Ethically, the use of vaccination gives rise to a number of issues. For individuals, there is the question, which few find taxing, as to whether they should accept, for themselves or their children, the very small risk of vaccination as a prophylaxis against future illness. Given the issues around population immunity, it also raises questions about whether we are all under some ethical obligation to be vaccinated – private decisions can have public consequences. And lastly there is the more political question as to whether there is a role for the state in mandating or even compelling vaccination.
Although vaccines are regulated and tested thoroughly, as with all health interventions, they may still carry small risks for an individual. A person’s decision to vaccinate either themselves or their child requires balancing these risks against the benefits accrued through vaccination. As the risks are relatively small, vaccination can benefit large numbers of people in return for a small degree of risk to individuals.
In contrast, individual choices not to vaccinate can expose others to risk. If sufficient numbers refuse immunisation and population immunity collapses, epidemics can sweep through the community. Not all people at risk have made the decision not to vaccinate, for example neonates, people for whom vaccination is contraindicated, and those whose immune systems are compromised.
There are several issues that may lead people to question the advantages of being vaccinated. At an individual level, it can be difficult to weigh up the respective costs and benefits of vaccination. Public perceptions regarding the prevalence and severity of a disease can also influence the decision making of individuals. In this respect, vaccination programmes have become the victims of their own success. As the mortality and morbidity associated with their target diseases have become so unusual as to fall out of popular memory, so public perception has begun to focus on potential threats from vaccines, which are comparatively minor.
Reflecting the high value placed on autonomy and individual liberty, routine vaccination is voluntary in the UK. Individuals can choose whether to vaccinate themselves and parents are viewed as the best people to make health decisions for their children. It is important that these decisions are informed. Public health campaigns are therefore used to encourage take-up of vaccination programmes and provide parents and individuals with reliable and consistent information about their safety and importance.
Outbreaks of communicable disease either in the UK or Europe can lead some to question whether there is a need for a different approach.
There are jurisdictions that mandate vaccination for some diseases (e.g. France, Italy, Czech Republic). Other countries while not mandating childhood vaccination, go beyond a purely voluntary system. These approaches use financial or other benefits as incentives, apply penalties, or prevent school enrolment for non-vaccinated children (e.g. Australia, USA). Exceptions exist for people with a genuine reason for not being vaccinated. Although there is evidence to suggest that these schemes may increase uptake, there are also drawbacks: punitive systems can lead to a lower uptake in voluntary vaccinations and the cost effectiveness of incentive-based programmes can vary.
Switching to a mandatory or quasi-mandatory scheme may also have unintended consequences. The consensual approach in the UK has helped to ensure public approval and a high take-up of programmes. A move away from this may be seen by the public as confrontational and could lead to public mistrust of government public health interventions and messages more generally.