An ethics of HPV vaccination: beyond principlism

Healy et al. rightly raise the question of the role of medical ethics in the face of an absence of vaccination or insufficient vaccination coverage against human papillomavirus (HPV), as such vaccination can prevent almost 90% of infection-related cancers.¹ Given this high percentage, and its significance in terms of public health, an ethical responsibility could be evoked in terms of lost time, but also in terms of the resulting human and economic costs of this disease and its treatment.² According to the authors, the recommendations in force may bear the major responsibility for this failure, as they have resulted in parents being insufficiently well informed of the need to get their children vaccinated against this virus. Our analysis of the problem converges with that of the authors on this point, but diverges clearly on the subject of satisfaction, based on the four principles of autonomy, beneficence, non-malevolence and justice, better known as “principlism” in bioethics,³ at least outside of the English-speaking world.

Let us first clarify several empiric elements. In the United States, the most recent epidemiological data indicate that vaccination can decrease the incidence of cervical cancer by 9% in women aged 20 to 24 years, whereas screening alone yielded a decrease of only 2.29%.⁴ However, this decrease in incidence is limited to cervical cancer. An increase in oropharyngeal cancers and cancers of the anal canal has been observed in both sexes, but with a difference between the sexes, the incidence of oropharyngeal cancers being five times higher in men than in women. The follow-up period is currently too short to draw any firm conclusions, given that the median age at onset of other tumors linked to HPV is beyond 60 years. This information is little publicized, if at all, revealing the major effect of certain taboos linked to sexuality, probably with multifactorial causes. However, the fact remains that vaccination has led to a decrease in the number of cervical cancers diagnosed in American women, following a non-sexual early vaccination strategy against HPV. Similar results have been obtained in Europe,⁵ notably in Sweden,⁶ and the United Kingdom.⁷

Conversely, in Japan, the risk of cervical cancer is predicted to increase in the next few years. This is an interesting story, echoing perfectly the elements discussed above. In 2010, Japan issued a recommendation that all girls aged 13 to 16 years should be vaccinated against HPV. As a result, by 2013, the rate of vaccination was close to 70%. However, following scare stories in the press, the Japanese authorities decided to suspend this recommendation, leading to a decrease in vaccination rates to less than 1%. Almost none of the girls and young women born after 2000 have, thus, been vaccinated. As a result, the reported rates of cytological abnormalities in this generation is proving significantly higher than that in the previous generation, which was largely vaccinated. Other countries around the world are also concerned by this phenomenon, which, at the end of the day, constitutes a real, relatively complex global health problem.^8–10 In our view, it is because of this that principlism is intrinsically inappropriate for dealing with ethical issues at the global scale.

Principlism is an ethical theory mostly developed by the American philosophers and bioethicists Tom Beauchamp and James Childress. It is based on moral duties associated with modern western semantics and focusing on “freedom of conscience” or “universalism”, and a contemporary conceptualization originating from the English-speaking world guided by the “right to life” or “particularism”, revealing attempts to resolve problems exclusively at individual level.¹¹ Here lies one of the causes of the inadequacy of principlism: an “ethnocentricity” applicable to only a few countries. Another ethical theory may, therefore, be more pertinent: the “global bioethics” of the American biochemist and bioethicist Van Rensselaer Potter.¹² In this theory, moral duties, which are ethnocentric and abstract, are replaced by non-ethnocentric concrete ethical goals: improvements in the quality of life and survival of individuals and of society, through major public health programs taking environmental impacts and cultural differences into account.¹³

It may, nevertheless, be necessary to rework this theory, to distinguish between the collective and individual levels, and to construct sets of criteria no longer restricted to the medical or biological domain. Indeed, in the case of HPV, given the available scientific results, the need for a collective obligation for vaccination appears evident, for both girls and boys, associated with early detection no longer limited to the cervix, but also including the otorhinolaryngological, urological and proctological spheres, in relation to real, existing sexual practices. Such an obligation would not, of course, prevent individual refusals, and it is here that healthcare professionals and education could have a crucial role to play.¹⁴ However, the sorts of educational programs concerning sexuality and the disease that could be envisaged in modern secular societies would not be possible in traditional and religious societies or communities. Heterogeneous and variable criteria must, therefore, be developed, going beyond the utopic universalism of some, whilst refusing the lethal “contextualism” of others.¹⁵

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