There can be little doubt about the ethical imperative to ensure adequate vaccination uptake against certain infectious diseases. In the face of vaccine refusal, health authorities and providers instinctively appeal to coercive approaches or increased education as methods to ensure adequate vaccine uptake. Recently, some have argued that public fear around Ebola should be used as an opportunity for such approaches, should an Ebola vaccine become available. In this article, the author describes the difficulties associated with (...) coercion and education when addressing vaccine opposition. Both coercion and education can cause opposite effects than intended in certain circumstances. The correct area of focus is to address the breakdown in trust within clinical relationships. The author presents suggestions for an approach towards vaccine refusal that may be more promising. (shrink)

Vaccine refusal is not a free rider problem. The claim that vaccine refusers are free riders is inconsistent with the beliefs and motivations of most vaccine refusers. This claim also inaccurately depicts the relationship between an individual’s immunization choice, their ability to enjoy the benefits of community protection, and the costs and benefits that individuals experience from immunization and community protection. Modeling vaccine refusers as free riders also likely distorts the ethical analysis of vaccine (...) refusal and may lead to unsuccessful policy interventions. (shrink)

Parents in the US and other societies are increasingly refusing to vaccinate their children, even though popular anti-vaccine myths – e.g. ‘vaccines cause autism’ – have been debunked. This book explains the epistemic and moral failures that lead some parents to refuse to vaccinate their children. First, some parents have good reasons not to defer to the expertise of physicians, and to rely instead upon their own judgments about how to care for their children. Unfortunately, epistemic self-reliance systematically distorts (...) beliefs in areas of inquiry in which expertise is required. Second, vaccine refusers and mainstream medical authorities are often committed to different values surrounding health and safety. For example, while vaccine advocates stress that vaccines have low rates of serious complications, vaccine refusers often resist vaccination because it is ‘unnatural’ and because they view vaccine-preventable diseases as a ‘natural’ part of childhood. Finally, parents who refuse vaccines rightly resist the utilitarian moral arguments – ‘for the greater good’ – that vaccine advocates sometimes make. Unfortunately, vaccine refusers also sometimes embrace a pernicious hyper-individualism that sanctions free-riding on herd immunity and that cultivates indifference to the interpersonal and social harms that unvaccinated persons may cause. (shrink)

In a recent article, "Can One Both Contribute to and Benefit from Herd Immunity?", Lucie White argues that vaccine refusal is more like free riding than we have claimed that it is. Here, we critically reply to White’s arguments.

In bioethics vaccine refusal is often discussed as an instance of free riding on the herd immunity of an infectious disease. However, the social science of vaccine refusal suggests that the reasoning behind refusal to vaccinate more often stems from previous negative experiences in healthcare practice as well as deeply felt distrust of healthcare institutions. Moreover, vaccine refusal often acts like an exit mechanism. Whilst free riding is often met with sanctions, exit, according (...) to Albert Hirschman’s theory of exit and voice is most efficiently met by addressing concerns and increasing the quality and number of feedback channels. If the legitimate grievances responsible for vaccine refusal are not heard or addressed by healthcare policy, further polarization of attitudes to vaccines is likely to ensue. Thus, there is a need in the bioethics of vaccine refusal to understand the diverse ethical questions of this inflammable issue in addition to those of individual responsibility to vaccinate. (shrink)

Background Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature. Methods Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field (...) of Research codes, and normative content was analysed using a framework analytical approach. Results Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled ‘refusal arguments’); and (2) Whether strategies for dealing with those who reject vaccines are justifiable (‘response arguments’). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent’s will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom. Conclusions This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy. (shrink)

I argue that a parental prerogative to sometimes prioritize the interests of one’s children over the interests of others is insufficient to make the parental refusal of routine childhood vaccines morally permissible. This is because the moral permissibility of vaccine refusal follows from such a parental prerogative only if the only (weighty) moral reason in favor of vaccination is that vaccination is a means for promoting the interests of others. However, there are two additional weighty moral reasons (...) in favor of routine vaccination: fairness and concern for the vulnerable. These moral reasons in favor of vaccination are not defeated by a parental prerogative to prioritize the interests of one’s children over the interests of others. (shrink)

Vaccine refusers often seem motivated by disgust, and they invoke ideas of purity, contamination and sanctity. Unfortunately, the emotion of disgust and its companion ideas are not directly responsive to the probabilistic and statistical evidence of research science. It follows that increased efforts to promulgate the results of vaccine science are not likely to contribute to increased rates of vaccination among persons who refuse vaccines because of the ‘ethics of sanctity’. Furthermore, the fact that disgust-based vaccine (...) class='Hi'>refusal is not monolithic – vaccine refusers manifest disgust at different objects and invoke different ideas about purity and contamination – further complicates public health efforts to increase vaccination rates. (shrink)

Neoliberal cultural frames of individual choice inform mothers’ accounts of why they refuse state-mandated vaccines for their children. Using interviews with 25 mothers who reject recommended vaccines, this article examines the gendered discourse of vaccine refusal. First, I show how mothers, seeing themselves as experts on their children, weigh perceived risks of infection against those of vaccines and dismiss claims that vaccines are necessary. Second, I explicate how mothers see their own intensive mothering practices—particularly around feeding, nutrition, and (...) natural living—as an alternate and superior means of supporting their children’s immunity. Third, I show how they attempt to control risk through management of social exposure, as they envision disease risk to lie in “foreign” bodies outside their networks, and, therefore, individually manageable. Finally, I examine how these mothers focus solely on their own children by evaluating—and often rejecting—assertions that their choices undermine community health, while ignoring how their children benefit from the immunity of others. By analyzing the gendered discourse of vaccines, this article identifies how women’s insistence on individual maternal choice as evidence of commitment to their children draws on and replicates structural inequality in ways that remain invisible, but affect others. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while others disagree. We offer a (...) framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

Vaccine refusal forces us to confront tensions between many values, including scientific expertise, parental rights, children’s best interests, social responsibility, public trust, and community health. Recent outbreaks of vaccine-preventable and emerging infectious diseases have amplified these issues. The prospect of a coronavirus disease 2019 vaccine signals even more friction on the horizon. In this contentious sociopolitical landscape, it is therefore more important than ever for clinicians to identify ethically justified responses to vaccine refusal.

Proponents of vaccine mandates typically claim that everyone who can be vaccinated has a moral or ethical obligation to do so for the sake of those who cannot be vaccinated, or in the interest of public health. I evaluate several previously undertheorised premises implicit to the ‘obligation to vaccinate’ type of arguments and show that the general conclusion is false: there is neither a moral obligation to vaccinate nor a sound ethical basis to mandate vaccination under any circumstances, even (...) for hypothetical vaccines that are medically risk-free. Agent autonomy with respect to self-constitution has absolute normative priority over reduction or elimination of the associated risks to life. In practical terms, mandatory vaccination amounts to discrimination against healthy, innate biological characteristics, which goes against the established ethical norms and is also defeasible a priori. (shrink)

Contributions to COVID-19 vaccination programmes promise valuable collective goods. They can support public and individual health by creating herd immunity and taking the pressure off overwhelmed public health services; support freedom of movement by enabling governments to remove restrictive lockdown policies; and improve economic and social well-being by allowing businesses, schools, and other essential public services to re-open. The vaccinated can contribute to the production of these goods. The unvaccinated, who benefit from, but who do not contribute to these goods (...) can be morally criticised as free-riders. In this paper defends the claim that in the case of COVID-19, the unvaccinated are unfair free-riders. I defend the claim against two objections. First, that they are not unfair free-riders because they lack the subjective attitudes and intentions of free-riders; second, that although the unvaccinated may be free-riders, their free-riding is not unfair. (shrink)

This piece explores legal, ethical, and policy arguments associated with using interventions that leverage feelings of shame and social exclusion to promote uptake of childhood immunizations by parents.

Vaccine refusal has increasingly been the focus of public health concern. Rates of children who are up to date on vaccines have declined in recent years, and vaccine refusal has been implicated in disease outbreaks. Most research on children who are not fully immunized identifies white affluent mothers as most likely to opt out by choice and Black mothers as more likely to face structural barriers that limit access to vaccines for their children. In this paper, (...) we analyze social media posts and online discussions among Black mothers to better understand their concerns about vaccines. Unlike white women who reject vaccines as a personal choice, Black mothers express unique concerns about the role of the state in their lives. Specifically, some Black mothers using social media view vaccines as a white technology and claim that white women have greater freedom in opting out of vaccines without the same risks to their families. They describe efforts to strategize interactions with pediatricians and other healthcare providers who can report them to social service agencies or block access to welfare and nutritional benefits for their families if they refuse vaccines. Black women’s experiences with structural gendered racism in interactions with healthcare and education systems shape vaccine decisions and should be taken seriously. (shrink)

Marshall and O’Leary’s thoughtful response to our article suggests that dismissal policies are ethically justifiable because they might induce parents to immunize their children. This outcome is conceivable, but we have only anecdotes about how often it occurs. Such evidence became the thin reed on which the American Academy of Pediatrics rested its new policy of tolerating the practice of dismissing vaccine-hesitant parents. It seems likely that relatively few parents would agree to vaccinate because they were threatened with dismissal. (...) Other heavy-handed interventions have failed to move most such parents. When Washington state made nonmedical exemptions more difficult to obtain, nearly two-thirds of vaccine refusers were unmoved and their children remained unvaccinated. Even if dismissal threats led some parents to accept vaccines, this alone would not justify a dismissal policy. The benefits would still have to be weighed against the risks of dismissing those families who do not change their minds. (shrink)

BackgroundVaccination against human papillomavirus (HPV) is a pivotal tool for preventing a significant cause of cervical cancer. One particular culturally recognized context associated with negative attitudes toward the HPV vaccine is the religiousness of parents. However, relatively speaking, there remains a scarcity of studies that have focused specifically on religious groups, especially non-Christian groups. PurposeTo better understand the basis for members of an ultra-Orthodox Jewish community to object to the HPV vaccine and how such objections can and cannot (...) be reduced, thereby improving cultural competence—namely, the cultural understanding and ethical addressing of HPV vaccination refusal. MethodsThis qualitative study conducted semi-structured interviews with ten Israeli ultra-Orthodox mothers who are opposed to administering the HPV vaccine to their daughters. The content analysis addressed these results and extracted the major issues arising from these particular interviews. ResultsFour main novel insights were found pertaining to the negative stance toward HPV vaccination among mothers in an ultra-Orthodox Jewish community: (a) lack of knowledge about the HPV vaccine is not part of the reasoning against it; (b) rabbinical authority might have a lesser influence than expected for the moderation of HPV vaccine refusal; (c) complicated viewpoints regarding childhood vaccination may be the larger non-moderating context for HPV vaccination refusal; and (d) cultural competence is important for the ability to change the negative attitudes toward HPV vaccination. ConclusionsThe study may improve cultural competence regarding HPV vaccination and contribute to decreasing objections to the HPV vaccine in ultra-Orthodox communities. (shrink)

This article argues that non-consensual vaccination is morally impermissible, for the same reasons for which sexual assault is not permissible. Likewise, mandatory vaccination is morally akin to sexual harassment, and therefore is not to be allowed.

A recent American Academy of Pediatrics (AAP) clinical report states that it is an acceptable option for pediatric care clinicians to dismiss families who refuse vaccines. This is a clear shift in guidance from the AAP, which previously advised clinicians to “endeavor not to discharge” patients solely because of parental vaccine refusal. While this new policy might be interpreted as encouraging or recommending dismissal of vaccine-refusing families, it instead expresses tolerance for diverse professional approaches. This is unlike (...) the earlier guidance, which promoted a unified response to vaccine refusal. In fact, the resolution (which was presented at the AAP’s Annual Leadership Forum) that led to this clinical report also calls on the AAP “to continue to support pediatricians who continue to provide health care to children of parents who refuse to immunize their children.” However, the shift toward embracing dismissal as an acceptable response to vaccine refusal may erode professional solidarity. Pediatricians are clearly divided on this question; most do not dismiss vaccine-refusing families. By declaring that dismissal is an acceptable option, the AAP has sanctioned a practice that may be unfair to the many clinicians who do not dismiss these families. Clinicians who adopt a policy of dismissal toward families who refuse vaccines might impose burdens on colleagues who remain willing to offer care to those families, and their actions might show insufficient commitment to the efforts of their profession to promote health for all children. (shrink)

COVID-19 vaccine refusal seems like a paradigm case of irrationality. Vaccines are supposed to be the best way to get us out of the COVID-19 pandemic. And yet many people believe that they should not be vaccinated even though they are dissatisfied with the current situation. In this paper, we analyze COVID-19 vaccine refusal with the tools of contemporary philosophical theories of responsibility and rationality. The main outcome of this analysis is that many vaccine-refusers are (...) responsible for the belief that they should not be vaccinated and epistemically rational in holding it. This is an important result because it provides insights into the legitimacy of certain public health policies. In particular, this result shows that a public health policy that would abandon the project of convincing certain vaccine-refusers with reasons – e.g., by simply making vaccination compulsory – is prima facie illegitimate. (shrink)

Although medical and public health practitioners aim for high rates of vaccination, parent vaccination concerns confound doctors and complicate doctor-patient interactions. Medical and public health researchers have studied and attempted to counter antivaccination sentiments, but recommended approaches to dispel vaccination concerns have failed to produce long-lasting effects. We use observations made during a small study in a rural area in a southeastern state to demonstrate how a shift away from analyzing vaccination skepticism as a national issue with a global remedy (...) reveals the nuances in vaccination sentiments based on locality. Instead of seeing antivaccinationists as a distinct public based on statistical commonalities, we argue that examining vaccination beliefs and practices at the local level offers a fuller picture of the contextualized nature of vaccination decisions within the psychosocial spaces of families. A view of vaccination that emphasizes the local public, rather than a globally conceived antivaccination public, enables medical humanists and rhetoricians to offer important considerations for improving communications about vaccinations in clinical settings. (shrink)

Priority for solid organ transplant generally does not consider the underlying cause of the need for transplantation. This paper argues that a distinctive set of factors justify assigning lower priority to willfully unvaccinated individuals who require transplant as a result of suffering from COVID‐19. These factors include the personal responsibility of the patients for their own condition and the public outrage likely to ensue if willfully unvaccinated patients receive organs at the expense of vaccinated ones. The paper then proposes a (...) three‐prong test for similar deviations from the current allocation standard that incorporates patient responsibility, foreseeability and avoidability, and the frequency of the occurrence. (shrink)

There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. (...) We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics. (shrink)

There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID-19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. (...) We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics. (shrink)

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We (...) apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions. (shrink)

Dealing with the continuously increasing rates of families wanting to either significantly delay or completely postpone their infant's vaccines has created an alarmingly untenable dilemma for the general pediatricians dealing with these families on a daily basis. Pediatricians must decide whether to continue to provide substandard care by foregoing many or most of the infant's highly recommended protective vaccines, or whether to dismiss from the practice the family who refuses vaccines. Much has been written about why they should retain these (...) families, but this paper will discuss some reasonable rationales as to why nearly 40% of pediatricians choose dismissal of these families. (shrink)

Thousands of U.S. parents choose to refuse or delay the administration of selected vaccines to their children each year, and some choose not to vaccinate their children at all. While most physicians continue to provide care to these families over time, using each visit as an opportunity to educate and encourage vaccination, an increasing number of physicians are choosing to dismiss these families from their practice unless they agree to vaccinate their children. This paper will examine this emerging trend along (...) with the reasons given by those who advocate such an approach. I will argue that the strategy of refusing to allow families into a clinic unless they agree to vaccinate their children is misguided, and the arguments for doing so fail to stand up to close scrutiny. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both. Furthermore, some of the arguments in support of dismissal policies ignore the importance of professional obligation and appear to favor self-interest over the interest of the patient. (shrink)

Vaccine refusal harms and risks harming innocent bystanders. People are not entitled to harm innocents or to impose deadly risks on others, so in these cases there is nothing to be said for the right to refuse vaccination. Compulsory vaccination is therefore justified because non-vaccination can rightly be prohibited, just as other kinds of harmful and risky conduct are rightly prohibited. I develop an analogy to random gunfire to illustrate this point. Vaccine refusal, I argue, is (...) morally similar to firing a weapon into the air and endangering innocent bystanders. By re-framing vaccine refusal as harmful and reckless conduct my aim is to shift the focus of the vaccine debate from non-vaccinators’ religious and refusal rights to everyone else’s rights against being infected with contagious illnesses. Religious freedom and rights of informed consent do not entitle non-vaccinators to harm innocent bystanders, and so coercive vaccination requirements are permissible for the sake of the potential victims of the anti-vaccine movement. (shrink)

Context In response to outbreaks of vaccine‐preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as “vaccine mandates.” However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context‐specific instruments. (...) Their legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. Methods In this paper, we introduce a taxonomy for classifying real‐world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). Findings A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute—salience —which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. Conclusion Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments. (shrink)

In a recent article in this journal, Kowalik argues that compulsory vaccination unjustifiably infringes on the autonomy of vaccine refusers. While accepting Kowalik’s central premises, we argue that, when appropriately expanded in scope, autonomy considerations do not undermine the justifiability of compulsory vaccination. Vulnerable individuals—including the very old, the very young and those with compromised immune systems—face an omnipresent risk of contracting a potentially fatal vaccine-preventable illness and are thus prevented from accessing public goods by coercive pressure. Consequently, (...) when we consider an appropriately broad scope of autonomy constraints, autonomy considerations do not undermine the case for mandating vaccination. (shrink)

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or (...) abstract away from the diverse values that are relevant to the ethical justifications of particular political communities’ vaccine‐mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine‐mandate policies implicate various values. (shrink)

This open access book discusses individual, collective, and institutional responsibilities with regard to vaccination from the perspective of philosophy and public health ethics. It addresses the issue of what it means for a collective to be morally responsible for the realisation of herd immunity and what the implications of collective responsibility are for individual and institutional responsibilities. The first chapter introduces some key concepts in the vaccination debate, such as ‘herd immunity’, ‘public goods’, and ‘vaccine refusal’; and explains (...) why failure to vaccinate raises certain ethical issues. The second chapter analyses, from a philosophical perspective, the relationship between individual, collective, and institutional responsibilities with regard to the realisation of herd immunity. The third chapter is about the principle of least restrictive alternative in public health ethics and its implications for vaccination policies. Finally, the fourth chapter presents an ethical argument for unqualified compulsory vaccination, i.e. for compulsory vaccination that does not allow for any conscientious objection. The book will appeal to philosophers interested in public health ethics and the general public interested in the philosophical underpinning of different arguments about our moral obligations with regard to vaccination. (shrink)

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO (...) to military service. We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. (shrink)

The rapid development of widely available and effective vaccines has been integral to the international response to the COVID-19 pandemic. However, a significant minority of those offered vaccination have refused, often due to their adherence to ‘anti-vax’ beliefs. These beliefs include that vaccines are dangerous, render the recipient magnetic or contain government microchips.During the pandemic, numerous calls were made for those voluntarily refusing vaccination to be deprioritised when allocating scarce healthcare resources. While these calls were rejected, the likelihood of the (...) same calls being made during future pandemics necessitates a thorough examination of the ethical implications entailed by such a policy.Here, I consider an intuitive argument for the use of vaccination status when allocating healthcare resources. This argument claims that, by avoiding vaccination, vaccine refusers are failing to fulfil a social obligation to protect those around them from harm by facilitating herd immunity. They are, therefore, less deserving of healthcare than their vaccinated peers.I explore three objections to this argument. While a first objection, asserting that no individual can be held responsible for a failure to develop herd immunity, fails, I find two further responses, respectively asserting the primacy of patient autonomy and highlighting the harms deprioritising vaccine refusers would cause to disadvantaged minorities, compelling. I, therefore, conclude that vaccination status should not be considered during healthcare resource allocation, as such discrimination would disproportionately harm marginalised communities. (shrink)

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage or at the development stage. The Catholic Church’s position is that, if there are (...) alternatives, Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies. (shrink)

While rich countries like the USA and UK are starting to vaccinate their populations against COVID-19, poor countries may lack access to a vaccine for years. A global effort to provide vaccines through the COVAX facility Accelerator) aims to distribute 2 billion vaccinations by the end of next year, but the USA has refused to join and even those rich countries that have joined are entering into bilateral deals with pharmaceutical companies to buy up the supply. Canada, for instance, (...) has already secured enough to vaccinate its entire population nine times over, and the USA, European Union, UK, Australia and Japan can vaccinate their populations between 2 and 8 x.1 Vaccine nationalism is neither ethically justified, nor even in rich countries’ long-term self-interest. No one deserves the luck of their birth and few have much control over their country of residence. So, when there are four ventilators per 12 million people in some low-income and middle-income countries, and people are being buried in cardboard boxes in mass graves, it is simply unconscionable to argue that wealthy countries can keep their vaccines to themselves or even help their populations first.2 Vaccine nationalism fails to respect basic human rights and the people who have them. Moreover, many argue that rich countries have contributed to global poverty through a shared and violent history of colonialism and oppression and profit from instituting, upholding and sustaining coercive rules that often exacerbate, rather than alleviate, global poverty.3 Be that as it may, putting basic health systems in place to ensure everyone can get vaccinated, not only against COVID-19 but a host of other terrible diseases, would better protect even the rich from …. (shrink)

This article provides a systematic analysis of the proposal to use Covid‐19 vaccination status as a criterion for admission of patients with Covid‐19 to intensive care units (ICUs) under conditions of resource scarcity. The general consensus is that it is inappropriate to use vaccination status as a criterion because doing so would be unjust; many health systems, including the UK National Health Service, are based on the principle of equality of access to care. However, the analysis reveals that there are (...) several unique features of Covid vaccination status in the context of a pandemic that make this issue disanalogous to cases (such as lung cancer caused by smoking) discussed previously. First, there is equality in access to care at the point of vaccination; the unvaccinated refuse the offer of preventive care when they decline vaccination, weakening their claim to ongoing care if they become ill (this is qualitatively different from ‘poor lifestyle choices’ such as smoking). Second, the decision of one person to refuse vaccination substantially increases the risk that they will become seriously ill and need ICU care; the person who chooses not to get vaccinated thus potentially increases the pressure on intensive care bed provision, as well as increasing the risk that he or she will infect others who in turn might end up needing ICU care. Third, justice cuts both ways, and giving unvaccinated patients equal priority may itself be unjust when other patients have reduced their risk of ending up on the ICU by getting vaccinated. (shrink)

The issues and problems of mandatory vaccination policy and roll out in First Nations communities are unique and do not concern the safety and effectiveness of vaccines. These issues are also independent of more specific arguments of mandatory vaccination of healthcare workers as a condition of employment. As important as these issues are, they do not consider the complex politics of ongoing settler colonialism and First Nations community relations. In this paper, we also set aside the very real problems of (...) disinformation, hesitancy, scientific and health illiteracy, and other concerns that drive vaccine hesitancy and refusal. These affect all communities, including First Nations communities. We, instead describe the dominant arguments in favour of mandatory vaccination and critique them in terms of the disputed legitimacy of Settler-Colonial decision-making as it impacts First Nations communities. We contend cultural responsiveness and safety—not state compulsion—must remain the first principles of any engagement—including vaccination—with First Nations Peoples, families, and communities. (shrink)

I argue that there are significant moral reasons in addition to harm prevention for making vaccination against certain common infectious diseases compulsory. My argument is based on an analogy between vaccine refusal and tax evasion. First, I discuss some of the arguments for compulsory vaccination that are based on considerations of the risk of harm that the non‐vaccinated would pose on others; I will suggest that the strength of such arguments is contingent upon circumstances and that in order (...) to provide the strongest defence possible of compulsory vaccination, such arguments need to be supplemented by additional arguments. I will then offer my additional argument for compulsory vaccination: I will argue that in both cases of vaccine refusal and of tax evasion individuals fail to make their fair contribution to important social and public goods, regardless of whether each individual contribution ‘makes a difference’. While fairness considerations have sometimes been used to support a moral duty to vaccinate, they have not been appealed to in order to argue for a legal duty to vaccinate. I will suggest that this is due, among other things, to a misapplication of the principle of the least restrictive alternative in public health. Finally, I will address nine possible objections to my argument. (shrink)

Recent arguments over whether certain public health interventions should be mandatory raise questions about what counts as a "mandate." A mandate is not the same as a mere recommendation or the standard of practice. At minimum, a mandate should require an active opt-out and there should be some penalty for refusing to abide by it. Over-loose use of the term "mandate" and the easing of opt-out provisions could eventually pose a risk to the gains that truly mandatory public health interventions, (...) such as childhood vaccines, have provided over the last 50 years. Already, confusion about what counts as a mandate, and about what criteria should be used to determine when a public health intervention should be implemented as a mandate, has led to some inappropriate public policy decisions. For instance, by any reasonable criteria, the yearly influenza vaccine should be mandatory for health care workers. To enforce this mandate, those who refuse vaccination should be required to sign a waiver, and patients - especially those at high risk from flu - should be informed when they receive care from unvaccinated practitioners. (shrink)

This article considers how the metaphor of the vaccine line and the subjectivity of the line jumper came to frame COVID vaccination experiences. Drawing on analysis of interviews (n = 24) with self-identified vaccine line jumpers, this article reports on three narratives that arose across interviews: (1) vaccine line jumping is a necessary strategy of health-advocacy, (2) vaccines are personal healthcare tools earned through individual merit, and (3) vaccine refusal is a problem of belief rather (...) than access. Findings advance research about the personalization of vaccination and public health while contributing insights about the constrained subjectivities that people adopt in individualistic health landscapes. (shrink)

A COVID-19 vaccine mandate is being introduced for health and social care workers in England, and those refusing to comply will either be redeployed or have their employment terminated. We argue th...

Objectives: Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study’s objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified. Design: A survey among nursing home physicians. Setting & Participants: We sent a questionnaire to all (356) nursing (...) homes in the Netherlands, to be completed by one of the physicians. Results: We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03). Conclusions: In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures. (shrink)

Respect for autonomy is problematic in relation to public health programmes such as vaccination, as the success of such programmes depends on widespread compliance. European countries have different policies for dealing with objectors to vaccination programmes. In some countries compliance is compulsory, while in others objectors are exempted or allowed to enter the programme under specific conditions. In this paper I argue that the objectors should not be treated as a homogenous group as is done in the above-mentioned policies. Objectors (...) have different arguments for not participating in vaccination programmes. Considering the value of respect for autonomy, some but not all of these arguments need to be accommodated by authorities. The concept of 'narrative autonomy' provides criteria to distinguish between tenable and untenable claims to the right to refuse vaccination. Narrative autonomy understands autonomy as essentially linked to identity, as this provides the moral framework with which we assess our first-order preferences. The above-mentioned concept of autonomy is derived from the concept of narrative identity as described by Marya Schechtman. She suggests that the application of the Articulation Constraint and the Reality Constraint enables us to establish the validity of personal narratives. Additionally, form and content features of identity, as proposed by Anthony Laden, will be used as criteria to establish the compatibility of the defectors' arguments with shared scientific and political values. Such compatibility is essential to accommodate respect for autonomy in the context of public health. (shrink)

For contagious diseases like measles a successful immunization program can result in herd protection. Small outbreaks may still occur but fade out soon, because the possibilities for the pathogen to spread in the ‘herd’ are very small. This implies that people who refuse to participate in such a program will still benefit from the protection it offers, but they don’t do their part in maintaining protection. Isn’t that a case of freeriding—and isn’t that unfair towards all the people who do (...) collaborate? If so, that might be considered an additional ground for making vaccination mandatory or compulsory.In this paper I argue that vaccination refusal can be considered as freeriding, but that this might not be unfair. The public good of herd protection is a peculiar public good because it supervenes on private benefits that are enjoyed by all who do opt for vaccination. For vaccinated individuals, the additional benefit of herd protection comes about, as it were, for free, and hence they can’t complain that others benefit without sharing in the burdens. There are however still other grounds for making vaccination compulsory or at least for seeing refusal as a morally wrong choice. (shrink)

Transplant centers and physicians in the United States have limited guidance on the information which they can and cannot provide to transplant candidates regarding donors of potential organs. Patients may refuse organs for a variety of reasons ranging from pernicious requests including racism to misinformation about emerging medicine as with the COVID-19 vaccine and infection. Patient autonomy, organ stewardship, and equity are often at odds in these cases, but precedent indeed exists to help address these challenges. This work uses (...) such cases to highlight the urgent need for uniform, national policy prohibiting informational requests unrelated to well-established risks. (shrink)