Case Assignment
Author
Institutional Affiliations
Author’s Note
Case Assignment
Immunization and Religious Exemption
The refusal to school vaccination has been increasing in the United States while still majority of the parents are convinced of the advantages of vaccination for their children’s health. There are several political, geographical and religious factors for the refusal of vaccination. Schools have made it mandatory to admit children who have been vaccinated, nonetheless, all states offer medical exemptions while some states offer exemptions based on religion and philosophical beliefs. Three states California, Virginia and Mississippi have completely disallowed all non-medical exemptions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7hZbNG3E","properties":{"formattedCitation":"(Shaw et al. 2018)","plainCitation":"(Shaw et al. 2018)","noteIndex":0},"citationItems":[{"id":430,"uris":["http://zotero.org/users/local/9Hfkg8Y0/items/RGFFLB6N"],"uri":["http://zotero.org/users/local/9Hfkg8Y0/items/RGFFLB6N"],"itemData":{"id":430,"type":"article-journal","title":"Immunization Mandates, Vaccination Coverage, and Exemption Rates in the United States","container-title":"Open Forum Infectious Diseases","volume":"5","issue":"6","source":"PubMed Central","abstract":"Background\nVaccination coverage among children entering kindergarten in the United States is high, but interstate variations exist. The relationship between state immunization laws and vaccination coverage has not been fully assessed. We evaluated associations of state laws on both measles, mumps, and rubella (MMR) and diphtheria, tetanus, and pertussis (DTaP) vaccination coverage and exemptions to school immunization requirements.\n\nMethods\nWe conducted a retrospective, longitudinal analysis of the effect of state immunization laws on vaccination coverage and exemptions among US kindergarteners from SY 2008 to SY 2014. The primary outcome measures were state-level kindergarten entry vaccination coverage rates for 2-dose MMR and 4-dose DTaP vaccines. Secondary outcome measures included rates of state-level exemptions (ie, medical, religious, philosophical) to school immunization requirements.\n\nResults\nWe found that state policies that refer to Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Health Department–led parental education was associated with 5.1% and 4.5% increases in vaccination rates. Permission of religious and philosophical exemptions was associated with 2.3% and 1.9% decreases in MMR and DTaP coverage, respectively, and a 1.5% increase in both total exemptions and nonmedical exemptions, respectively.\n\nConclusions\nWe found higher vaccination coverage and lower nonmedical exemption rates for MMR and DTaP vaccines in states adopting Advisory Committee on Immunization Practices guidelines for school entry. Adherence to these best practices was a successful strategy to increase vaccination coverage and reduce vaccination exemptions.","URL":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016709/","DOI":"10.1093/ofid/ofy130","ISSN":"2328-8957","note":"PMID: 29977973\nPMCID: PMC6016709","journalAbbreviation":"Open Forum Infect Dis","author":[{"family":"Shaw","given":"Jana"},{"family":"Mader","given":"Emily M"},{"family":"Bennett","given":"Brittany E"},{"family":"Vernyi-Kellogg","given":"Olesya K"},{"family":"Yang","given":"Y Tony"},{"family":"Morley","given":"Christopher P"}],"issued":{"date-parts":[["2018",6,2]]},"accessed":{"date-parts":[["2019",11,15]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Shaw et al. 2018). However, with the introduction of first vaccination in the early 19th century, numerous people have refused to get their children vaccinated. The prominent group of people who object the vaccination belong to certain religious groups primarily Protestant Christian congregations. Their belief is that vaccination is an act of intervention with the divine providence. Protestantism gives parents the right to decide if they would like to vaccinate their children or not. Some people who vaccinated their children and there were some side effects of vaccination, consider it as God’s sign that they had disobeyed the God and that was their punishment for making wrong decision ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BsVAKQCl","properties":{"formattedCitation":"(Pel\\uc0\\u269{}i\\uc0\\u263{} et al. 2016)","plainCitation":"(Pelčić et al. 2016)","noteIndex":0},"citationItems":[{"id":433,"uris":["http://zotero.org/users/local/9Hfkg8Y0/items/W2UA9FL2"],"uri":["http://zotero.org/users/local/9Hfkg8Y0/items/W2UA9FL2"],"itemData":{"id":433,"type":"article-journal","title":"Religious exception for vaccination or religious excuses for avoiding vaccination","container-title":"Croatian Medical Journal","page":"516-521","volume":"57","issue":"5","source":"PubMed Central","DOI":"10.3325/cmj.2016.57.516","ISSN":"0353-9504","note":"PMID: 27815943\nPMCID: PMC5141457","journalAbbreviation":"Croat Med J","author":[{"family":"Pelčić","given":"Gordana"},{"family":"Karačić","given":"Silvana"},{"family":"Mikirtichan","given":"Galina L."},{"family":"Kubar","given":"Olga I."},{"family":"Leavitt","given":"Frank J."},{"family":"Cheng-tek Tai","given":"Michael"},{"family":"Morishita","given":"Naoki"},{"family":"Vuletić","given":"Suzana"},{"family":"Tomašević","given":"Luka"}],"issued":{"date-parts":[["2016",10]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Pelčić et al. 2016). Religion has a strong influence on making decisions related to vaccination and parents often use religious objection as a justification to avoid the vaccination.
Ethical Principles
The ethical implications of the pediatric vaccination revolve around the autonomy of parents for making decisions if their children should get vaccination and the total benefits of vaccination to the public health. The ethical dilemma involves the public health sectors including stakeholders, policymakers, health practitioners and other professionals. The issues of individual’s autonomy regarding vaccination decision, vaccine mandates and the process of vaccine exemptions are noted in the ethical myriad of the public health policy. The ethical approach that initiates the debate over vaccination include the benefits and burden based on who gets vaccination. Who should bear the burden of vaccination while who should receive the benefits of the herd immunity? Should people be allowed to continue having vaccinations when others are at some level of risk? Other concerns involve the autonomy of the children or individuals making decisions about their vaccination or seeking informed consent. There is a need to devise an ethical framework that characterizes the vaccine mandates particularly the importance of individual autonomy, principles of beneficence, non-maleficence, morality, justice and utilitarianism. Thus, the ethical debate over vaccination is quite similar to other social contracts as some actions and policies might provide benefit to the society while contradicting with the individual beliefs and interests. The responsibility of the utility and benefits of vaccination lie with the policy makers, health providers and researchers. It is also imperative to understand the difference of opinions and respect the practices of vaccine refusers ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TcgvBAkB","properties":{"formattedCitation":"(Hendrix et al. 2016)","plainCitation":"(Hendrix et al. 2016)","noteIndex":0},"citationItems":[{"id":436,"uris":["http://zotero.org/users/local/9Hfkg8Y0/items/MI22DFDY"],"uri":["http://zotero.org/users/local/9Hfkg8Y0/items/MI22DFDY"],"itemData":{"id":436,"type":"article-journal","title":"Ethics and Childhood Vaccination Policy in the United States","container-title":"American Journal of Public Health","page":"273-278","volume":"106","issue":"2","source":"PubMed Central","abstract":"Childhood immunization involves a balance between parents’ autonomy in deciding whether to immunize their children and the benefits to public health from mandating vaccines. Ethical concerns about pediatric vaccination span several public health domains, including those of policymakers, clinicians, and other professionals., In light of ongoing developments and debates, we discuss several key ethical issues concerning childhood immunization in the United States and describe how they affect policy development and clinical practice. We focus on ethical considerations pertaining to herd immunity as a community good, vaccine communication, dismissal of vaccine-refusing families from practice, and vaccine mandates., Clinicians and policymakers need to consider the nature and timing of vaccine-related discussions and invoke deliberative approaches to policymaking.","DOI":"10.2105/AJPH.2015.302952","ISSN":"0090-0036","note":"PMID: 26691123\nPMCID: PMC4815604","journalAbbreviation":"Am J Public Health","author":[{"family":"Hendrix","given":"Kristin S."},{"family":"Sturm","given":"Lynne A."},{"family":"Zimet","given":"Gregory D."},{"family":"Meslin","given":"Eric M."}],"issued":{"date-parts":[["2016",2]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Hendrix et al. 2016). In an effort to look for the greater good of the society, there is a need to reach out to individuals who cannot afford of lack awareness about vaccination. The principle of utilitarianism best applies in this case as the purpose of public health programs is to ensure greater health outcomes. There also ethical concerns related to family traditions and cultural values such as familial piety in some cultures makes it hard for an individual to have personal choices. There are some societies that do not rely on individualism rather they believe in the concept of collectivism. Such cultural diversity in health care settings also create ethical debates and make it hard for the policy makers to proceed with any decision that benefits all without any disagreements.
Individual rights vs Greater Societal good
In an ideal society, the individual rights and the societal good are interrelated and must be given due consideration to improve the combined effect of goodness in society. Individual rights are provided and guaranteed by the constitution and the government to its citizens. Individual rights have always been a key concern towards the revolution and foundation of the country. These rights emphasize the individuality and choices to ensure that the people can decide for themselves. If individuals are given the right to decide for their vaccination, they can make decisions without any societal, familial or religious pressure, rather they can get the opportunity to decide on the basis of their choice and wellbeing. It is also important to respect an individual’s beliefs and values as it is an integral part of public health ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"F8o105zQ","properties":{"formattedCitation":"(Shestack 2017)","plainCitation":"(Shestack 2017)","noteIndex":0},"citationItems":[{"id":439,"uris":["http://zotero.org/users/local/9Hfkg8Y0/items/RPNNVWZH"],"uri":["http://zotero.org/users/local/9Hfkg8Y0/items/RPNNVWZH"],"itemData":{"id":439,"type":"chapter","title":"The philosophic foundations of human rights","container-title":"Human Rights","publisher":"Routledge","page":"3-36","author":[{"family":"Shestack","given":"Jerome J."}],"issued":{"date-parts":[["2017"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Shestack 2017). The greater societal good or the common good is a situation where the individual rights should be stepped down so that decisions can be made in favor of a collective good for a group of people or a whole society. However, as per the constitution, it is the responsibility of the government to ensure the societal good. It is thus important for the state to device and implement such policies and laws that offer greater benefits. Thus, the decisions related to the vaccination should be made on the basis of the need and by keeping in consideration the medical research, advances in the medication and prevention strategies and implications of the vaccinations. Therefore, all states have made it compulsory for students to be enrolled in the public school to get vaccinated first. Many religious and philosophical also support the ideology of the common good and promotes the usage of vaccination.
Medical Research
With the increased interest of the medical researchers to bring about reforms in the public health, it has become evident that the research should be evidence based and cover all ethical dilemmas. The empirical research is solely based on the observations, technology and the right methods used. People in the medical industry have different values and beliefs and it becomes extremely hard to resolve any value based differences on the basis of scientific evidence. The questions that are needed to be addressed, selection of methods and interpretation of results are all filtered through unacknowledged and subconscious values. Different kinds of values reinforce different priorities and thus ethical judgements differ accordingly ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"47cnojUJ","properties":{"formattedCitation":"(Kelly et al. 2015)","plainCitation":"(Kelly et al. 2015)","noteIndex":0},"citationItems":[{"id":440,"uris":["http://zotero.org/users/local/9Hfkg8Y0/items/P48MRRRC"],"uri":["http://zotero.org/users/local/9Hfkg8Y0/items/P48MRRRC"],"itemData":{"id":440,"type":"article-journal","title":"The importance of values in evidence-based medicine","container-title":"BMC Medical Ethics","page":"69","volume":"16","issue":"1","source":"BioMed Central","abstract":"Evidence-based medicine (EBM) has always required integration of patient values with ‘best’ clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored.","DOI":"10.1186/s12910-015-0063-3","ISSN":"1472-6939","journalAbbreviation":"BMC Medical Ethics","author":[{"family":"Kelly","given":"Michael P."},{"family":"Heath","given":"Iona"},{"family":"Howick","given":"Jeremy"},{"family":"Greenhalgh","given":"Trisha"}],"issued":{"date-parts":[["2015",10,12]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Kelly et al. 2015). It is evident that public health research and practice nurtures ethical concerns that are needed to be looked upon by novel approaches as compared to traditional biomedical ethics. The two most important components of the public health research are the normative criteria depending on the ethical justifications and a structural methodological style for the implementation of research results on to public health issues. The normative foundation consists of five substantial criteria and seven procedural steps that allow to make an ethically right decision. The methodological style consist of six steps that are applied for practicing public health policies.
The normative criteria include five steps including expected health benefits in regards of the target population. It includes the potential harm or burden in order to identify any negative effects and adopt for alternative intervention measures. Next criteria is the impact on autonomy that includes health empowerment, individuals’ autonomy and privacy. The remaining criterion are the impact on equity and expected efficiency. However, the conditions for making a fair decision include transparency, consistency, reasoning, participation, management of conflicts of interest, readiness for revisions and regulation. The six important steps in conducting any medical research with a systematic methodology are description of goals, methods and population; specification of normative criteria; evaluation of public health intervention; synthesis of evaluation; recommendations for the study design and implementation; and monitoring the ethical implications ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GNVJGN7U","properties":{"formattedCitation":"(Marckmann et al. 2015)","plainCitation":"(Marckmann et al. 2015)","noteIndex":0},"citationItems":[{"id":443,"uris":["http://zotero.org/users/local/9Hfkg8Y0/items/7HJMTJ7D"],"uri":["http://zotero.org/users/local/9Hfkg8Y0/items/7HJMTJ7D"],"itemData":{"id":443,"type":"article-journal","title":"Putting Public Health Ethics into Practice: A Systematic Framework","container-title":"Frontiers in Public Health","volume":"3","source":"Frontiers","abstract":"It is widely acknowledged that public health practice raises ethical issues that require a different approach than traditional biomedical ethics. Several frameworks for public health ethics have been proposed, however, none of them provides a practice-oriented combination of the two necessary components: (1) A set of normative criteria based on an explicit ethical justification and (2) a structured methodological approach for applying the resulting normative criteria to concrete public health issues. Building on prior work in the field and integrating valuable elements of other approaches to public health ethics, we present a systematic ethical framework that shall guide professionals in planning, conducting, and evaluating public health interventions. Based on a coherentist model of ethical justification, the proposed framework contains (1) an explicit normative foundation with five substantive criteria and seven procedural conditions to guarantee a fair decision process, and (2) a six-step methodological approach for applying the criteria and conditions to the practice of public health and health policy. The framework explicitly ties together ethical analysis and empirical evidence, thus striving for evidence-based public health ethics. It shall provide normative guidance to those who analyze the ethical implications of public health practice including academic ethicists, health policy makers, health technology assessment bodies, and public health professionals. It will enable those who implement a public health intervention and those affected by it (i.e. the target population) to critically assess whether and how the required ethical considerations have been taken into account. Thereby, the framework can contribute to assuring the quality of ethical analysis in public health. Whether the presented framework will be able to achieve its goals has to be determined by evaluating its practical application.","URL":"https://www.frontiersin.org/articles/10.3389/fpubh.2015.00023/full","DOI":"10.3389/fpubh.2015.00023","ISSN":"2296-2565","title-short":"Putting Public Health Ethics into Practice","journalAbbreviation":"Front. Public Health","language":"English","author":[{"family":"Marckmann","given":"Georg"},{"family":"Schmidt","given":"Harald"},{"family":"Sofaer","given":"Neema"},{"family":"Strech","given":"Daniel"}],"issued":{"date-parts":[["2015"]]},"accessed":{"date-parts":[["2019",11,15]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Marckmann et al. 2015). Such a refined research methodology provides results that can be applied over wider populations with sound evidence. These factors help identify the ethical implications of any medical issue and helps the policy makers and public health providers with data that can be used for making important decisions.
Recommendations
It is recommended to focus on evidence based research for the implementation of ethical regulations and policies in order to avoid any public disagreements. The governments should maintain such policies that promote the public health and look for the greater societal good along with respecting individuals’ beliefs and values. Vaccination is a critical topic but it needs to be solved and all institutions should come over the same page. The not so old measles outbreak is an example that should be considered and used to spread awareness among people who oppose the vaccination in their children. The vaccination exemptions laws should be strict and solely based on medical conditions. States should make it mandatory for all children to get vaccinated before taking admission in the public schools. The vaccination laws should be similar for all to avoid any unexpected epidemics. This might hurt religious sentiments of few groups of people, however, the states should focus on the greater benefit. The biomedical and ethical research should follow a refined methodology in order to avoid any complications and present quality results.
References
ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Hendrix, Kristin S., Lynne A. Sturm, Gregory D. Zimet, and Eric M. Meslin. 2016. “Ethics and Childhood Vaccination Policy in the United States.” American Journal of Public Health 106(2): 273–78.
Kelly, Michael P., Iona Heath, Jeremy Howick, and Trisha Greenhalgh. 2015. “The Importance of Values in Evidence-Based Medicine.” BMC Medical Ethics 16(1): 69.
Marckmann, Georg, Harald Schmidt, Neema Sofaer, and Daniel Strech. 2015. “Putting Public Health Ethics into Practice: A Systematic Framework.” Frontiers in Public Health 3. https://www.frontiersin.org/articles/10.3389/fpubh.2015.00023/full (November 15, 2019).
Pelčić, Gordana et al. 2016. “Religious Exception for Vaccination or Religious Excuses for Avoiding Vaccination.” Croatian Medical Journal 57(5): 516–21.
Shaw, Jana et al. 2018. “Immunization Mandates, Vaccination Coverage, and Exemption Rates in the United States.” Open Forum Infectious Diseases 5(6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016709/ (November 15, 2019).
Shestack, Jerome J. 2017. “The Philosophic Foundations of Human Rights.” In Human Rights, Routledge, 3–36.
