Cross jurisdictional collaboration efforts and emergency vaccine plans that are consistent with Tribal sovereignty are essential to public health emergency preparedness. The widespread adoption of clearly written federal, state, and local vaccine plans that address fundamental assumptions in vaccine distribution to Tribal nations is imperative for future pandemic response.

Parental confidence in vaccines is waning. To sustain and improve childhood vaccine coverage rates, insights from multiple disciplines are needed to understand and address the socio-cultural factors contributing to decreased vaccine confidence and uptake.

Preventive vaccination can protect not just vaccinated individuals, but also others, which is often a central point in discussions about vaccination. To date, there has been no systematic study of self- and other-directed motives behind vaccination. This article has two major goals: first, to examine and distinguish between self- and other-directed motives behind vaccination, especially with regard to vaccinating for the sake of third parties, and second, to explore some ways in which this approach can help to clarify and guide (...) vaccination debates and policy. I propose conceiving of vaccination in terms of three basic elements: the vaccination decision-maker, the vaccine recipient and the primary beneficiary. I develop a taxonomy based on the relations between these elements to distinguish four kinds of vaccination: self-protective, paternalistic, altruistic and indirect. I finally discuss the case of human papillomavirus vaccine regulation for men and women to show how each kind of vaccination is associated with and raises specific ethical questions. (shrink)

Vaccine research, as well as the development, testing, clinical trials, and commercial uses of vaccines involve complex processes with various biological data that include gene and protein expression, analysis of molecular and cellular interactions, study of tissue and whole body responses, and extensive epidemiological modeling. Although many data resources are available to meet different aspects of vaccine needs, it remains a challenge how we are to standardize vaccine annotation, integrate data about varied vaccine types and resources, and support advanced (...) vaccine data analysis and inference. To address these problems, the community-based Vaccine Ontology (VO) has been developed through collaboration with vaccine researchers and many national and international centers and programs, including the National Center for Biomedical Ontology (NCBO), the Infectious Disease Ontology (IDO) Initiative, and the Ontology for Biomedical Investigations (OBI). VO utilizes the Basic Formal Ontology (BFO) as the top ontology and the Relation Ontology (RO) for definition of term relationships. VO is represented in the Web Ontology Language (OWL) and edited using the Protégé-OWL. Currently VO contains more than 2000 terms and relationships. VO emphasizes on classification of vaccines and vaccine components, vaccine quality and phenotypes, and host immune response to vaccines. These reflect different aspects of vaccine composition and biology and can thus be used to model individual vaccines. More than 200 licensed vaccines and many vaccine candidates in research or clinical trials have been modeled in VO. VO is being used for vaccine literature mining through collaboration with the National Center for Integrative Biomedical Informatics (NCIBI). Multiple VO applications will be presented. (shrink)

Vaccine refusal harms and risks harming innocent bystanders. People are not entitled to harm innocents or to impose deadly risks on others, so in these cases there is nothing to be said for the right to refuse vaccination. Compulsory vaccination is therefore justified because non-vaccination can rightly be prohibited, just as other kinds of harmful and risky conduct are rightly prohibited. I develop an analogy to random gunfire to illustrate this point. Vaccine refusal, I argue, is morally similar to firing (...) a weapon into the air and endangering innocent bystanders. By re-framing vaccine refusal as harmful and reckless conduct my aim is to shift the focus of the vaccine debate from non-vaccinators’ religious and refusal rights to everyone else’s rights against being infected with contagious illnesses. Religious freedom and rights of informed consent do not entitle non-vaccinators to harm innocent bystanders, and so coercive vaccination requirements are permissible for the sake of the potential victims of the anti-vaccine movement. (shrink)

Coronavirus vaccines have made their debut. Now, allocation practices have stepped into the spotlight. Following Centers for Disease Control and Prevention guidelines, states and healthcare institutions initially prioritised healthcare personnel and elderly residents of congregant facilities; other groups at elevated risk for severe complications are now becoming eligible through locally administered programmes. The question remains, however: whoelseshould be prioritised for immunisation? Here, we call attention to individuals institutionalised with severe mental illnesses and/or developmental or intellectual disabilities—a group highly susceptible (...) to the damages of COVID-19, recent research shows, and critical to consider for priority vaccination. The language describing both federal-level and state-level intentions for this population remains largely vague, despite the population’s diversity across age, diagnosis, functional status and living arrangement. Such absence of specificity, in turn, leaves room for confusion and even neglect of various subgroups. We review data stressing this group’s vulnerability, as well as select state plans for priority vaccination, highlighting the importance of clarity when describing intentions to vaccinate, or even generally care for, diverse populations composed of distinct subgroups in need. (shrink)

ABSTRACT Legislation recently adopted by the United States Congress provides producers of pandemic vaccines with near‐total immunity from civil lawsuits without making individuals injured by those vaccines eligible for compensation through the Vaccine Injury Compensation Program. The unusual decision not to provide an alternative mechanism for compensation is indicative of a broader problem of inconsistency in the American approach to vaccine‐injury compensation policy. Compensation policies have tended to reflect political pressures and economic considerations more than any cognizable set (...) of principles. This article identifies a set of ethical principles bearing on the circumstances in which vaccine injuries should be compensated, both inside and outside public health emergencies. A series of possible bases for compensation rules, some grounded in utilitarianism and some nonconsequentialist, are discussed and evaluated. Principles of fairness and reasonableness are found to constitute the strongest bases. An ethically defensible compensation policy grounded in these principles would make a compensation fund available to all individuals with severe injuries and to individuals with less‐severe injuries whenever the vaccination was required by law or professional duty. (shrink)

Respect for autonomy is problematic in relation to public health programmes such as vaccination, as the success of such programmes depends on widespread compliance. European countries have different policies for dealing with objectors to vaccination programmes. In some countries compliance is compulsory, while in others objectors are exempted or allowed to enter the programme under specific conditions. In this paper I argue that the objectors should not be treated as a homogenous group as is done in the above-mentioned policies. Objectors (...) have different arguments for not participating in vaccination programmes. Considering the value of respect for autonomy, some but not all of these arguments need to be accommodated by authorities. The concept of 'narrative autonomy' provides criteria to distinguish between tenable and untenable claims to the right to refuse vaccination. Narrative autonomy understands autonomy as essentially linked to identity, as this provides the moral framework with which we assess our first-order preferences. The above-mentioned concept of autonomy is derived from the concept of narrative identity as described by Marya Schechtman. She suggests that the application of the Articulation Constraint and the Reality Constraint enables us to establish the validity of personal narratives. Additionally, form and content features of identity, as proposed by Anthony Laden, will be used as criteria to establish the compatibility of the defectors' arguments with shared scientific and political values. Such compatibility is essential to accommodate respect for autonomy in the context of public health. (shrink)

Strategies to increase influenza vaccination rates have typically targeted healthcare professionals and individuals in various high-risk groups such as the elderly. We argue that they should focus on increasing vaccination rates in children. Because children suffer higher influenza incidence rates than any other demographic group, and are major drivers of seasonal influenza epidemics, we argue that influenza vaccination strategies that serve to increase uptake rates in children are likely to be more effective in reducing influenza-related morbidity and mortality than those (...) targeting HCPs or the elderly. This is true even though influenza-related morbidity and mortality amongst children are low, except in the very young. Further, we argue that there are no decisive reasons to suppose that children-focused strategies are less ethically acceptable than elderly or HCP-focused strategies. (shrink)

The Covid‐19 pandemic needs to be considered from two perspectives simultaneously. First, there are questions about which policies are most effective and fair in the here and now, as the pandemic unfolds. These polices concern, for example, who should receive priority in being tested, how to implement contact tracing, or how to decide who should get ventilators or vaccines when not all can. Second, it is imperative to anticipate the medium‐ and longer‐term consequences that these policies have. The case (...) of vaccine rationing is particularly instructive. Ethical, epidemiological, and economic reasons demand that rationing approaches give priority to groups who have been structurally and historically disadvantaged, even if this means that overall life years gained may be lower. (shrink)

Vaccines are not the only public health tool, but they are critical in routine and emergency settings. Achieving optimal vaccination rates requires timely access to vaccines. However, we have persistently failed to secure, distribute, and administer vaccines in a timely, effective, and equitable manner despite an enduring rhetoric of global health equity.

The 2015 Disneyland outbreak of measles in the US unequivocally brought to light what had been brewing below the surface for a while: a slow but steady decline in vaccination rates resulting in a rising number of outbreaks. This can be traced back to an increasing public questioning of vaccines by an emerging anti-vaccination movement. This article argues that, in the face of diminishing vaccination rates, childhood vaccinations should not be seen as part of the domain of parental choice (...) but, instead, as a non-negotiable legal obligation. The first part of the article formulates and defends two arguments in favour of unqualified mandatory childhood vaccination laws. First, government should not permit parents to put their children at avoidable risk of death and suffering; second, government should guard the common good of herd immunity to protect vulnerable persons. The second part rejects legal and pragmatic objections against such mandatory vaccination laws. (shrink)

There can be little doubt about the ethical imperative to ensure adequate vaccination uptake against certain infectious diseases. In the face of vaccine refusal, health authorities and providers instinctively appeal to coercive approaches or increased education as methods to ensure adequate vaccine uptake. Recently, some have argued that public fear around Ebola should be used as an opportunity for such approaches, should an Ebola vaccine become available. In this article, the author describes the difficulties associated with coercion and education when (...) addressing vaccine opposition. Both coercion and education can cause opposite effects than intended in certain circumstances. The correct area of focus is to address the breakdown in trust within clinical relationships. The author presents suggestions for an approach towards vaccine refusal that may be more promising. (shrink)

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or abstract away from (...) the diverse values that are relevant to the ethical justifications of particular political communities’ vaccine‐mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine‐mandate policies implicate various values. (shrink)

Parents in the US and other societies are increasingly refusing to vaccinate their children, even though popular anti-vaccine myths – e.g. ‘vaccines cause autism’ – have been debunked. This book explains the epistemic and moral failures that lead some parents to refuse to vaccinate their children. First, some parents have good reasons not to defer to the expertise of physicians, and to rely instead upon their own judgments about how to care for their children. Unfortunately, epistemic self-reliance systematically distorts (...) beliefs in areas of inquiry in which expertise is required. Second, vaccine refusers and mainstream medical authorities are often committed to different values surrounding health and safety. For example, while vaccine advocates stress that vaccines have low rates of serious complications, vaccine refusers often resist vaccination because it is ‘unnatural’ and because they view vaccine-preventable diseases as a ‘natural’ part of childhood. Finally, parents who refuse vaccines rightly resist the utilitarian moral arguments – ‘for the greater good’ – that vaccine advocates sometimes make. Unfortunately, vaccine refusers also sometimes embrace a pernicious hyper-individualism that sanctions free-riding on herd immunity and that cultivates indifference to the interpersonal and social harms that unvaccinated persons may cause. (shrink)

I argue that a parental prerogative to sometimes prioritize the interests of one’s children over the interests of others is insufficient to make the parental refusal of routine childhood vaccines morally permissible. This is because the moral permissibility of vaccine refusal follows from such a parental prerogative only if the only (weighty) moral reason in favor of vaccination is that vaccination is a means for promoting the interests of others. However, there are two additional weighty moral reasons in favor (...) of routine vaccination: fairness and concern for the vulnerable. These moral reasons in favor of vaccination are not defeated by a parental prerogative to prioritize the interests of one’s children over the interests of others. (shrink)

The COVID-19 vaccine is one way to prevent the spread of COVID-19. Indonesia has produced Indovac, a COVID-19 vaccine made by Biofarma which has the opportunity to be distributed to countries in the Indo-Pacific Region. This article aims to explain the opportunities and challenges of Indonesia's vaccine diplomacy during the COVID-19 pandemic to the Indo-Pacific region through Biofarma. By using a vaccine diplomacy approach and qualitative methods with System Dynamic analysis, this article concludes that (i) The opportunity for Indonesia's vaccine (...) diplomacy to the Indo-Pacific is 44% and (ii) The simulation results for all parameters have the opportunity to increase Indonesia's progress in the Indo-Pacific except for the parameters of cooperation with special actors vaccine. The challenges for Indonesia's Covid-19 vaccine diplomacy to the Indo-Pacific come from the United States, India, Japan, Australia and Singapore. (shrink)

Vaccine hesitancy has been a major cause for concern throughout the COVID-19 pandemic. The World Health Organization have previously addressed vaccine hesitancy via the ‘3C model’ (Convenience, Complacency, and Confidence). Recent scholarship has added two more ‘Cs’ (Context and Communication) to formulate a ‘5C model’ that is more equipped to adapt to the uncertainties of the pandemic. This paper focuses on the four ‘Cs’ that explicitly concerns trust (Complacency, Confidence, Context, and Communication) and phenomenologically distinguishes confidence from trust. Experts view (...) vaccines in terms of confidence, where the prospect of an undesirable outcome is extremely rare. Hence, not vaccinating and compromising herd immunity is seen to be unreasonable. Hesitant individuals contest the expert perspective and view vaccines in terms of trust, where the prospect of disappointment is likely. From this perspective, to vaccinate is to take a risk, and it is within reason to have the freedom to choose otherwise. This paper focuses on the hesitant perspective to identify the two social indicators of trust in vaccines most prominently shown during the COVID-19 pandemic in the Global North: (i) the expert reaction to hesitant concerns and (ii) the loss of freedom in relation to vaccine requirements. (shrink)

Vaccine refusers often seem motivated by disgust, and they invoke ideas of purity, contamination and sanctity. Unfortunately, the emotion of disgust and its companion ideas are not directly responsive to the probabilistic and statistical evidence of research science. It follows that increased efforts to promulgate the results of vaccine science are not likely to contribute to increased rates of vaccination among persons who refuse vaccines because of the ‘ethics of sanctity’. Furthermore, the fact that disgust-based vaccine refusal is not (...) monolithic – vaccine refusers manifest disgust at different objects and invoke different ideas about purity and contamination – further complicates public health efforts to increase vaccination rates. (shrink)

Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of the interdependence of (...) humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society. (shrink)

An increasing vaccine hesitancy among parents, which has resulted in insufficient rates of immunization, provides reason to reconsider childhood vaccination practices. Studies suggest that parents' decision-making process concerning whether to vaccinate their child is highly influenced by cognitive biases. These biases can be utilized to increase vaccination uptake via changes in the choice context. This article considers childhood vaccination programmes, which involve children being vaccinated in school or daycare unless their parents actively ‘opt out’. We suggest that such programmes reconcile (...) parents' decisional authority and vaccination duties. First, opt-out childhood vaccination based in schools or daycare centres are not disrespectful of parental authority. Second, the programme aligns the default setting with a moral obligation to vaccinate one's child that most parents have. (shrink)

Many have argued that human enhancement, in particular bioenhancement via genetic engineering, brain-interventions or preimplantation embryo selection, is problematic even if it can be safely implemented. Various arguments have been put forward focusing on issues such as the undermining of autonomy, uneven distribution and unfairness, and the alteration of one’s identity, amongst others. Nevertheless, few, if any, of these thinkers oppose vaccines. -/- In what follows, I argue for the permissibility of a limited set of cognitive enhancements – in (...) particular, the enhancement of evaluative judgment and self-control – by analogy with the permissibility of vaccines. As a result, it follows that if one accepts the permissibility of vaccines one will also, other things being equal, be committed to the permissibility of these enhancements. I then consider and respond to a number of possible objections in order to defend and clarify my position. (shrink)

Vaccines are responsible for many global public health successes, such as the eradication of smallpox and significant reductions in other serious infections like diphtheria, pertussis, tetanus, polio and measles. However, mass vaccination has also been the subject of various ethical controversies for decades. Several factors need to be considered before any vaccine is deployed at national programme like the potential burden of disease in the country or region, the duration of the protection conferred, herd immunity in addition to individual (...) protection, vaccine-related risks, financing and the logistical feasibility of the large-scale vaccination. Moreover, several ethical dilemmas revolve around authority and mandates for vaccination, informed consent, benefits vs. risks, and disparities in access to vaccination. This review paper aims to elaborate the ethical issues involved in mass vaccination programme and present some additional challenges in the context of a resource-poor settings of public health in Bangladesh. (shrink)

The Covid-19 pandemic elevated global attention to the complex problem of allocating and disseminating newly approved vaccines. Following early calls for vaccine equity,1 global health leaders made progress but struggled to fully realize distribution goals.2 With respect to vaccination rates, low and middle income countries have not achieved full parity with high income countries.3 In this issue, Harmon, Kholina, and Graham follow longstanding critiques of market-based vaccine procurement to propose “legal and practical solutions for realizing a new access to (...) vaccines environment”4 that will, they suggest, further the goal of global health justice. (shrink)

We argue that, from the point of view public health ethics, vaccination is significantly analogous to seat belt use in motor vehicles and that coercive vaccination policies are ethically justified for the same reasons why coercive seat belt laws are ethically justified. We start by taking seriously the small risk of vaccines’ side effects and the fact that such risks might need to be coercively imposed on individuals. If millions of individuals are vaccinated, even a very small risk of (...) serious side effects implies that, statistically, at some point side effects will occur. Imposing such risks raises issues about individual freedom to decide what risks to take on oneself or on one’s children and about attribution of responsibility in case of adverse side effects. Seat belt requirements raise many of the same ethical issues as vaccination requirements, and seat belt laws initially encountered some opposition from the public that is very similar to some of the current opposition to vaccine mandates. The analogy suggests that the risks of vaccines do not constitute strong enough reasons against coercive vaccination policies and that the same reasons that justify compulsory seat belt use—a measure now widely accepted and endorsed—also justify coercive vaccination policies. (shrink)

Since the outbreak of the Coronavirus disease 2019 (Covid-19), tremendous efforts have been made by scientists, health professionals, business people, politicians, and laypeople around the world. Covid-19 vaccines are one of the most crucial innovations that help fight against the virus. This paper attempts to revisit the Covid-19 vaccines production process by employing the serendipity-mindsponge-3D creativity management theory. Vaccine production can be considered an information process and classified into three main stages. The first stage involved the processes of (...) absorbing information (e.g., digital data and open science) and rejecting unhelpful information (e.g., misinformation and fake news) for effectively acquiring useful insights. Useful insights were later employed by experts, enterprises, governments, and international organizations through interdisciplinary coordinated efforts for developing vaccines within a short period. Finally, the appearance of multiple types of vaccines enabled more strategic options for vaccine distribution and administration. Findings from this vaccine creativity management process could be used as critical lessons for further improvements of vaccination programs. (shrink)

It has been proposed that the urgency of having a vaccine as a response to SARS-CoV-2 is so great, given the potential health, economic and social benefits that we should override the established s...

Vaccination involves priming the immune system with an antigenic agent that mimics a virus or bacterium, which results in immunity against the “real” microorganism. Collective vaccination policies have played an important role in the control of infectious disease worldwide. They can serve the utilitarian aim to protect public health – hence welfare – and also promote fairness: making essential vaccines accessible to all members of the public. Yet as more and more vaccines are developed, societies face the question (...) of how far to go in expanding public programs. Decisions about adopting new vaccines in the program will require combining scientific evidence about the disease and the vaccine, with value judgments about, for example, the extent to which a disease poses a threat to public health. It makes sense to promote transparency of such deliberations because one cannot expect that citizens simply accept every government vaccination policy. (shrink)

The global rollout of Covid-19 vaccination has amplified concerns regarding vaccination hesitancy, which presents a formidable challenge for public health authorities. While widespread vaccination is imperative for containing the virus, hesitancy arises from multiple factors, including apprehensions about potential long-term vaccine side-effects and misconceptions about vaccination. This has prompted discussions about the feasibility of mandating Covid-19 vaccination, especially for specific groups like healthcare professionals and the general public. This paper critically examines the tension between a paternalistic approach and individual autonomy, (...) advocating for a balanced strategy that considers both public health imperatives and individual rights. Drawing insights from existing literature, the study emphasizes the need for a nuanced and pragmatic approach to address vaccine hesitancy effectively. (shrink)

Context In response to outbreaks of vaccine‐preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as “vaccine mandates.” However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context‐specific instruments. Their legally and morally (...) significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. Methods In this paper, we introduce a taxonomy for classifying real‐world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). Findings A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute—salience —which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. Conclusion Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments. (shrink)

A short piece exploring some arguments for mandating vaccination for Covid-19.

This article examines an argument which may negatively influence measles vaccination uptake. According to the argument, an individual child in a highly vaccinated society may be better off by being non-vaccinated; the child does not risk vaccine adverse effects and is protected against measles through herd immunity. Firstly, the conclusion of the argument is challenged by showing that herd immunity’s protection is unreliable and inferior to vaccination. Secondly, the logic of the argument is challenged by showing that the argument is (...) inherently self-defeating and therefore logically inconsistent. In practice the argument cannot be used to protect children against measles. Measles vaccination is undoubtedly best for children, even in highly vaccinated societies. Only if a medical contraindication to vaccination exists should vaccination be waived in favour of reliance on herd immunity. This places obligations on those who stand in care relationships with the child: parents, healthcare providers, and the state. (shrink)

In principle, mandatory vaccination in employment could be justified in certain circumstances. These include: the availability of safe and effective vaccination; if alternative, less coercive strategies did not work; and, the costs to the individual were proportionate. However, in COVID-19, the long term safety of vaccines is yet to be established. Vaccines should be made available by employers, and voluntary vaccination encouraged.

COVID-19 vaccine refusal seems like a paradigm case of irrationality. Vaccines are supposed to be the best way to get us out of the COVID-19 pandemic. And yet many people believe that they should not be vaccinated even though they are dissatisfied with the current situation. In this paper, we analyze COVID-19 vaccine refusal with the tools of contemporary philosophical theories of responsibility and rationality. The main outcome of this analysis is that many vaccine-refusers are responsible for the belief (...) that they should not be vaccinated and epistemically rational in holding it. This is an important result because it provides insights into the legitimacy of certain public health policies. In particular, this result shows that a public health policy that would abandon the project of convincing certain vaccine-refusers with reasons – e.g., by simply making vaccination compulsory – is prima facie illegitimate. (shrink)

Vaccine hesitancy is a growing threat to public health. The reasons are complex but linked inextricably to a lack of trust in vaccines, expertise and traditional sources of authority. Efforts to increase immunization uptake in children in many countries that have seen a fall in vaccination rates are two-fold: addressing hesitancy by improving healthcare professional-parent exchange and information provision in the clinic; and, secondly, public health strategies that can override parental concerns and values with coercive measures such as mandatory (...) and presumptive vaccination. It is argued that such conflicting, parallel approaches seriously risk undermining trust that is crucial for sustaining herd immunity. Although public health strategies can be ethically justified in limiting freedoms, a parent-centered approach seldom acknowledges how it is impacted by contemporaneous coercive measures. In addition, the clinical encounter is not well suited to helping parents consider the public dimensions of vaccination, despite these being important for trust formation and informed decision-making. Efforts to address vaccine hesitancy require more consistent engagement of parental and citizen views. Along with evidence-based information, debates need to be informed by ethical support that equips parents and professionals to respond to the private and public dimensions of vaccination in a more even-handed, transparent manner. Efforts to address vaccine hesitancy need to avoid simple reliance on either parental values or coercive public policies. To do this effectively requires increasing citizen engagement on vaccination to help inform a parent-centered approach and legitimize public policy measures. In addition, cultivating a more ethically consistent strategy means moving beyond the current silos of health ethics - clinical and public health ethics. (shrink)

Mandatory vaccination, including for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and effectiveness is high, the expected utility of mandatory vaccination is greater than the alternatives, and the penalties or costs for non-compliance are proportionate. I describe an algorithm for justified mandatory vaccination. Penalties or costs could include withholding of benefits, imposition of fines, provision of community service or loss of freedoms. I argue that under conditions of risk or perceived (...) risk of a novel vaccination, a system of payment for risk in vaccination may be superior. I defend a payment model against various objections, including that it constitutes coercion and undermines solidarity. I argue that payment can be in cash or in kind, and opportunity for altruistic vaccinations can be preserved by offering people who have been vaccinated the opportunity to donate any cash payment back to the health service. (shrink)

The Ebola epidemic that broke out inWest Africa West AfricaAfrica towards the end of 2013 had been brought under reasonable control by 2015. The epidemic had severely affected three countries. This case study is about a phase I/II clinical trial Phase I/II clinical trial of a candidate Ebola virus vaccine in 2015 in a sub-Saharan AfricanSub-Saharan Africa country which had not registered any cases of the Ebola virus disease. The study was designed as a randomized double-blinded trialRandomized double blinded trial. (...) It was sponsored and funded by one of the biggest Northern multinational pharmaceutical companiesPharmaceutical companies. The protocol received ethics clearance from the relevantNational Ethics Committee national ethics committeeEthics committee. The study was coordinated and managed at the local branch of a big Northern diagnostic laboratoryDiagnostic laboratory and a laboratory of a local regional hospital. The overall study was a multi-countryMulti-country, multi-siteMulti-site trial aimed at recruiting a total of 3,000 research participantsResearch participants across four or five sub-Saharan African countries. For this country, the recruitmentRecruitment sites were two big cities, each aiming to recruit 200 participants: adults at the first site and childrenChildren at the second. The target sampleSample size was almost achieved at the first site but, before the study commenced at the second site, some members of raised the alarm that the governmentGovernment was carelessly risking the health, safetySafety and lives of citizens in the cause of an unproven vaccine that could precipitate a public health disaster. The trial was immediately suspended. A commentary on this case, and on the importance of trustTrust, is provided by Katharine Browne and Doris Schroeder at the end of this chapter. It highlights differences between this case and a phase I Ebola vaccine trial in CanadaCanada in 2014. (shrink)

This article provides a systematic analysis of the proposal to use Covid‐19 vaccination status as a criterion for admission of patients with Covid‐19 to intensive care units (ICUs) under conditions of resource scarcity. The general consensus is that it is inappropriate to use vaccination status as a criterion because doing so would be unjust; many health systems, including the UK National Health Service, are based on the principle of equality of access to care. However, the analysis reveals that there are (...) several unique features of Covid vaccination status in the context of a pandemic that make this issue disanalogous to cases (such as lung cancer caused by smoking) discussed previously. First, there is equality in access to care at the point of vaccination; the unvaccinated refuse the offer of preventive care when they decline vaccination, weakening their claim to ongoing care if they become ill (this is qualitatively different from ‘poor lifestyle choices’ such as smoking). Second, the decision of one person to refuse vaccination substantially increases the risk that they will become seriously ill and need ICU care; the person who chooses not to get vaccinated thus potentially increases the pressure on intensive care bed provision, as well as increasing the risk that he or she will infect others who in turn might end up needing ICU care. Third, justice cuts both ways, and giving unvaccinated patients equal priority may itself be unjust when other patients have reduced their risk of ending up on the ICU by getting vaccinated. (shrink)

What does vaccine justice require at the domestic and global levels? In this essay, using the COVID-19 pandemic as a backdrop, we argue that deliberative-democratic participation is needed to answer this question. To be effective on the ground, abstract principles of vaccine justice need to be further specified through policy. Any vaccination strategy needs to find ways to prioritize conflicting moral claims to vaccine allocation, clarify the grounds on which low-risk people are being asked to vaccinate, and reach a balance (...) between special duties toward countrymen and universal duties toward foreigners. Reasonable moral disagreement on these questions is bound to exist in any community. But such disagreement threatens to undermine vaccine justice insofar as the chosen vaccination strategy (and its proposed specification of vaccine justice) lacks public justification. Inclusive democratic deliberation about vaccine justice is a good mechanism for tackling such moral disagreement. By allowing residents and citizens to participate in the specification of abstract principles of vaccine justice, and their translation into policy, democratic deliberation can enhance the legitimacy of any vaccination strategy and boost compliance with it. (shrink)

An increasing vaccine hesitancy among parents, which has resulted in insufficient rates of immunization, provides reason to reconsider childhood vaccination practices. Studies suggest that parents' decision‐making process concerning whether to vaccinate their child is highly influenced by cognitive biases. These biases can be utilized to increase vaccination uptake via changes in the choice context. This article considers childhood vaccination programmes, which involve children being vaccinated in school or daycare unless their parents actively ‘opt out’. We suggest that such programmes reconcile (...) parents' decisional authority and vaccination duties. First, opt‐out childhood vaccination based in schools or daycare centres are not disrespectful of parental authority. Second, the programme aligns the default setting with a moral obligation to vaccinate one's child that most parents have. (shrink)

Recent advances have highlighted the outstanding role of the innate immune system for instructing adaptive immunity. Translating this knowledge into successful immunotherapies like vaccines, however, has proven to be a difficult task. This essay is based on the hypothesis that immune responses are tightly scaled to the infectious threat posed by a given microbial stimulus. A meticulous immunological risk‐assessment process is therefore instrumental for eliciting well‐balanced responses and maintaining immune homeostasis. The immune system makes fine distinctions, for example, between (...) live and dead bacteria, or pathogenic and non‐pathogenic microorganisms. Here, I discuss recent evidence for some of the mechanisms underlying these distinctions and speculate on strategies for therapeutically targeting the immunological risk‐assessment machinery. (shrink)

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. (...) We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. (shrink)

In attempting to provide protection to individuals and communities, childhood immunization has benefits that far outweigh disease risks. However, some parents decide not to immunize their children with some or all vaccines for reasons including lack of trust in governments, health professionals, and vaccine manufacturers. This article employs a theoretical analysis of trust and distrust to explore how twenty-seven parents with a history of vaccine rejection in two Australian cities view the expert systems central to vaccination policy and practice. (...) Our data show how perceptions of the profit motive generate distrust in the expert systems pertaining to vaccination. Our participants perceived that pharmaceutical companies had a pernicious influence over the systems driving vaccination: research, health professionals, and government. Accordingly, they saw vaccine recommendations in conflict with the interests of their child and “the system” underscored by malign intent, even if individual representatives of this system were not equally tainted. This perspective was common to parents who declined all vaccines and those who accepted some. We regard the differences between these parents—and indeed the differences between vaccine decliners and those whose Western medical epistemology informs reflexive trust—as arising from the internalization of countering views, which facilitates nuance. (shrink)

Objectives: Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study’s objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified. Design: A survey among nursing home physicians. Setting & Participants: We sent a questionnaire to all (356) nursing (...) homes in the Netherlands, to be completed by one of the physicians. Results: We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03). Conclusions: In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures. (shrink)

Vaccination can protect vaccinated individuals and often also prevent them from spreading disease to other people. This opens up the possibility of getting vaccinated for the sake of others. In fact, altruistic vaccination has recently been conceptualized as a kind of vaccination that is undertaken primary for the benefit of others. In order to better understand the potential role of altruistic motives in people’s vaccination decisions, we conducted two focus group studies with a total of 37 participants. Study 1 included (...) three focus groups on the subject of HPV vaccination for boys. Study 2 included three focus groups on the subject of pertussis and measles vaccination for childcare workers. We found substantial evidence of other-regarding motives across all focus groups, which suggests that altruistic motives could be an important factor when it comes to people’s vaccination decisions. We address the significance of these findings for vaccination policy surrounding HPV vaccination for boys and vaccination for childcare workers. We also extend the findings to normative work on vaccination for the sake of others more generally. (shrink)

Recent arguments over whether certain public health interventions should be mandatory raise questions about what counts as a "mandate." A mandate is not the same as a mere recommendation or the standard of practice. At minimum, a mandate should require an active opt-out and there should be some penalty for refusing to abide by it. Over-loose use of the term "mandate" and the easing of opt-out provisions could eventually pose a risk to the gains that truly mandatory public health interventions, (...) such as childhood vaccines, have provided over the last 50 years. Already, confusion about what counts as a mandate, and about what criteria should be used to determine when a public health intervention should be implemented as a mandate, has led to some inappropriate public policy decisions. For instance, by any reasonable criteria, the yearly influenza vaccine should be mandatory for health care workers. To enforce this mandate, those who refuse vaccination should be required to sign a waiver, and patients - especially those at high risk from flu - should be informed when they receive care from unvaccinated practitioners. (shrink)