Elsevier

Vaccine

Volume 22, Issues 23–24, 13 August 2004, Pages 3122-3126
Vaccine

Ethical principles for collective immunisation programmes

https://doi.org/10.1016/j.vaccine.2004.01.062Get rights and content

Abstract

Ethical issues arise in discussion of both the content and implementation of collective immunisation programmes. In this paper we propose and discuss seven principles that may guide reflection and debate in this controversial area. Whilst this paper is not intended to be a final and complete account of the relevant principles for collective immunisation programmes we hope that it can help stimulate more active discussion of these issues. Debate about these principles may help to make moral conflicts more explicit and open up the possibility of resolution. We argue that analysis and discussion of the ethical issues should be part of any justification of collective vaccination programmes.

Introduction

During the last 50 years, immunisation programmes have been highly successful in protecting people against infectious diseases. Despite this success, immunisation continues to raise a whole series of ethical problems that can be divided, very roughly, into two groups. The first arise due to the development, introduction, and availability of new vaccines. For example, it is not self-evident that all available and affordable vaccines should be incorporated into national or international vaccination programmes. What principles should be applied in deciding what counts as an adequate programme? Where choices have to be made about priorities in this area, how should they be made? The importance of protection against bioterrorism only reinforces the urgency of questions like these. The second set of issues are concerned with the implementation of vaccination programmes: the means that are used to aim at high vaccination rates, and the information and communication processes. Is compulsory immunisation acceptable? Which standards of information disclosure should be adopted?

One way to advance ethical discussion of these issues is to see whether we can agree a set of suitable guiding principles to be used to formulate coherent and ethically justified collective vaccination programmes. Recently, bioethicists have discussed different ethical perspectives and moral considerations that should be central in public health ethics [1], [2], [3]. If such considerations are applied to vaccination programmes, the resulting norms could play a similar role to that of Wilson and Jungner’s well-known principles for screening programmes [4]. In this paper we articulate such principles for collective vaccination. These principles are a reformulation of earlier versions that have been discussed and debated with experts in the fields of public health and ethics, notably at the Health Council of The Netherlands [5], [6]; during a special workshop at the 6th Conference of the International Association of Bioethics (Brasilia 2002); and at meetings with Dutch paediatricians working in community health care.

Section snippets

Assumptions and focus

Some remarks concerning our focus and our basic assumptions should be made before presenting and explaining the principles for vaccination.

We focus in this paper on those collective vaccination programmes which aim to improve public health and which are normally organised, sponsored and carried out by government or government-linked organisations. Our first substantive assumption is that governments have an obligation to protect the public’s health and welfare [2]. Vaccination is an important

The seven principles for collective vaccination programmes

  • 1.

    Collective vaccination programmes should target serious diseases that are a public health problem.

  • 2.

    Each vaccine, and the programme, as a whole must be effective and safe.

  • 3.

    The burdens and inconveniences for participants should be as small as possible.

  • 4.

    The programme’s burden/benefits ratio should be favourable in comparison with alternative vaccination schemes or preventative options.

  • 5.

    Collective vaccination programmes should involve a just distribution of benefits and burdens.

  • 6.

    Participation should,

Local and global applications

One last general point remains to be made. It is certain that there will be significant differences between local and global perspectives upon the application and interpretation of these principles. Diseases that are a serious public health problem in one country might be less urgent in another or when considered from a global perspective. For example, varicella (chicken pox) is a common disease in developed countries but it is not clear that a mass vaccination campaign for this disease is

Conclusion

Governments have a strong responsibility to promote and protect public health. Collective vaccination programmes are an essential element in that task. However, it is important to recognise that decisions made by governments and health authorities with reference to such programmes have important ethical dimensions. This is true in relation to making decisions about introducing new vaccines (or about re-introducing old vaccines, such as, smallpox) and in relation to the implementation of

Acknowledgements

Marcel Verweij’s research has been sponsored by The Netherlands Organization of Health Research and Development. We thank Dan Wikler, Margaret Battin, and Julian Savulescu, as well as members of two committees of the Dutch Health Council for their helpful comments on previous versions of our paper.

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