Ethics of (Mandatory) Vaccination
There's been a reemergence of vaccine-preventable infectious diseases over the last decade or so, including measles outbreaks in Texas, California, and NY and whooping cough in California. This has largely been attributed to an increase in exemptions, likely due to the negative media attention still lingering from the original MMR/autism fictitious claim and from the overall drastic decrease in disease that leads some to believe these diseases are no longer worth vaccinating against (a truly scary thought). Even a randomized controlled trial, by many considered the gold standard of research, found you can't easily undue the anti-vaccination mindset. Mandatory vaccination is Constitutional and almost all states allow exemptions for various non-medical reasons (religious and ideological). Recent debate has centered on whether non-medical exemptions should be eliminated.
Given this reemergence of diseases and the ongoing debate surrounding requiring vaccination, I thought an apropos way to begin this blog would be with a post on the ethics of vaccination, both a history and current example.
History of Mandatory Vaccination
Compulsory vaccination in the U.S. was established in the federal Supreme Court case Jacobson v. Massachusetts, which ruled that the common good allowed a state to require vaccination. This 1905 landmark decision held that the common good - defined as safety and health - could override personal liberty in the matter of vaccination laws.
Henning Jacobson, a resident of Cambridge, Massachusetts, refused smallpox vaccination required by a recently enacted regulation of the city, and was assessed a $5 fine (roughly $125 in today's currency). Mr. Jacobson refused on the grounds the vaccination caused harm and violated his personal liberties granted by the U.S. Constitution, citing the Preamble and the 14th amendment; namely, Section 1 of the 14th amendment, which states "No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law".
The case progressed from the local court to the state supreme court, each time being upheld as constitutional, and consequently, Mr. Jacobson was in violation of the law and required to pay the original $5 fine. Ultimately the U.S. Supreme Court agreed to hear the case and address the question, "[is the state's] statute, so construed, therefore, inconsistent with the liberty which the Constitution of the United States secures to every person against deprivation by the state". In other words, the Court examined the notion of a state's police powers, the extent, and enforceability of such. In a 7 to 2 court decision, the Justices ruled that the safety and health of the citizens of Massachusetts were superior to the individual right, and by extension, compulsory vaccination is constitutional both within the Massachusetts and U.S. constitutions.
Modern Day Impact
Over one hundred years removed from this decision, this case is still discussed and analyzed in scholarly works, indicating the sustained relevance of the tensions and conflicts. The U.S. Supreme Court cited this case 69 times through 2004. In addition to granting compulsory vaccination at the state level, Jacobson v. Massachusetts has been used to justify public health initiatives ranging from quarantine of diseased individuals to mandatory motorcycle helmet laws. Despite establishing a legal precedent for mandatory vaccinations, resistance to government required vaccination persists, often from ideological, cultural, or religious beliefs, and many states have amended the vaccination laws to allow for exemptions. It is therefore important for public health to recognize its powers are not only a legal action, but also a moral obligation to consider individual preferences.
When describing the modern day impact of Jacobson v. Massachusetts, James Colgrove and Ronald Bayer wrote in the American Journal of Public Health that the greatest public health threat is one where the individual chose a path that "cost society money in health care and lost productivity". That is, the common good of a public health ordinance is more likely to be examined in a financial model downstream from the point of impact. Returning to mandatory vaccination, the government argued that the cost to society is far greater for the (presumably uninsured) individual who does not vaccinate and develops disease, as the public must assume the cost of hospitalization, treatment, and recovery (such as through disability payments and unemployment insurance).
The question often arises as to whether the U.S. Supreme Court decision was a product of its time, the so called Lochner era, or would look differently upon this case were it argued today, especially given the Court's view on an individual's right to refuse medical treatment. There seems to be a consensus, however, that the Court would uphold Jacobson v. Massachusetts. When examining cases involving individual liberty and state interests, the Court tends to side with the state, and as Lawrence Gostin observed, the Court's "outcome would certainly reaffirm the basic power of government to safeguard the public's health".
Present Day Example: Mandating HPV Vaccination
HPV has been linked to several types of cancers of the reproductive organs, and an effective vaccination exists that can protect individuals from disease. Therefore it seems desirable to mandate vaccination in children before they engage in sexual activity, exposing themselves to the viruses. By impeding transmission of the virus, future morbidity and mortality can be lessened both in the individual and possibly in the community through herd effect. The Centers for Disease Control and Prevention advocate for vaccination of all males and females beginning at age 11.
However, there are a variety of concerns expressed over mandating HPV vaccination. These may include the overall public health benefit (the burden of cervical cancer versus other cancers), the mode of transmission (sexual contact), long-term safety and effectiveness, increasing number of childhood vaccinations, and, as some would argue, implied message of approving "casual" sexual contact. Some of these reasons are unique to HPV disease pathogenesis, such as cervical cancer. For example, HPV is a sexually transmitted virus where only sexually active individuals are truly at risk for infection, which differs from, for example, measles where solely being in the community puts one at risk. Mandatory vaccinations have historically only focused on these community-risk diseases, and therefore there is not a clear precedent for casual contact diseases.
As it is ultimately up to the individual states to decide whether HPV vaccination should be mandated (i.e., state sovereignty granted through the Bill of Rights), as well as what type of exemptions are allowed, the pathway towards mandatory vaccination differs for each state. Since 2006, 42 states and territories have attempted enactment of some sort of HPV vaccination law, with 26 of those specifically including compulsory administration to school aged children. To date, only Virginia and Washington, DC have mandatory vaccination laws on the books, and both provide provisions for exemptions. While there has been no shortage of attempted legislation, the current environment has proved quite difficult to enact any sort of mandated HPV legislation, instead relying on parents (and adolescents) to ultimately make the best decision for their children (or themselves).
At present, the best solution may be to ensure that the HPV vaccine is available and accessible to individuals' opting-in. That is, adolescents should be empowered to request and receive the vaccination from their providers with few hurdles in the process. So how does Jacobson v Massachusetts fit in this discussion? Mandated policy, while clearly constitutional, will continue to be a "battle of ideas" not unlike the battle of ideas over a hundred years ago. Moving forward, the best path may simply be to present the facts in a clear objective fashion, enable legislation to remove barriers to vaccination, and continue to let parents and adolescents decide whether to receive the HPV vaccination.