by David Isaacs
The Vatican addressed this issue in 2005 in a carefully considered statement, ‘Moral Reflections on Vaccines Prepared from Cells Derived from Aborted Foetuses’. It says alternative vaccines should be used if possible, and that pressure should be put on pharmaceutical companies to behave ethically and not put families in morally invidious positions, but that children’s health should be the primary concern. It concludes that children and their parents should not be denied vaccines, particularly rubella vaccine, which if not given would result in significant harm to the child, their parents and society.
Hippocrates for the modern era
In the 1970s, in response to atrocities like Tuskegee, the medical profession strove to rediscover the principles of Hippocrates and re-enunciate them in modern terms. After a number of different iterations, United States philosopher Tom Beauchamp and ethicist Jim Childress enunciated in 1977 four commonly used bioethical principles, widely adopted since as guides to how doctors should behave. Of course, being doctors, we give them grandiose names: beneficence, non-maleficence, equity and autonomy.
Beneficence is doing good: a clear moral obligation for all doctors. Non-maleficence is a concept that dates back to the original Hippocratic Oath, and is often expressed using the Latin phrase ‘primum non nocere’ (first do no harm). Hippocrates never actually said these words; after all, he spoke Greek, not Latin. But he did say that a physician should promise to ‘abstain from doing harm’ and promise to ‘use treatment to help the sick according to [his or her] ability and judgment, but never with a view to injury and wrong-doing’. Close enough.
Equity is similar to justice; it refers to correcting or attempting to correct a wrong. An equitable distribution of resources implies that money should be spent on competing interests in a fair manner.
Autonomy is often considered the most important principle of all: the right to choose for oneself. The famous 19th century English philosopher John Stuart Mill wrote:
The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. Over himself, over his own body and mind, the individual is sovereign.
A competent individual should be allowed to decide what to do without coercion. This concept is encapsulated in the word ‘autonomy’ itself: it derives from the Greek for ‘self’ and ‘law’.
Immunisation and autonomy
If we apply Beauchamp and Childress’s four principles to immunisation, we can see that it does more good than harm. Like all medical interventions, from taking aspirin to major surgery, vaccines occasionally cause harm, but nowadays they are overwhelmingly safe and effective.
My own view is that people who do not immunise their children are making a poor choice. But the principle of respect for people’s autonomy says that we should let them decide for themselves, even if we do not agree with their choices.
There are some interesting points to consider here. Mill expressly specified that we should respect autonomy as long as it does not do harm to others. In medicine we take this principle as far as saying that if a mentally competent mother of young children is bleeding to death and we could save her easily with a blood transfusion, but she says no because of a strongly held belief, such as a Jehovah’s Witness might hold, we are morally obliged to respect her autonomy. And many of us have had to watch in horror as a young person bled to death when we knew we could save them. Such is the level of respect we hold for the principle of autonomy.
But what about parents’ choices when it comes to their children? Society believes that we should usually respect the principle of choice as it applies to the choices parents make about how they raise their children. But children are not their parents’ possessions to do with as they like. Children have rights too, and although parents’ rights and their children’s rights usually coincide, sometimes they differ.
Parents have responsibilities to their children: they are not allowed to harm them to excess, either physically or emotionally. They cannot beat them or sexually assault them or neglect them. If parents make choices that will seriously harm their child, the State reserves the power to intervene. This is the basis of child protection laws.
If a child of Jehovah’s Witness parents is in life-saving need of a blood transfusion, doctors will try to persuade the parents first, but if the conflict cannot be resolved the doctors will apply to the courts to over-ride the parents. The courts almost invariably rule for an intervention that will save the child’s life, on the grounds that the child is too young to make an autonomous choice, and should be kept alive so they can grow up, in case they would have decided differently to their parents’ wishes. John Stuart Mill might have said that the parents’ decision does harm another, namely their child, and so their right to make the decision about the child’s transfusion is forfeit.
Does the assertion that Jehovah’s Witness children need to be able to grow up to make their own decisions also apply to immunisation? In some countries this is one of the reasons given for compulsory immunisation: a child who is damaged by or even dies from a preventable infection might have chosen to be immunised if allowed to grow up and make their own choice.
However, the counter-argument is that we generally trust parents to make good choices regarding their children’s healthcare. This is not because parents own their children, but because most parents love their children, will try to make wise choices on their behalf and will have to live with the consequences if those choices turn out badly.
Doctors and other members of society are very reluctant to interfere with parental decision-making about their children’s health. For this reason, in many places, including Australia, the United Kingdom and many American States, routine childhood immunisation is optional, not compulsory. But there are specific situations regarding immunisation in which the risks to the child from not immunising are greater, and the usual rules about parental choice and compulsion may not apply.
In 2009, I was consulted about a newly born baby whose mother was known to have chronic hepatitis B infection; she and the baby’s father had refused to allow doctors to immunise the baby. Historically, between a quarter and a third of all people with chronic hepatitis B infection have died young because they developed cirrhosis of the liver or liver cancer. The prognosis is better with modern medicine, but chronic hepatitis B is still a serious infection with lifelong implications. The risk that a baby will develop chronic hepatitis B infection from its mother varies according to how active the mother’s infection is.
In this case, the mother’s infection was relatively quiescent and the risk to the baby without any intervention was 10% (a 1 in 10 chance). However, we knew that injecting the baby with hepatitis B vaccine (and giving an injection of antibody at birth to mop up any virus and increase the protection) would reduce the risk to 1% (a 1 in 100 chance). There is ample evidence that both the vaccine and the immunoglobulin (antibody) are extremely safe. We tried to persuade the parents to let us protect their baby, but they were adamant in their belief that the aluminium in the vaccine was toxic and would be harmful. We pointed out that if their child caught hepatitis B, they would be at greatly increased risk of liver cancer, a risk which could probably have been prevented by the vaccine. The parents did not change their minds.
Although routine childhood immunisation is not mandatory in Australia, in this particular, non-routine situation the risk was much higher than normal. We explained that we would be prepared to ask a judge for a court order to make their baby a ward of court. The parents would be allowed to make their case for no immunisation to the court and the court would decide on the merits of the case. If we were successful, the baby would remain with the parents but the court would rule that health authorities could immunise the baby.
The parents still did not agree to immunisation. We decided we had a duty to try to protect the infant. Because the proposed intervention was very safe and min
imally invasive, and the outcome if the baby became infected was serious and could quite possibly shorten the baby’s life significantly, we felt justified in asking a court to decide whether or not it was reasonable to overrule the parents to protect their child.
We went to court and won the case, but it was a pyrrhic victory. The parents left the hospital secretly and went on the run with the baby and a three-year-old sibling, evading child protection staff and making frequent phone calls to the media saying, ‘The doctors are infringing our rights.’ Anti-immunisation lobby groups championed their cause. We pointed out that the baby had rights too, and that in this case the parents’ and the baby’s rights were in conflict, and that the court had ruled that the baby’s rights took precedence, not us.
The vaccine and immunoglobulin are usually given at birth, ideally within two to three days of birth; the greater the delay the less effective they will be because the virus will have infected the baby. After the family had been on the run for a week, it was probably too late to immunise the child, and the authorities quietly dropped the pursuit.
Although the baby in this case was never given hepatitis B vaccine, there were some positive aspects of the case. It set a legal precedent, so that when similar cases have gone to the Australian courts since, the court has usually ruled in favour of the doctors. (In contrast, in an identical situation, a New Zealand court ruled in favour of the parents.)
On the few subsequent occasions when my colleagues and I have faced similar situations, we have been able to tell the parents that we are prepared to go to court, and that precedent suggested we would probably win. Confronted with this knowledge, the parents I have counselled have all decided to have their children immunised against hepatitis B. I have been able to continue seeing the baby and the parents in clinic in an atmosphere of mutual respect, giving the baby each dose of hepatitis B vaccine while respecting the parents’ decision about other routine childhood vaccines.
There are special situations in which the risk of non-immunisation is even higher than with maternal hepatitis B. For example, a child who catches rabies after being bitten or scratched by a rabid animal (for example, a raccoon in the United States, a dog or a monkey in Asia, or a bat in Australia) is virtually certain to die, unless they are given vaccine soon after the injury. If the parents refused the vaccine, almost everyone would see it as a child protection issue and the courts would rule that the child must be made a ward of court and given the vaccine.
The diseases prevented by routine childhood immunisation are now sufficiently rare that the risk that a normal unimmunised child will develop one of them and be severely harmed is in fact very low. This is why we as a society feel able to let parents decide whether or not their children should receive routine childhood immunisations.
Immunisation and other people’s rights
Of course, a decision not to immunise has an impact beyond the individual child and their parents. Other parents may well say: ‘If you do not immunise your child, you are being selfish and putting my child at risk. You talk about your right to decide, but what about my child’s right to be healthy?’
If all the children but one or two in a child care facility or school are immunised, the unimmunised children will be protected through herd immunity. But if lots of parents decide not to immunise their children, infections will spread through the population. This was starkly illustrated by outbreaks of measles in Europe in 2017, resulting in at least 35 deaths – 31 in Romania, two in Italy and one each in Germany and Portugal.
Measles vaccine is 95 to 98% effective, so when measles is circulating, up to 1 in every 20 immunised children will still catch it. Their parents will be understandably critical of the ‘selfish’ parents who permit measles to circulate. They may see them as ‘freeloaders’ who allow their children to be protected by other immunised children without incurring any risk or effort.
We are all members of communities, and as such we have some obligations to others, although opinions will vary as to the extent of these obligations. Do we have a moral obligation to get our children immunised to protect other children at their child care facility or school?
The measles outbreaks in some European countries have been blamed on falling uptakes of childhood measles vaccine following the MMR–autism scare described in Chapter 11. Italy, where there were more than 3000 cases of measles in 2017, thereafter banned unimmunised children from attending State schools, with fines and even removal of the child from parental custody as penalties for non-compliance. In Romania, where an outbreak of measles infected over 6000 people in less than a year and killed 31 children, draft legislation making immunisation against measles compulsory was hotly debated due to public opposition. In the United Kingdom, however, where the autism saga originated, measles immunisation levels recovered without legislation.
Making immunisation compulsory has two big problems. As well as infringing parents’ freedom to make their own health choices, it may alienate people who feel they are not trusted to choose wisely. Arguably, people are more likely to value immunisation and to trust the medical profession regarding vaccine safety if they are allowed to choose whether or not to immunise their children. Compulsion – as with smallpox vaccine in the 19th century in the United Kingdom and the United States – may well generate opposition. It also engenders suspicion. If a vaccine is safe and effective, why do we need to make it compulsory?
If immunisation is made compulsory, there will need to be sanctions for parents who refuse it, and these sanctions should surely be proportionate. In Belgium in 2008, two sets of parents were fined and sentenced to imprisonment for five months for refusing to allow their children to undergo compulsory polio immunisation. In practice, the sentence was suspended and the parents decided that polio vaccine was preferable to prison. Such a punitive approach literally threatens to infringe the parents’ liberty, and is almost certain to entrench anti-immunisers in their beliefs about the iniquity of State intervention.
The risk of contracting a particular infection, the risk of serious harm for children who do contract the infection and the risk from the vaccine will vary from infection to infection. The risk that Belgian children would catch or transmit polio in 2008 was negligible, so the Belgian Government’s decision to introduce legislation making polio immunisation – but not other immunisations – compulsory was puzzling. Their decision to threaten parents who dissented with imprisonment was even more contentious. Perhaps they were trying to make a point, but the rationale was questionable and the implementation heavy-handed, and there is a danger that such incidents will stimulate more outraged opposition than could be justified by any slight temporary improvement in immunisation rates.
Many jurisdictions have passed laws allowing child care facilities and schools to exclude unimmunised children during an outbreak of measles or whooping cough in order to protect other immunised children; this seems a good compromise. In Australia, many States have gone further, and introduced a policy banning any unimmunised children from attending child care centres and after-school care, colloquially called ‘No Jab No Play’.
Australia’s national ‘No Jab No Pay’ legislation also requires children to be fully immunised for parents to be eligible for the Family Tax Benefit, Child Care Benefit and Child Care Rebate. This could be seen as an incentive by those who approve of immunisation, or as a punishment by those who disapprove: carrot or stick. The big risk is that the legislation penalises socially disadvantaged parents who do not get their children immunised because of circumstances, not ideology.
Most parents in Australia immunise their children as a result of education, not compulsion, so resorting to legislation could be seen as unnecessary and disrespectful of people’s freedom to choose. The counter-argument is that legislation is effective in improving immunisation rates, and that as long as there is exemption for conscientious objectors, ‘No Jab No Pay’ and ‘No Jab No Play’ are ethically justifiable. Australian law makes parents put seat-belts on their ch
ildren in cars. An injection is a bit more invasive and the risks from an immunisation are a bit higher, but the ethical difference constituted by these matters of degree is debatable.
In 2017, a well-nourished, healthy seven-year-old girl cut her foot while playing in the garden. In her northern New South Wales town, only 70% of children are immunised by age five, compared with over 93% nationally. Like 30% of children in her ‘alternative’ community, she was unimmunised.
Her parents cleaned her foot thoroughly, but within days she developed excruciating spasms in her leg, followed by spasms in other muscles and had difficulty breathing, all caused by tetanus. She was treated for some weeks in a paediatric intensive care unit, with a tube inserted down her trachea to give artificial ventilation to save her life.
Vaccine advocates called the girl’s parents irresponsible; anti-vaccination groups blamed the doctors for not diagnosing the girl’s symptoms more quickly. Australia reports two to seven cases of tetanus a year, but only in unimmunised children and elderly adults.
The parents’ decision not to immunise this poor girl cost her a great deal of pain, an intensive care admission and, nearly, her life. In addition, her intensive care stay cost the government, and thus taxpayers, a great deal of money. Occasional disasters like this raise questions about compulsory immunisation or suggestions that the parents should be charged for the hospital stay. But if we believe in a public health service and in respecting parental choice in general, we should have second thoughts about such punitive measures.
‘Altruistic immunisation’
Some vaccines are given not primarily to protect the child but to protect others. One example is rubella vaccine for boys. As we’ve heard, Australia now immunises boys as well as girls against rubella, not to protect the boys, who would only ever catch a mild infection, but to stop the virus from circulating and to protect women of child-bearing age. This means that boys also benefit, because they are less likely to have daughters or sons or nieces or nephews with the horrible condition of congenital rubella syndrome. The parents of young boys already accept the tiny risk of harm in order to protect society from rubella. Any society would want to help families avoid having a baby with this condition.