Vaccinations—Between free will and coercion

ABSTRACT

Dynamically changing social situation associated with migrations, increasing freedom rights, popularity of anti-vaccine movements and the resulting from that decrease in herd immunity, forces the medical society and the governments of various countries to reflect on the attitude toward vaccinations. Issues of freedoms and self-determination frequently do not accept any medical coercion in case of prophylactic vaccinations, however, recent waves of epidemics revealed that there is a necessity for undertaking strict legal actions to encourage vaccinations. After analyzing various legal approaches toward vaccinations we believe that personal coercion in case of vaccination refusal has too far reaching sanctions and propose the possibility of balancing the right to autonomy and the medical coercion. We postulate that vaccination refusal should be equivalent with covering frequently high medical costs in case of infection, The threat of financing medical treatment should influence the decision making process of those opposing vaccinations simultaneously respecting their rights not too get vaccinated.

KEYWORDS:

• anti-vaccine movements
• coercion
• epidemic
• freedom
• law
• penalties
• vaccinations

Mass vaccinations and their avoidance is becoming a pivotal issue for the healthcare system. Outbursts of epidemics and the popularity of anti-vaccine movements forces us to reflect on the limits of medical interventions in the human body and the limits of freedoms granted to individuals in situation of population health risks. Paradoxically, the growing importance of individual's rights is in opposition to the possible risks caused by their irrational implementation and execution.

Laws of particular countries, depending on their historically developed concepts of individual's autonomy and granted freedoms, either do not refer directly to the vaccination requirement (Western Europe), associate being vaccinated with educational possibilities (USA since June 2015), public health (Australia since 2016), try to persuade their citizens by applying financial penalties (Poland) or even restricting their freedom (Pakistan).¹

From the legal perspective, as it constitutes the central axis of the expressed opinion, compulsory vaccinations as an invasive procedure may be identified as a forced medical intervention in case of refusal. However, together with the development of our civilization, they became a method of protecting the individual and the society against disease spread.²

In opposition to this prevention emerged anti-vaccination movements (first in the late Nineteenth Century), which for various medical, religious and philosophical reasons questioned the legitimacy and purpose of mass vaccination.³ The wave of criticism and emerging anti-vaccine movements were among others an outcome of Wakefield's publication that tied vaccinations with increased incidence of autism and enteritis, and I. Sinclair's publication on the hidden facts of vaccinations.⁴

Analyzing recent years in vaccinations, it must be underlined that legislatures of various counties are gradually trying to enforce vaccinations, which in turn causes a conflict between using specific forms of coercion and individual's rights to refuse any medical intervention. Any form of coercion in this context can be interpreted as a restriction of freedom, autonomy and the granted rights. Thus, this area is defined on one side by individual's autonomous decision and on the other by the possible serious risks to the healthy individuals and the society (increasing number of those unvaccinated decreases herd immunity).

In 2015, California introduced a duty (not coercion) into legislature enforcing obligatory vaccinations by not accepting children who do not have current vaccinations to public schools or theme parks. Furthermore, it has also limited the possibilities of evading vaccination by removing personal beliefs (religious or philosophical) as reasons for vaccination refusal (Bill SB 277). California became the third state after West Virginia and Mississippi, which refuses exemptions from immunization based on religious or philosophical beliefs.⁵ In Europe the situation concerning vaccinations depends on the legislature of individual countries. In Germany (former German Democratic Republic) until 1989, there was vaccination coercion, which was frowned upon as a characteristic of a totalitarian regime. However, the wave of measles incidence in Germany and a child's death caused a discussion on the possibility of introducing vaccination coercion.⁶ Once again, in 2013, health authorities in a Berlin district Tempelhof-Schoeneberg decided that in order to be accepted to school it is necessary to have a filled out vaccination card or a doctor's note ascertaining that the child already had measles.⁶ The Croatian Constitutional Tribunal upheld the obligation to vaccinate children, recognizing that child's rights to health is more important than the parent's right to decide. Since mid-2014, all children will obligatorily be vaccinated against diphtheria, pertussis, tetanus, polio, measles, mumps, rubella and tuberculosis.⁷ In Italy, where vaccination against measles is not mandatory, but only recommended, there was a significant increase in measles incidence in 2011 compared to 2010. In Poland failing to get vaccinated is an offense that may result in a fine. In most European countries vaccinations are recommended as mandatory, but individual states generally recommend, not force, the more that their absence may be in some way sanctioning.

So far, existing solutions for vaccination coercion include: administrative requirements, fines and solutions that condition social existence (education, social assistance, freedom restriction). It should be firmly stated that none of these solutions seem to find a rational solution between keeping individual's freedoms and population health safety.

The presented solution subtly balances individual's autonomy and a form of coercion by equating the decision of abandoning vaccinations with the obligation to bear treatment costs in case of infection. Analyzing legal experience, failing to fulfill certain obligations resulting in a monetary fine seems to prove effective and preventive. Therefore, it is worth to consider the possibility of introducing financial responsibility for refusing vaccinations, which is to be twofold. First, it should concern parents/guardians who refuse to vaccinate their children, in which case they should cover treatment costs if infection occurs and second should consider adults who also refuse vaccination and analogously will be required to pay for hospitalization and subsequent therapy. This financial penalty would be enforced, in both cases, only upon infection, about which the person refusing vaccinations would be informed prior to making this choice and would have to sign proper, legally binding documents. The threat of covering treatment costs in case of refusal to vaccinate and subsequent infection of a child or oneself will definitely appeal to the imagination of those who are reluctant to get vaccinated and at the same time will not interfere with their rights or freedoms. The maxim that you finance the treatment of a disease for the occurrence of which you are responsible would be something to consider during the decision making process.

What we propose seems to a great extend balance out health security and individual's autonomy. Penalizing the individual only upon infection would cause less controversies and be more effective than the currently existing legal solutions, which are directed at enforcing the obligation of vaccinations rather than sanction negative outcomes.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.