Legislating health care: balancing between vaccine mandates and personal freedoms
By: Jessica Lamb
To establish my perspective, let me begin by stating that I believe unequivocally everyone who can be vaccinated should be. I think boys should be vaccinated against HPV [i], and everyone should get a yearly flu shot. For a long time I was on the fence – I certainly wanted to get vaccines against diseases like measles for myself and my family, but I was undecided regarding whether I should bother to get the flu shot if I am currently healthy. Should I worry if others don’t want to get their shots? I approached this issue purely in terms of individual protection – how likely am I to benefit from my decision?
Researchers have developed epidemiological models that hypothesize a limited supply of flu vaccine and sought to optimize outcome through selective immunization in order to minimize mortality, morbidity or economic loss. Regardless of the end goal, the answer was always the same: to vaccinate school-aged kids and their parents. Even if the primary goal is to prevent flu-related complications in the elderly, it is more effective to vaccinate children rather than those groups you are specifically trying to target [ii]. This reality is due in part to how and by whom the flu tends to be transmitted, as well as herd immunity. If enough members of a population are immunized, that immunity will protect the whole group, vaccinated and unvaccinated alike. In light of these concepts, I came to understand that community-wide vaccination efforts may be more important than the efforts of an individual.
There is evidence that vaccine mandates are more effective at achieving high levels of immunization than a simple recommendation [iii], and that benefits the community through herd immunity. That being said, the needs of the community must be balanced with the personal autonomy, as our society places great value on individual freedoms, particularly freedom of religion. While some people might wish to opt out of vaccination due to cost or inconvenience, very often it is a matter of personal beliefs – because one’s religion instructs that avoiding certain medical interventions is a demonstration of faith, or because one believes that a vaccine is more likely to harm than protect. Here we come to a slippery slope – one of these lines of reasoning is religious in nature, but both are matters of belief. Is one a more compelling reason for exemption? Should either be allowed? Most states say that religious objection is where the line should be drawn [iv], and this does seem largely effective. After all, despite allowing for a religious exemption, the US has high compliance with vaccine mandates, and we herd immunity is achieved in most cases.
Vaccines are the ounce of prevention that is worth far more than the pound of cure, and decades of scientific data indicate that they benefit both the community and the individual. Mandates have been proven to be effective, and if there is any point to having them, there must be a line drawn somewhere concerning acceptable exemptions. A reasonable approach would be to think carefully about when a requirement, as opposed to recommendation, is appropriate [v], and to create strict exemption rules. Beyond that, public education is needed to improve compliance with recommendations and minimize those who view such requirements as an imposition. For further reading that highlights how effective vaccines have been for our society, refer to [vi].
[i]This is the current CDC recommendation, though the arguments are about protecting males against concerns such as genital warts and penile cancer rather than improving group immunity – perhaps the reason Cervarix, which is more limited and protects primarily against cervical cancer, is not licensed for use in males. http://www.cdc.gov/std/hpv/stdfact-hpv-vaccine-hcp.htm
[iii] This study focuses on recent varicella mandates http://www.ncbi.nlm.nih.gov/pubmed/21715035
[iv] Thirty states offer a religious but not a “philosophical” exemption to vaccine laws. Two states – Mississippi and West Virginia only offer medical exemptions. http://www.ncsl.org/issues-research/health/school-immunization-exemption-state-laws.aspx
[v] This article supports requiring HPV vaccination based on public health concerns, but questions whether it should be tied to school entry since adverse effects of HPV aren’t tied too closely to the safety of the school environment. This begs the question, how else should a legal obligation to vaccinate be enforced? http://pediatrics.aappublications.org/content/122/2/e504.full
[vi] http://www.nytimes.com/ref/health/healthguide/esn-vaccinations-ess.html and http://www.cdc.gov/vaccines/vac-gen/policies/downloads/vacc_mandates_chptr13.pdf (check out table 13-1 on p. 266 for actual numbers on how disease has been eliminated due to vaccines)