Tom & Katrien

In 1798 the British physician, Edward Jenner, described how he had used infective material from the pustules of patients suffering from cowpox to inoculate healthy children in order to immunise them against the much deadlier smallpox virus. Within a decade, vaccination against smallpox was an increasingly common phenomenon across Europe and America. But not everyone was convinced about the efficacy or safety of the vaccine and substantial numbers of people refused to be vaccinated.

The legal response to this recalcitrance was predictable. It began in 1806 when the Napolenonic administration mandated smallpox vaccination in two Italian provinces. This was rapidly followed by a law mandating that all university students in mainland France had to be vaccinated too. Across the Atlantic the Americans adopted similar legal policies. In the vanguard was the state of Massachusetts, whose government passed a law in 1809 requiring the whole population to be vaccinated. In this respect, Jenner’s homeland was a little slow off the mark. Eventually, however, the Vaccination Act of 1853 came in to force and required all newborns to be vaccinated against smallpox before they reached the age of 3 months.

Different countries adopted diverse policies in relation to “conscientious objections”. Sweden, for example, allowed these but Germany did not. Different countries also varied in terms of punishment for non-compliance. Interestingly, the UK took a relatively hard line in relation to punitive action. British parents who refused to vaccinate their children were made to pay a fine and some were even imprisoned for their disobedience.

The public response to mandatory legislation was, at times, quite fierce. In the UK a number of anti-vaccine riots took place and after a particularly huge protest in Leicester in 1885 the government responded by ordering a Royal Commission. The end result of all the controversy was the Vaccination Act of 1898 which enabled parents to conscientiously object to vaccines and also dropped cumulative penalties against parents unwilling to vaccinate their children.

This is all ancient history now. Smallpox was eradicated in the 1970s and few remember the anti-vaccine rebellions of the 19th century. However, the debate about vaccines and mandatory vaccine legislation never entirely disappeared. Instead it changed focus and centred on vaccines against diseases such as measles, mumps, rubella, human papillomavirus, influenza and hepatitis B.

In many countries mandatory vaccines against these kinds of diseases is routine. In Poland and Belgium some vaccines are “directly” compulsory while in most states in America and Australia the vaccines tend to be “indirectly” compulsory. In most parts of America the compulsion is indirect in the sense that children – with some exceptions – will not be enrolled in school unless they are vaccinated. In Australia the compulsion is indirect in the sense that state benefits, like means-tested maternity allowance, can be withheld if children are not vaccinated.

In the UK the debate about mandatory vaccines has recently been reignited following an outbreak of measles in Swansea. A Yougov poll carried out in the wake of the outbreak suggests that a majority support legislation that would require parents to vaccinate their children against MMR. On the other hand, a significant minority of citizens continue to resist this idea and the British Medical Association seems not to have changed its stance since it published a document in 2003 stating that vaccines should not be compulsory in the UK.

The efficacy and safety of vaccines varies. However, there is wide consensus within the medical and scientific profession that the vaccines which are compulsory in some countries are efficacious and safe. There is also evidence that mandatory vaccinations laws increases the number of people who receive vaccines and decreases the incidence of vaccine-preventable infections. As such, the basic ethical arguments in favour of mandatory childhood vaccines are strong: such policies prevent vaccinated children from developing deadly diseases and they rarely cause harm.

Thanks to the concept of herd immunity, vaccines also protect those who cannot be vaccinated - such as the very young or the very ill. So mandating vaccines protects the most vulnerable members of society too.

Arguably, mandating vaccines can also be justified on the basis of considerations of justice. This is partly because mandating vaccines ensures that the burdens and benefits of vaccination policies are shared by all. But it is also because mandatory vaccine policies help to ensure that more disadvantaged children – who are normally less likely to be vaccinated – receive the vaccines that they really need.

But mandating childhood vaccines is not ethically uncontroversial. For starters, such draconian policies trammel on the moral rights of parents to make decisions about their own children’s health. There are times when parental autonomy needs to be constrained, but it is not clear that the best interests of children are always served by denying parents the right to opt out of vaccine schedules. This is because any policy that alienates parents from health care professionals damages the trust that underpins the doctor-patient-parent relationship.

History warns us that forcing people to vaccinate children can provoke a backlash from a substantial minority of the population. This backlash will be driven not only by those who do not want their children to be vaccinated but also by libertarians who oppose governmental interference in family life. It is also worth noting that financial penalties will be regressive – affecting poorer families most – and that preventing children from enrolling at school unless they are vaccinated may violate children’s right to education and increase inequalities in child health.

This leaves us with a difficult quandary. Childhood vaccines are safe and effective and they protect the children who receive them as well as vulnerable groups who rely on herd immunity. On the other hand, parents, quite rightly, have wide discretion to determine what is in the best interests of their children and forcing unwilling parents to vaccinate their children could prove to be very divisive.

There are situations when mandatory vaccination policies are ethically permissible. For example, if smallpox was to rear its ugly head once more such an approach might be necessary. However, it is not clear that the likes of measles, mumps, and rubella pose a sufficient threat to warrant mandatory vaccination legislation.

Where and how we draw the line is a difficult matter. Some infectious diseases are so deadly that mandatory vaccination policies seem like reasonable invasions of parental autonomy. Other infectious diseases, however, do not make the grade. There is, inevitably, some arbitrianess about this. But before wielding the punitive power of the state it would seem wiser, especially in a country like the UK where vaccination rates are relatively high, to educate and gently persuade rather than cajole and force parents to vaccinate their children. Either way, the reaction should not be reflexive; such a harsh policy requires careful analysis and should not be imposed as a knee-jerk reaction in the immediate aftermath of an outbreak such as the recent one in Wales.