016, Vol 106, No. 2 AJPH Hendrix et al. Peer Reviewed Public Health Ethics 273

no appreciable impact on out- reminiscent of Hardin’s iconic unclear regarding both the ef- implications concerning
break likelihood or management. 1968 “Tragedy of the Com- fectiveness of communicating to vaccine-related public health
Although this belief might seem mons.”23,24 The analogy would the public the societal benefits of policy are numerous and at
at least somewhat justified for work as follows: a population that immunization and the prevalence the forefront of much recent
some diseases that may be elim- is appropriately vaccinated of free-riding among parents discussion—for example, man-
inated or nearly eradicated (such against highly infectious diseases deciding about vaccination for dating vaccines for school entry
as polio) or that have relatively is a common good to the very their children.28–31 Some parents and excluding unvaccinated
low levels of transmissibility, it is society of which its members are do invoke the herd immunity children from schools in the case
not justifiable for highly in- a part. Like Hardin’s fields that argument as a reason not to of outbreaks. Worth noting is
fectious diseases like measles. It must be maintained and replen- vaccinate, suggesting that it is that US vaccine policy decisions
does not take many unvaccinated ished over time, the failure of unnecessary that they expose can have ethical implications
individuals to approach the tip- which depletes the community their child to the risk of side- for other countries. For example,
ping point at which vaccine resources, so too must a com- effects from vaccination if ev- when the Centers for Disease
coverage levels are too low and munity maintain its immunity to eryone else is vaccinated to a level Control and Prevention (CDC)
are thus ineffective in preventing ensure its health and wellness. that prevents the spread of ill- and the Advisory Committee on
disease spread. This tipping Maintaining this common good nesses.32 Parental decision- Immunization Practices with-
point is called “herd immunity” requires that all vaccine-eligible making about vaccination lends drew recommendations to give
or “community immunity.”17,18 individuals be vaccinated. itself to analysis using game the- the rotavirus vaccine to 2-, 4-,
For measles, the herd immunity However, some individuals re- ory,33 which we will not pursue and 6-month-old children in
threshold is somewhat fragile fuse to vaccinate themselves and here, except to support the no- 1999 in response to rare in-
in that it requires a large pro- their children for nonmedical tion suggested by Shim et al. that tussusception cases,36 it became
portion (96%–99%) of a given reasons. Ultimately, as with vaccination decisions are not difficult to distribute the vaccine
population to be vaccinated to Hardin’s Tragedy of the Com- simply selfish or selfless but may in developing countries where
confer maximal protection.19,20 mons, as more individuals behave involve complex relationships rotavirus had much higher
Importantly, when that critical in a manner that fails to consider between these motivations.34 morbidity and mortality
threshold of immunity is the common good, there is This degradation of the rates.37,38
achieved, the benefits of pre- a detrimental effect on the overall community resource of herd The ethics of public health
venting the spread of an in- well-being of the group and, immunity is portrayed in stark policy surrounding childhood
fectious illness also extend to therefore, on the well-being of reality in the recent California immunization extend to issues
those who cannot themselves be each individual, including those measles outbreak. Furthermore, beyond individuals’ vaccination
vaccinated (e.g., young infants), individuals who chose to forgo when we consider data doc- decisions; they also include issues
the immunocompromised (e.g., vaccination. More specifically, in umenting geographic clusters of such as vaccine mandates and
those undergoing chemother- the case of childhood immuni- underimmunization around the how easily and by what process
apy), those for whom immunity zations, the individual interest United States,35 it becomes clear exemptions may be obtained. In
may have gradually worn off at stake is the parents’ right to that some locations have not an article published in March
over time, or those who have refuse immunization for their attained thresholds necessary to 2015, Gostin argues that vaccine
incomplete vaccination status. children, with the refusal often- stop vaccine-preventable illness mandates are a medium through
Illustrating this concept, news times based on inaccurate outbreaks, putting people— which the social contract of
headlines have recently featured information or lack of un- especially unvaccinated young public health is upheld.24 He
stories of individuals who are derstanding of the safety and ef- children, the immunocompro- further contends that states offer
immunocompromised and ficacy of vaccines. One may mised, and the elderly—at in- exemptions for religious and
whose avoidance of vaccine- question whether deference to creased risk for contracting an philosophical reasons not out of
preventable illnesses lies in herd individual parental decisions ex- illness. legal concerns but out of politi-
immunity—that is, in the hands tends to situations in which the cally motivated concerns.
of others who chose to vaccinate parents’ decision is (1) factually Clinical and professional
(or not).21 baseless and (2) potentially det- ethics emerge when deciding
rimental to the health of both the VACCINE ETHICS, THE about how best to assess one’s
children and the community. PUBLIC’S HEALTH, ongoing responsibility to
There is evidence that forgo- AND PERSONAL vaccine-refusing families in one’s
THE TRAGEDY OF THE ing vaccination for oneself CHOICE primary care practice.39,40
(HERD IMMUNITY) because others are vaccinated Vaccine ethics can be con- However, professional ethics also
COMMONS (free-riding) is evident in some ceptualized as a set of issues at the involve the judgment of non-
Some scholars liken the anti- adults’ vaccine decisions for intersection of public health clinicians, such as policymakers,
vaccine movement to a type themselves.22,25–27 However, policy, clinical ethics, and pro- public health personnel, and
of “free-rider” problem22 published data are mixed or fessional ethics. The ethical researchers; for example, in

274 Public Health Ethics Peer Reviewed Hendrix et al. AJPH February 2016, Vol 106, No. 2

determining how best to com- human papilloma virus vaccina- a responsibility to consider that problem in light of the current
municate with vaccine-hesitant tion, Field and Caplan42 propose their immunization decisions can debate about family refusal of the
families via public health mes- an ethical framework, characterizing affect others. Is there a line to be measles vaccine.
saging and how a researcher vaccine mandates as a debate in- drawn between respecting vac-
might communicate with volving competing ethical values— cine refusers’ choices and maxi-
vaccine-hesitant or vaccine- specifically, the values of individual mizing the greater good through PARENTS WHO
opposing study participants. autonomy and the principles of herd immunity? Is there a re- REFUSE VACCINES
Ethical questions in this vein beneficence, nonmaleficence, jus- sponsibility on behalf of practi- Families who refuse or resist
include whether it is acceptable tice, and utilitarianism. Therefore, in tioners, policymakers, and vaccination for their children
to leverage knowledge of human a very real sense vaccination debates researchers to be empathetic to often defend their position on the
psychology to capitalize on are similar to other types of deci- the rationale underlying vaccine basis that what they believe is in
phenomena like “anticipatory sions that constitute the unspoken refusers’ decisions? the best interests of their chil-
regret” to persuade or nudge social contract—membership in We have focused on the dren.52 Their reasons vary,
individuals to engage in healthy a community often places citizens perspectives of policymakers and however, with some believing
behaviors such as vaccine in the position of supporting actions clinicians in a developed setting that vaccines will harm and not
uptake. or policies judged to be for the in which there is infrastructure to help or that vaccination is “un-
How can a vaccine ethics overall benefit of society but that offer childhood immunizations, natural” and “natural” immunity
approach inform the debate might contradict individual beliefs track administration, and enforce is preferable.53 Others believe
about herd immunity? At its core, about what is in the best interests policies. In resource-limited that they will enjoy herd im-
vaccination is an action that im- of a particular person.42 settings, however, such in- munity without subjecting their
plicates several fundamental Although we have focused on frastructure may not exist or child to the risk of vaccinating
ethical principles. It invokes dis- health care providers, public individuals may not have op- (free-riding).28 Still others may
tributive justice insofar as benefits health personnel, and policy- portunities to receive vaccines. cite various nonmedical objec-
and burdens are allocated to those makers, we recognize that there To address this critical need and tions, ranging from the seemingly
who vaccinate and those who do are many other actors contrib- ethical obligation, there have justifiable (e.g., that there is no
not. It requires society to resolve uting to considerations sur- been multiple calls for govern- need to vaccinate one’s children
issues such as the following: Who rounding vaccine ethics. For ments of developed and for eliminated illnesses) to
bears the burden of vaccination example, there is the consider- resource-limited countries to conspiracy theories (e.g., that
and who benefits from herd ation that regulatory bodies work together to improve a government entity could
immunity? Should individuals be within a government have ethical childhood immunization cover- be conducting intelligence-
allowed to benefit when others responsibilities to monitor vac- age around the world.47,48 gathering operations under the
assume some level of risk (e.g., cines for safety after they are li- Developing sound and in- auspices of a vaccination pro-
from vaccination) and they do censed,43 which is an important formed policy, clinical practice, gram).54,55 To some observers,
not? It invokes beneficence and means of fostering public trust.44 and ongoing research efforts these reasons are not equally
nonmaleficence precisely be- However, the CDC’s funding for will require incorporating the defensible—it is one thing to
cause the benefits and harms to such monitoring has been his- perspectives of all stakeholders in reject vaccines because families
individuals and communities are torically limited compared with this milieu of vaccine consider- believe it is inconsistent with
seen to be in dispute, and it speaks funding for purchasing and pro- ations. Deliberative processes49 their sincerely held religious be-
to the foundational importance moting immunizations.44 The may be an approach to in- liefs (more defensible), but it is
of respect for personal autonomy budget requested for the CDC’s corporate the perspectives of another to reject vaccines because
insofar as individual choice (and, Immunization Program, which various stakeholders, although of a belief in a government
where children are involved, includes safety monitoring, de- reconciling diverse attitudes and conspiracy (less defensible).
surrogate decision-making) is creased by $51.5 million from recommendations is challeng- Similarly, there is a range of
a hallmark of informed consent. 2014 to 201545 and by $50.3 ing.50 One example of a de- views regarding the appropriate
In some ways, the herd immunity million from 2015 to 2016.46 liberative approach focusing on response toward parents who
debate is about finding ways to Importantly, the perspective public input is citizens’ juries,51 in take these positions. Some
honor the informed decisions of patients and patients’ parents as which the public’s attitudes, prominent bioethicists argue that
that individuals wish to make immunization decision-makers is beliefs, and recommendations nonvaccinators should be held
while protecting those who are also critical. These individuals are incorporated into policy accountable56—legally liable57,58
not capable of being vaccinated may or may not take into con- decisions. and perhaps even financially re-
themselves. sideration social responsibility As with many public health sponsible59—for their decisions.
Others have made similar and how their choices affect the problems, however, it is often There is a comparable argument
observations. Relying on ethical health of others. Ethical consid- difficult to satisfy all principles that holds that parents should
principles outlined by Beauchamp erations include whether and professional obligations si- be held accountable for acting (or
and Childress41 and focusing on patients (or their parents) bear multaneously. We consider this failing to—for example, when

February 2016, Vol 106, No. 2 AJPH Hendrix et al. Peer Reviewed Public Health Ethics 275

a parent objects to a blood practice families who refuse RESOLUTION nature of vaccine discussions,
transfusion on religious grounds) vaccines for nonmedical reasons. THROUGH BETTER health care providers may feel
in a manner that exposes their Encountering families who op- COMMUNICATION moral distress74 in determining
children to the risk of harm.60 pose some or all vaccines is Ethical issues also underlie the degree to which they should
These arguments invoke common among physicians. In the emerging body of research nudge vaccine-hesitant or op-
many of the principles discussed one survey, 54% of pediatrician on how best to communicate posing families to immunize their
in this essay. This is a distributive respondents indicated they had children. This moral distress
with vaccine-hesitant and
justice issue: everyone who is encountered one or more fami- would likely result from an eth-
vaccine-opposing families. Some
able should bear the burden of lies who opposed all vaccines.64 ical conflict between doing
argue that taking a “pre-
vaccination to receive the benefit Moreover, in this same survey, what the provider sees as best for
sumptive” approach during
of being protected from the 39% of pediatricians said they the child and for society
clinical encounters—in which
spread of vaccine-preventable would dismiss families who re- (i.e., vaccinating) and what is
the physician assumes the family
illnesses through herd immunity. fused all vaccines, with 28% best for fostering the therapeutic
will agree to recommended
It is also a matter of beneficence reporting they would dismiss relationship with that patient
vaccinations—results in higher
in that we should vaccinate to families who refused some vac- and the patient’s family
rates of vaccination uptake
help protect those who cannot be cines. More recent research has (i.e., respecting the family’s
than with a “participatory”
vaccinated.42,57,59,61 Some legal indicated that 25% of surveyed wishes and not pushing the family
approach—in which the physi-
scholars argue that, under tort pediatricians say they would al- too hard). Such distress is likely
cian makes no such assumption
remedy, as long as causality can be ways, often, or sometimes dismiss to be compounded by discomfort
and solicits the family’s input
demonstrated (an admittedly families from their practice for caused by counseling on an
on whether to vaccinate.70,71
difficult undertaking), there is refusing any vaccines in the pri- emotionally charged issue such as
Others have argued for a non-
a potential for recourse to hold mary childhood immunization vaccination.
adversarial,72 “guiding” ap-
nonvaccinators responsible series.65 It has been long known
should their failure to vaccinate and recently reiterated that proach12 in which the health
lead to infecting others.58 Argu- nonvaccinating patients pose care provider addresses the WHERE TO GO FROM
ments like these also invoke the a risk to others in the waiting family’s specific concerns to ulti- HERE
concept of retributive justice— room, especially infants who mately help them decide to Given the documented diffi-
how to punish those who com- are not yet old enough to be vaccinate. culty of communicating with
mit actions that may harm vaccinated or individuals All 3 of these communication vaccine-hesitant and vaccine-
others.62 This line of thinking whose immune systems are approaches have strengths and opposing families in a way that
would consider such issues as the compromised.66,67 potential drawbacks. The pre- addresses their concerns and re-
following: Should unvaccinated Physicians’ dismissal of sumptive approach is thought to spects their autonomy, coupled
children be subject to distancing vaccine-refusing families runs result in less vaccine resistance with challenges in communicat-
or exclusion policies, such as counter to recommendations among parents; however, some ing the greater good of vaccina-
being prevented from going to from the American Academy of are concerned that, with the re- tions in typical face-to-face
school, participating in after- Pediatrics (AAP) Committee duction or absence of shared clinical encounters, it is time to
school sports, or holding jobs? on Bioethics.68,69 The AAP decision-making, such ap- rethink how health care practi-
Should parents who opt to stresses that health care providers proaches may make families feel tioners, policymakers, and com-
forego vaccinations for their child should address vaccine refusal that the provider does not care municators approach vaccine
have tax benefits withheld or through hearing the family’s about their perspective or that education and communication.
reduced? There are corollary concerns and discussing the risks their autonomy is being From a policy and clinical ethics
examples of adults who refuse to that accompany not vaccinating encroached on.12,73 Alternately, perspective, this might mean
vaccinate themselves. In some one’s child. They argue that each with the participatory and guid- making the informed-consent
instances, there are punitive encounter with a vaccine-refusing ing approaches, patients could process more educationally in-
measures for failure to vaccinate family is an opportunity to leave the provider’s office un- tensive and applicable not only to
oneself—for example, health describe the importance of vaccinated for a period of time, parents choosing to immunize
care workers facing employment vaccination—an opportunity lost perhaps putting children at risk their children but also, and es-
termination for refusing in- if the family sought care elsewhere. for exposure to illness; however, pecially, to those refusing or
fluenza vaccination.63 The AAP position tries to craft health care providers and re- declining immunizations or
Related to the issue of a middle ground, acknowledging searchers argue that approaches requesting a modified schedule.
whether to hold parents re- the positions held by parents and like these are likelier to foster the Although findings regarding the
sponsible for refusing vaccina- believing that ongoing engage- therapeutic relationship between impact of educational and mes-
tion, health care providers are ment is better than disrupting or patients and their providers.12 saging efforts on vaccine attitudes
debating the ethics of refusing to altogether severing the therapeutic Moreover, related to the chal- and intentions are mixed, one
treat or dismissing from one’s relationship through dismissal. lenges and emotionally charged approach worth investigating

276 Public Health Ethics Peer Reviewed Hendrix et al. AJPH February 2016, Vol 106, No. 2

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