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Abstract
The novel coronavirus (SARS-CoV-2) pandemic has refocused attention on the issue of mandatory vaccination. Some have suggested that vaccines ought to be mandatory, while others propose more moderate alternatives, such as incentives. This piece surveys a range of possible interventions, ranging from mandates through to education. All may have their place, depending on circumstances. However, it is worth clarifying the options available to policymakers, since there is sometimes confusion over whether a particular policy constitutes a mandate or not. Further, I illustrate a different kind of alternative to mandatory vaccination. Rather than seeking less coercive alternatives to a mandate, we might instead employ an alternative mandate, which requires people to do something less than get vaccinated. For instance, we might merely require people to attend an appointment at a vaccine clinic. Whether this mandatory attendance policy is justified will depend on specific circumstances, but it represents another way to promote vaccination, without mandating it. In some cases, this may represent an appropriate balance between promoting public health goals and respecting individual liberty.
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Affiliation(s)
- Ben Saunders
- Corresponding author: Ben Saunders, University of Southampton, Southampton, SO17 1BJ, UK.
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2
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Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates. Pediatr Nephrol 2022; 37:2559-2569. [PMID: 35333972 PMCID: PMC8949834 DOI: 10.1007/s00467-022-05511-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 12/02/2022]
Abstract
The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.
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O'Doherty KC, Crann S, Bucci LM, Burgess MM, Chauhan A, Goldenberg MJ, McMurtry CM, White J, Willison DJ. Deliberation on Childhood Vaccination in Canada: Public Input on Ethical Trade-Offs in Vaccination Policy. AJOB Empir Bioeth 2021; 12:253-265. [PMID: 34328070 DOI: 10.1080/23294515.2021.1941416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Policy decisions about childhood vaccination require consideration of multiple, sometimes conflicting, public health and ethical imperatives. Examples of these decisions are whether vaccination should be mandatory and, if so, whether to allow for non-medical exemptions. In this article we argue that these policy decisions go beyond typical public health mandates and therefore require democratic input. METHODS We report on the design, implementation, and results of a deliberative public forum convened over four days in Ontario, Canada, on the topic of childhood vaccination. RESULTS 25 participants completed all four days of deliberation and collectively developed 20 policy recommendations on issues relating to mandatory vaccinations and exemptions, communication about vaccines and vaccination, and AEFI (adverse events following immunization) compensation and reporting. Notable recommendations include unanimous support for mandatory childhood vaccination in Ontario, the need for broad educational communication about vaccination, and the development of a no-fault compensation scheme for AEFIs. There was persistent disagreement among deliberants about the form of exemptions from vaccination (conscience, religious beliefs) that should be permissible, as well as appropriate consequences if parents do not vaccinate their children. CONCLUSIONS We conclude that conducting deliberative democratic processes on topics that are polarizing and controversial is viable and should be further developed and implemented to support democratically legitimate and trustworthy policy about childhood vaccination.
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Affiliation(s)
| | - Sara Crann
- Department of Psychology, University of Guelph, Guelph, Ontario, Canada
| | - Lucie Marisa Bucci
- Immunize Canada, c/o Canadian Public Health Association, Ottawa, Ontario, Canada
| | - Michael M Burgess
- W. Maurice Young Centre for Applied Ethics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Apurv Chauhan
- Department of Psychology, University of Guelph, Guelph, Ontario, Canada
| | - Maya J Goldenberg
- Department of Philosophy, University of Guelph, Guelph, Ontario, Canada
| | - C Meghan McMurtry
- Department of Psychology, University of Guelph, Guelph, Ontario, Canada
| | - Jessica White
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Donald J Willison
- Department of Psychology, University of Guelph, Guelph and Pediatric Chronic Pain Program, McMaster Children's Hospital, Hamilton, Ontario, Canada
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Hansson SO, Helgesson G, Juth N. Who should be tested in a pandemic? Ethical considerations. BMC Med Ethics 2021; 22:76. [PMID: 34158041 PMCID: PMC8218570 DOI: 10.1186/s12910-021-00640-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In the initial phase of the Covid-19 pandemic, difficult decisions had to be made on the allocation of testing resources. Similar situations can arise in future pandemics. Therefore, careful consideration of who should be tested is an important part of pandemic preparedness. We focus on four ethical aspects of that problem: how to prioritize scarce testing resources, the regulation of commercial direct-to-consumer test services, testing of unauthorized immigrants, and obligatory testing. MAIN TEXT The distribution of scarce resources for testing: We emphasize the use of needs-based criteria, but also acknowledge the importance of choosing a testing strategy that contributes efficiently to stopping the overall spread of the disease. Commercial direct-to-consumer test services: Except in cases of acute scarcity, such services will in practice have to be allowed. We propose that they should be subject to regulation that ensures test quality and adequate information to users. Testing of unauthorized immigrants, their children and other people with unclear legal status: Like everyone else, these individuals may be in need of testing, and it is in society's interest to reach them with testing in order to stop the spread of the disease. A society that offers comprehensive medical services to unauthorized immigrants is in a much better position to reach them in a pandemic than a society that previously excluded them from healthcare. Obligatory testing: While there are often strong reasons for universal testing in residential areas or on workplaces, there are in most cases better ways to achieve testing coverage than to make testing mandatory. CONCLUSION In summary, we propose (1) decision-making primarily based on needs-based criteria, (2) strict regulation but not prohibition of direct-to-consumer test services, (3) test services offered to unauthorized immigrants, preferably as part of comprehensive medical services, and (4) broad outreach of testing services whenever possible, but in general not obligatory testing.
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Affiliation(s)
- Sven Ove Hansson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden.
- Division of Philosophy, KTH Royal Institute of Technology, Teknikringen 76, 100 44, Stockholm, Sweden.
| | - Gert Helgesson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Niklas Juth
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden
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Swan R. Faith-Based Medical Neglect: for Providers and Policymakers. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2020; 13:343-353. [PMID: 33052253 PMCID: PMC7545013 DOI: 10.1007/s40653-020-00323-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2020] [Indexed: 06/11/2023]
Abstract
A substantial minority of Americans have religious beliefs against one or more medical treatments. Some groups promote exclusive reliance on prayer and ritual for healing nearly all diseases. Jehovah's Witnesses oppose blood transfusions. Hundreds of thousands of schoolchildren have religious or conscientious exemptions from immunizations. Such exemptions have led to personal medical risk, decreases in herd immunity, and outbreaks of preventable disease. Though First Amendment protections for religious freedom do not include a right to neglect a child, many states have enacted laws allowing religious objectors to withhold preventive, screening, and, in some states, therapeutic medical care from children. Religious exemptions from child health and safety laws should be repealed so that children have equal rights to medical care.
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Affiliation(s)
- Rita Swan
- Children’s Healthcare Is a Legal Duty Inc (CHILD), 136 Blue Heron Place, Lexington, KY 40,511 USA
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Shen AK. Finding a way to address a wicked problem: vaccines, vaccination, and a shared understanding. Hum Vaccin Immunother 2019; 16:1030-1033. [PMID: 31799892 DOI: 10.1080/21645515.2019.1695458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
A wicked problem is a complex one with innumerable causes, is difficult to describe, and does not have a right answer. Addressing vaccine hesitancy is a wicked problem that has existed since smallpox inoculation began in 1796. Spurred by a now-discredited and retracted paper by Wakefield, et al. in 1998 and facilitated by the ease of connectivity through social media, distrust in vaccination is highly publicized, currently contributing to the largest measles outbreak in the United States since 1994, threatening public health as more vaccine-preventable diseases may be on the rise. Research to address vaccine hesitancy has been focused on building vaccine confidence, understanding the effects of diseases themselves, who is trusted to make a recommendation (i.e. health-care professionals), the need for a strong recommendation, and characteristics of hesitant parents (e.g. values). Strategies focused on disease education and strong provider recommendations have had limited impact on increasing coverage rates and provide little insight into the underlying drivers to vaccination decision-making. With the goal of enhancing public trust and provider effectiveness in conversations between providers and parents, new frameworks are needed to build a richer understanding of provider-parent conversations around vaccination and vaccine decision-making.
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Abstract
BACKGROUND AND PURPOSE Little research has been performed investigating the effect of using a vaccine hesitancy (VH) screening tool to address specific vaccination concerns. The purpose of this study was to determine whether using a VH screening tool in conjunction with provider discussions addressing parental concerns affected the parental intent to vaccinate (ITV). METHODS This study used a pretest/posttest design to measure and categorize VH and ITV. CONCLUSIONS The total sample size was 89. Differences between previsit and postvisit questionnaires showed mean responses for questions that measured specific VH categories had slight increases in the level of VH. A regression analysis was conducted to predict the postvisit ITV. Questions measuring parental trust in the provider, beliefs on vaccine efficacy, and beliefs about the prevalence of vaccine preventable disease (VPD) in the community predicted 72% of the postvisit ITV responses. IMPLICATIONS FOR PRACTICE The utilization of a VH screening tool used in conjunction with provider education in an educated and mildly VH population did not positively affect the level of VH or the parental ITV. Additional research should investigate the role of parental trust in the provider, beliefs on vaccine efficacy, and the prevalence of VPD in the community affect parental ITV.
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Younger DS, Younger APJ, Guttmacher S. Childhood Vaccination: Implications for Global and Domestic Public Health. Neurol Clin 2016; 34:1035-1047. [PMID: 27719987 DOI: 10.1016/j.ncl.2016.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The role of vaccination in the control and prevention of endemic and emerging diseases cannot be overemphasized. Induction of host protective immunity may be the most powerful tool and effective strategy in preventing the spread of potentially fatal disease and emerging illnesses, in particular in susceptible immunologically naive hosts. The strategy for vaccination programs is engrained in population studies recognizing benefit for the health and economic welfare of at-risk indigenous populations. Worldwide collaboration is a necessary aspect of vaccine-preventable diseases recognizing that even a small number of wild-type cases of an eradicated disease in one region presents opportunities for re-emergence of the disease in geographically remote areas.
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Affiliation(s)
- David S Younger
- Division of Neuroepidemiology, Department of Neurology, New York University School of Medicine, New York, NY, USA; College of Global Public Health, New York University, New York, NY, USA.
| | - Adam P J Younger
- Public and Nonprofit Management and Policy, The Wagner Graduate School of Public Service, New York University, New York, NY, USA
| | - Sally Guttmacher
- College of Global Public Health, New York University, New York, NY, USA
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Walker ET, Rea CM. Pediatric Care Provider Density and Personal Belief Exemptions From Vaccine Requirements in California Kindergartens. Am J Public Health 2016; 106:1336-41. [PMID: 27196654 DOI: 10.2105/ajph.2016.303177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To understand contextual associations between medical care providers-pediatricians, family medical practitioners, and alternative medicine practitioners-and personal belief exemptions (PBEs) from mandated school entry vaccinations. METHODS Data on kindergarten PBEs from the California Department of Public Health were analyzed for 2010, 2011, and 2012, with each school sorted into Primary Care Service Areas (PCSAs). Provider data from federal sources and state records of alternative medicine providers, alongside controls for school factors, were used to estimate panel models. RESULTS Each 10% increase in the relative proportion of pediatricians in a given PCSA was associated with a statistically significant 11% decrease in PBE prevalence. The same increase in the proportion of family medical practitioners was associated with a 3.5% relative increase. Access to alternative medicine practitioners was also associated with a significantly higher PBE prevalence. CONCLUSIONS Medical provider contexts are associated with PBEs, reflecting a combination of contextual effects and self-selection of families into schools and PCSAs that share their preferences. The geographic distribution of child primary care services may be a key factor in a school's health risk associated with lack of immunization or underimmunization.
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Affiliation(s)
- Edward T Walker
- All of the authors are with the Department of Sociology, University of California, Los Angeles
| | - Christopher M Rea
- All of the authors are with the Department of Sociology, University of California, Los Angeles
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Hom LA, Silber TJ, Ennis-Durstine K, Hilliard MA, Martin GR. Legal and Ethical Considerations in Allowing Parental Exemptions From Newborn Critical Congenital Heart Disease (CCHD) Screening. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:11-17. [PMID: 26734736 DOI: 10.1080/15265161.2015.1115140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Critical congenital heart disease (CCHD) screening is rapidly becoming the standard of care in the United States after being added to the Recommended Uniform Screening Panel (RUSP) in 2011. Newborn screens typically do not require affirmative parental consent. In fact, most states allow parents to exempt their baby from receiving the required screen on the basis of religious or personally held beliefs. There are many ethical considerations implicated with allowing parents to exempt their child from newborn screening for CCHD. Considerations include the treatment of religious exemptions in our current legal system, as well as medical and ethical principles in relation to the rights of infants. Although there are significant benefits to screening newborns for CCHD, when a parent refuses for religious or personal beliefs, in the case of CCHD screening, the parental decision should stand.
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Childhood vaccination requirements: Lessons from history, Mississippi, and a path forward. Vaccine 2015; 33:5884-5887. [DOI: 10.1016/j.vaccine.2015.08.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/28/2015] [Accepted: 08/28/2015] [Indexed: 11/23/2022]
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Affiliation(s)
- Douglas J. Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington; and Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Saad B. Omer
- Rollins School of Public Health, Emory University, Atlanta, Georgia
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Wang E, Clymer J, Davis-Hayes C, Buttenheim A. Nonmedical exemptions from school immunization requirements: a systematic review. Am J Public Health 2014; 104:e62-84. [PMID: 25211732 DOI: 10.2105/ajph.2014.302190] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease. We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. State laws influence exemption rates, but policy implementation, exemptors' vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.
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Affiliation(s)
- Eileen Wang
- Eileen Wang is with the Department of the History and Sociology of Science, University of Pennsylvania, Philadelphia. Jessica Clymer is with the School of Nursing, University of Pennsylvania. Cecilia Davis-Hayes is with the Columbia University College of Physicians and Surgeons, New York, NY. Alison Buttenheim is with the School of Nursing, the Leonard Davis Institute, and the Center for Public Health Initiatives, University of Pennsylvania
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Chi DL. Caregivers who refuse preventive care for their children: the relationship between immunization and topical fluoride refusal. Am J Public Health 2014; 104:1327-33. [PMID: 24832428 PMCID: PMC4056200 DOI: 10.2105/ajph.2014.301927] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The aim of this study was to examine caregivers' refusal of preventive medical and dental care for children. METHODS Prevalence rates of topical fluoride refusal based on dental records and caregiver self-reports were estimated for children treated in 3 dental clinics in Washington State. A 60-item survey was administered to 1024 caregivers to evaluate the association between immunization and topical fluoride refusal. Modified Poisson regression models were used to estimate prevalence rate ratios (PRRs). RESULTS The prevalence of topical fluoride refusal was 4.9% according to dental records and 12.7% according to caregiver self-reports. The rate of immunization refusal was 27.4%. In the regression models, immunization refusal was significantly associated with topical fluoride refusal (dental record PRR = 1.61; 95% confidence interval [CI] = 1.32, 1.96; P < .001; caregiver self-report PRR = 6.20; 95% CI = 3.21, 11.98; P < .001). Caregivers younger than 35 years were significantly more likely than older caregivers to refuse both immunizations and topical fluoride (P < .05). CONCLUSIONS Caregiver refusal of immunizations is associated with topical fluoride refusal. Future research should identify the behavioral and social factors related to caregiver refusal of preventive care with the goal of developing multidisciplinary strategies to help caregivers make optimal preventive care decisions for children.
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Affiliation(s)
- Donald L Chi
- Donald L. Chi is with the Department of Oral Health Sciences, School of Dentistry, University of Washington, Seattle
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Antommaria AHM. An ethical analysis of mandatory influenza vaccination of health care personnel: implementing fairly and balancing benefits and burdens. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2013; 13:30-37. [PMID: 23952830 DOI: 10.1080/15265161.2013.814731] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Health care institutions have paid increasing attention to preventing nosocomial transmission of influenza through vaccination of health care personnel. While multifaceted voluntary interventions have increased vaccination rates, proponents of mandatory programs contend the rates remain unacceptably low. Conventional bioethical analyses of mandatory programs are inadequate; they fail to account for the obligations of nonprofessional personnel or to justify the weights assigned to different ethical principles. Using an ethics framework for public health permits a fuller analysis. The framework's focus on fairness accentuates the potential differences between the risk of transmitting infection and employment status, and the need to equitably evaluate exemptions. The framework's emphasis on balancing benefits and burdens highlights the need to justify a specific goal and questions the need to exclude all nonmedical exemptions. While mandatory vaccination programs are justifiable, greater attention should be paid to their implementation.
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