Shot or no shot, that is the question…
Why don’t people want to vaccinate?
I travel a lot for work, and some of the places I go to have some scary diseases. Rationally I wouldn’t travel to an area where cholera or typhoid or yellow fever was prevalent without my shots being up to date. Even though I know malaria prophylaxis doesn’t work all that well, and has side effects, I still choose to take it to reduce the risk of malaria.
Why would I trade off a moderately high probability of catching a highly infectious and life-threatening disease against an extremely low probability of experiencing complications from a vaccination?
Yet many parents decide not to vaccinate their children because of health concerns. And the debate is pretty emotional.
I think the science is good enough. After more than 250 years of vaccination, we can be quite confident that vaccination has a positive public health benefit, and usually an individual health benefit as well. And unvaccinated children run a risk of infecting others. Rationally, and altruistically, it seems like the sensible thing to do.
So am I being too Vulcan here? Why would anyone choose not to vaccinate? The Australian Government publication Immunisation Myths and Realities: responding to arguments against immunisation does an excellent job of presenting the facts and addressing the concerns of parents. However it is essentially a science-based argument without a moral dimension. The trouble is, the anti-vaccination lobby, though ostensibly making science-based arguments, is not arguing from science but from moral rights. As my undergraduate philosophy lecturer, the late Julius Kovesi, said in his 1967 book “Moral Notions”:
A moral notion does not make a roll-call of facts. There is a point in bringing certain features and aspects of actions and situations together as being relevant, and by removing this point, by removing the ‘evaluative element’, we are not left with the same facts minus evaluation.
An argument on facts without an acknowledgement of its philosophical and moral dimensions is not argument. Every human discourse takes place in a social context. Even science is not “pure”, but influenced and coloured by that social context. So though it may appear that the debate is about the validity of the science, each party in the discussion is taking an undeclared but nevertheless real philosophical position. However even understanding the issue as about morals and science doesn’t give us the full picture. Sometimes the argument is explicitly framed as a moral or ethical debate, but on enquiry turns out to be based on weak scientific or pseudo-scientific rationale.
The National Vaccine Advisory Committee in the US presents a quite elegant argument in “The Moral Right to Conscientious, Philosophical and Personal Belief Exemption to Vaccination“. This argument does frame the issue in moral terms, arguing that the state can only override individual autonomy and the right to informed consent when the state itself is at risk. The implied principle here is that where the consequences to the individual of compliance outweigh the benefits to the state or community of that compliance, the individual’s rights should take priority. As a principle inherent in medical ethics, no objection. But what if the negative consequences of individual compliance are relatively minor or probabilistically unlikely, but the positive benefit to the state of compliance or negative impact of non-compliance is material? Obvious examples here are bicycle helmets, speed limits and drink-driving laws. The individual inconvenience of compliance is small, but the societal benefits of that small inconvenience are large. Yet people will still treat the enforcement of a speed limit through use of a speed camera and fines as an invasion of individual rights. Clearly there is more than a pure rational and utilitarian choice operating.
Consider also the Australian Vaccination Network Inc. The AVN’s basic position is that vaccination should be an informed choice:
The medical community and government health authorities want to ensure that every child, and indeed, every adult, gets each vaccine on offer. But the ultimate decision is and must always remain with us – the child’s parents. After all, vaccination is not compulsory for school, pre-school or childcare in Australia and no parent will lose out on any government payment if they choose not to vaccinate.
The philosophical issues are recognised. A number of US states allow philosophical exemptions from vaccination of school children. However these states generally require documentation asserting that the child’s parent or guardian has been advised of the risks and benefits of immunisation and is making an informed choice not to vaccinate. There is no requirement in Australia that people who choose not to vaccinate are obliged to demonstrate that they understand the consequences of that choice.
There is also a tension between the rights of parents and the rights of children. To what extent does the right of a parent to decide outweigh the right of a child to receive a potentially life-saving treatment? The autonomy of children is given less weight than that of adults because they are seen as having less capacity to make decisions. However some autonomy exists, particularly in adolescents. This has informed the debate on HPV vaccination, for example.
The rights, autonomy, and desires of parents are important, but the consequences of the decision affect them indirectly. If respect for parental autonomy leads to denying children access to effective health care, the probability of harm and the loss of benefits are much greater for the children than for their parents.
Interestingly, the AVN asserts that it exists “because every issue has two sides”. However it presents a completely unilateral view. And I don’t mean the science – I mean that only the rights of parents are considered, not the rights of their children or their obligations to a larger community. And this highlights the issue. It is not about whether vaccines are good, bad or indifferent. It is about the tension between individual liberty and social duty.
Fundamentally, it can be framed as a conflict between autonomy and utilitarianism.  And this tension is a constant in society. Governments routinely impose constraints on individual liberty in the interests of wider goals. And these constraints may also serve to protect individual rights.
It is not entirely valid to frame the argument as a simple conflict between individual autonomy and state coercion. Some groups within society may have their autonomy curtailed as a consequence of their societal role. For example the right to avoid personal harm (including avoiding vaccination) is limited for military personnel, police and people in emergency services roles.
State-imposed duties can give rise to individual rights. For example a duty not to take or damage the property of others leads to a right to secure enjoyment of one’s own property.
One can also argue that the actions of a small group of individuals in declining vaccinations have a disproportionate negative effect on society as a whole. This arises through the concept of “herd immunity”.
Vaccination can also be seen through the lens of a moral imperative to act for the benefit of others. A principle missing from the anti-vaccination debate is that by vaccinating oneself or one’s children, one both receives some positive individual benefit (protection from disease) and accepts a small individual risk of a negative consequence in order to positively benefit a wider group.
Are anti-vaccination campaigners being selfish? Are pro-vaccination arguments founded on false facts? I wouldn’t go that far. Do both sides need to be more explicit about their underlying philosophical position, and clearer about how their position balances individual rights and social duties? Absolutely. That’s where common understanding will arise.
 Balog, Joseph E. “The Moral Justification for a Compulsory Human Papillomavirus Vaccination Program”, Am J Public Health. 2009 April; 99(4): 616-822.
 Field, Robert I.; Caplan, Arthur L. “A Proposed Ethical Framework for Vaccine Mandates: Competing Values and the Case of HPV”, Kennedy Institute of Ethics Journal, Volume 18, Issue 2, June 2008, pages 111-124.
 Jeroen Luyten, Antoon Vandevelde, Pierre Van Damme, and Philippe Beutels, “Vaccination Policy and Ethical Challenges Posed by Herd Immunity, Suboptimal Uptake and Subgroup Targeting” Public Health Ethics (2011) 4(3): 280-291 doi:10.1093/phe/phr032