Group Title: Emerging Themes in Epidemiology 2006, 3:13
Title: Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values
CITATION PDF VIEWER THUMBNAILS PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00100228/00001
 Material Information
Title: Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values
Series Title: Emerging Themes in Epidemiology 2006, 3:13
Physical Description: Archival
Creator: Salmon DA
Omer SB
Publication Date: 38987
 Record Information
Bibliographic ID: UF00100228
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: Open Access: http://www.biomedcentral.com/info/about/openaccess/

Downloads

This item has the following downloads:

individual_freedoms ( PDF )


Full Text


Emerging Themes in Epidemiology


0
BioMled Central


Commentary

Individual freedoms versus collective responsibility: immunization
decision-making in the face of occasionally competing values
Daniel A Salmon*1,2,3 and Saad B Omer2,3


Address: 'Department of Epidemiology and Health Policy Research, College of Medicine, University of Florida, Gainesville, Florida, USA, 2Institute
for Vaccine Safety, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA and 3Department of International Health, Johns
Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Email: Daniel A Salmon* das@ehpr.ufl.edu; Saad B Omer somer@jhsph.edu
* Corresponding author


Published: 27 September 2006
Emerging Themes in Epidemiology 2006, 3:13 doi: 10.1 186/1742-7622-3-13


Received: 08 August 2006
Accepted: 27 September 2006


This article is available from: http://www.ete-online.com/content/3/1/13
2006 Salmon and Omer; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Modern public health strives for maximizing benefits for the highest number of people while
protecting individual rights. Restrictions on individual rights are justified for two reasons-for the
benefit of the individual or the benefit of the community.
In extreme situations there may be a need to protect the health of an individual and particularly a
child; even by overriding individual/parental autonomy. However, The American Academy of
Pediatrics recently concluded that "Continued (vaccine) refusal after adequate discussion should be
respected unless the child is put at significant risk of serious harm (as, for example, might be the
case during an epidemic). Only then should state agencies be involved to override parental
discretion on the basis of medical neglect".
Many countries have compulsory immunization requirements. These laws curtail individual
autonomy in order to protect the community from infectious diseases because unvaccinated
individuals pose risk to the community including vaccinated individuals (since vaccines are not
100% efficacious), children too young to be vaccinated, and persons who have medical vaccine
contraindications. There are situations where there can be a real or perceived divergence between
individual and community benefits of vaccination. This divergence may occasionally be based upon
current scientific evidence and may exemplify the need for overriding individual autonomy. A
divergence between individual and community benefits may also exist when there are ideological
beliefs incongruent with vaccination or individuals are unaware of or do not accept available
scientific evidence.
When the state curtails individual freedoms for the collective good, it should address several issues
including the magnitude of the individual and community risk, the strength of the individual's
conviction, wider and long-term consequences of restricting individual autonomy, effective risk
communication, best available scientific evidence, and transparency of the decision making process.


Modem public health evolved in 19th century Europe
under the shadow of utilitarian ideas of Jeremy Bentham
and John Stuart Mill and retains its utilitarian leanings.


However, the impulse to maximize benefit for the highest
number of people is counterbalanced by the Kantian
threshold of a categorical imperative: "Act only according to


Page 1 of 3
(page number not for citation purposes)







Emerging Themes in Epidemiology 2006, 3:13



that maxim by which you can at the same time will that it
should become a universal law" [1] that preserves individ-
ual autonomy and emphasizes ideas such as informed
consent.

Restrictions on individual rights are justified for two rea-
sons for the benefit of the individual or the benefit of
the community. In extreme situations there may be a need
to protect the health of an individual and particularly a
child even by overriding individual/parental autonomy.
The American Academy of Pediatrics recently concluded
that "Continued (vaccine) refusal after adequate discus-
sion should be respected unless the child is put at signifi-
cant risk of serious harm (as, for example, might be the
case during an epidemic). Only then should state agencies
be involved to override parental discretion on the basis of
medical neglect". Endemic transmission of common
childhood vaccine preventable diseases, such as pertussis
and varicella, may not meet this criterion of significant
risk of serious harm. Due to the preventive nature of vac-
cines, in contrast to therapeutic treatment of existing dis-
ease, it is difficult to determine with confidence if an
unvaccinated person will in fact contract disease.

Many countries have compulsory immunization require-
ments [2]. These laws curtail individual autonomy in
order to protect the community from infectious diseases
because unvaccinated individuals pose risk to the com-
munity including vaccinated individuals (since vaccines
are not 100% efficacious), children too young to be vacci-
nated, and persons who have medical vaccine contraindi-
cations [3,4]. In the United States (US), this reasoning is
supported by several Supreme Court decisions including
the landmark Jacobsen v. Massachusetts [5]. However,
despite their overall societal benefit, vaccines cause severe
adverse reactions in a small proportion of vaccinees. To
further the societal benefits of high vaccine coverage while
attempting to offset the harm for the small proportion of
individuals injured by vaccines, the US established the
National Vaccine Injury Compensation Program to pro-
vide no-fault compensation for vaccine injured persons
[6].

There are situations where there can be a real or perceived
divergence between individual and community benefits
of vaccination. This divergence may occasionally be based
upon current scientific evidence and may exemplify the
need for overriding individual autonomy. Use of the oral
polio vaccine (OPV) in the US in the early 1990s is such
an example. The sustained use of OPV led to the elimina-
tion of polio in the US, with the last cases of wild polio
reported in 1979. While OPV is extremely safe and effec-
tive, the vaccine very rarely caused vaccine associated par-
alytic polio (VAPP) resulting in 5-7 cases of VAPP
annually with near universal use of OPV in the US. Once


http://www.ete-online.com/content/3/1/13



polio had been effectively controlled in the US, prevent-
ing the indigenous transmission of polio, the risks of the
vaccine (VAPP) may have been greater than the risk of dis-
ease. Assuming the individual does not travel to a region
where polio is still endemic, a roughly one in a million
risk of VAPP is highly unlikely, but still greater than the
risk of wild polio. Yet, if a substantial number of individ-
uals were not vaccinated because of this individual risk/
benefit analysis, polio would likely have been reintro-
duced into the US, as the disease is only a plane ride away,
leading to a tragedy of the commons [7]. While this diver-
gence in individual versus community benefits was short-
lived (the US switched to the inactivated polio vaccine
that can not cause VAPP), such a situation can cause a
dilemma for parents, health care providers and policy
makers.

A divergence between individual and community benefits
may also exist when there are ideological beliefs incongru-
ent with vaccination or individuals are unaware of or do
not accept available scientific evidence. Ideological beliefs
that may influence persons to forgo vaccination include
religious issues (i.e. the use of cell lines from aborted
fetuses to make vaccine) and a general belief that 'natural'
disease is preferable to vaccines. Recent controversy sur-
rounding association between the MMR vaccine and
autism exemplify situations where some individuals per-
ceive the individual risks of vaccination to outweigh the
benefits. Despite carefully designed epidemiological stud-
ies [8-12] and reviews by external groups [13-17] finding
no association between MMR vaccines and autism, a sub-
stantial proportion of parents maintain a belief that vac-
cines cause autism. From the perspective of these parents,
the benefits of MMR vaccination may not outweigh the
(perceived) autism risk. The community risk/benefit anal-
ysis is likewise dependent on one's knowledge base and
perception of the science undoubtedly individual vac-
cine refusal can lead to resurgence of disease [18,19].

Irrespective of the circumstances, when the state acting
as an agent of the society-curtails individual freedoms for
the collective good, the state assumes certain responsibil-
ities and should address the following issues. First, how
great a risk does a particular health behavior entail for the
individual and the community? Moreover, a distinction
should be made between vaccine refusal among adults
versus parental vaccine refusal, as a parent does not have
an absolute right to put a child at risk even if the parent is
willing to accept such risk for him or herself. Second, con-
sideration needs to be given to the strength of the individ-
ual's conviction. The infringement upon autonomy is
related to how strongly the individual opposes the inter-
vention. Non-compliance with a public health interven-
tion should at least be a function of conviction not
laziness. Third, policies that restrict individual rights to


Page 2 of 3
(page number not for citation purposes)








Emerging Themes in Epidemiology 2006, 3:13




forgo a public health intervention must keep sight of the
wider and long-term consequences of restricting individ-
ual autonomy. A draconian approach to vaccine policy
risks public backlash and undermining the sustainability
of vaccine programs. Fourth, public authorities should
not be reflexively dismissive of concerns regarding the
efficacy and safety of the intervention raised by the indi-
viduals whose rights are being restricted. Effective risk
communication including clear and coherent descrip-
tion of the reasons for restricting individual rights is the
responsibility of the entity imposing the restrictions. Fifth,
all related decisions should be grounded in science. It is
important that the decision-making process be dynamic
and must be designed to be constantly informed by the
emerging scientific evidence even if the new evidence is
contrary to the current scientific wisdom. Moreover, the
decision making process should be transparent.

In summary, there may be situations where there is an eth-
ically valid public health justification for restricting indi-
vidual rights both in circumstances where such actions
benefit the community and in situations where the
actions only benefit the individual. However, restrictions
should only be placed after meeting certain conditions to
ensure judicious use of this power.


References
I. Encyclopaedia Britannica. Categorical imperative
www.britannica.com/eb/article-9020788]


http://www.ete-online.com/content/3/1/13




14. American Medical Association. The relationship between
the MMR vaccine and autism, From the Vaccine Education
Center Newsletter [http://www.ama-assn.org/ama/pub/category/
13697.html]
15. World Health Organization. Statement on the use of MMR
vaccines [http://www.who.int/vaccine safety/topics/mmr/
mmr autism/en/]
16. Halsey NA, Hyman SL, Conference Writing Panel: Measles-Mumps-
Rubella vaccine and autism spectrum disorder: report from
the new challenges in childhood immunizations conference
convened in Oak Brook, Illinois, June 12-13, 2000. Pediatrics
2001, 107:E84.
17. Immunization Safety Review Committee: Immunization Safety
Review: Vaccines and Autism. Washington: Institute of Medicine,
National Academy Press. 17 May 2004
18. Gangarosa EJ, Galazka AM, Wolfe CR, Phillips LM, Gangarosa RE,
Miller E, Chen RT: Impact of anti-vaccine movements on per-
tussis control: the untold store. Lancet 1998, 351:356-361.
19. Atkinson P, Cullinan C, Jones J, Fraser G, Maguire H: Large out-
break of measles in London: reversal of health inequalities.
Arch Dis Child 2005, 90:424-425.


[http://


2. Salmon DA, Teret SP, Maclntyre CR, Salisbury D, Halsey NA: Com-
pulsory Vaccination and Conscientious or Philosophical
Exemptions: Past, Present and Future. Lancet 2006,
367:436-442.
3. Salmon DA, Haber M, Gangarosa EJ, Phillips L, Smith N, Chen RT:
Health consequences of religious and philosophical exemp-
tions from immunization laws: individual and societal risks of
measles. JAMA 1999, 282:47-53.
4. Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman
RE: Individual and community risks of measles and pertussis
associated with personal exemptions to immunizations.
JAMA 2000, 284:3145-3150.
5. jacobson v. Commonwealth of Massachusetts, 197 U.S. I I (1905) .
6. Smith MH: National Childhood Vaccine Injury Compensation
Act. Pediatrics 1988, 82:264-269.
7. Hardin G: The tragedy of the commons. Science 1968,
162:1243-1248.
8. Smeeth L, Cook C, Fombonne E, Heavey L, Rodrigues LC, Smith PG,
Hall AJ: MMR vaccination and pervasive developmental disor-
ders: a case-control study. Lancet 2004, 364:963-969.
9. Makela A, Nuorti JP, Peltola H: Neurologic disorders after mea-
sles-mumps-rubella vaccination. Pediatrics 2002, 110:957-963.
10. DeStefano F, Bhasin TK, Thompson WW, Yeargin-Allsopp M, Boyle
C: Age at First Measles-Mumps-Rubella Vaccination in Chil-
dren With Autism and School-Matched Control Subjects: A
Population-Based Study in Metropolitan Atlanta. Pediatrics
2004, I 3:259-266.
II. Madsen KM, Hviid A, Vestergaard M, Schendel D, Wohlfahrt J,
Whorsen P, Olsen J, Melbye M: A population-based study of
measles, mumps, and rubella vaccination and autism. N Engl
J Med 2002, 347:1477-1482.
12. Honda H, Shimizu Y, Rutter M: No effect of MMR withdrawal on
the incidence of autism: a total population study. j Child Psychol
Psychiatry 2005, 46:572-579.
13. Medicines Commission Agency/Committee on Safety of Medicines:
The safety of MMR vaccine. Curr Probl Curr Pharmacovigilance
1999, 25:9-10.


Page 3 of 3
(page number not for citation purposes)


Publish with BioMed Central and every
scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours you keep the copyright
Submit your manuscript here: BioMedcentral
http://www.biomedcentral.com/info/publishingadv.asp




University of Florida Home Page
© 2004 - 2010 University of Florida George A. Smathers Libraries.
All rights reserved.

Acceptable Use, Copyright, and Disclaimer Statement
Last updated October 10, 2010 - - mvs