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Prioritizing Parental Liberty in Non-medical Vaccine Exemption Policies: A Response to Giubilini, Douglas and Savulescu

Prioritizing Parental Liberty in Non-medical Vaccine Exemption Policies: A Response to Giubilini,... Abstract In a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions (NMEs) to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and Savulescu give insufficient weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally. Introduction We place primary importance on liberty in health care decision-making (Largent, 2011), including the liberty of parents to make decisions for their children (Largent, 2012; Navin, 2015; Navin and Wasserman, forthcoming). We agree with the American Academy of Pediatrics (AAP) that parents should be free to refuse medical interventions (including vaccines) for their children when doing so does not place children at ‘significant risk of serious harm’ (AAP Committee on Bioethics, 2016), something that vaccine refusal does not cause under normal conditions (AAP Committee on Bioethics, 2013). In the USA, childhood immunization requirements usually apply to almost all forms of childcare and schooling, including state-recognized day-care centers and all schools (public, private, charter or online). Many parents rely on day care, and few parents are able to homeschool their children. In this context, parents who do not have access to non-medical exemptions (NMEs) to immunization requirements do not have a meaningful liberty to make decisions about their children’s vaccination status. We have argued for a type of reform to NME policies that takes parental liberty for granted and imposes burdens on parents who wish to access social goods, in this case state-regulated schools and day cares (Navin and Largent, 2017). In what we call an Inconvenience model for NME policies, parents who are not strongly committed to refuse vaccines will choose to vaccinate rather than bear a burden of some sort. Giubilini, Douglas and Savulescu (2017) claim we have given short shrift to the value of fairness. They argue for a type of NME policy they call Contribution, according to which parents must purchase their liberty to refuse vaccines by contributing to valuable public health goods. Inconvenience vs. Eliminationism California has recently abolished NMEs (this is an instance of what we call Eliminationism), and the American Medical Association (AMA) urges all the US states to do likewise (AMA, 2015). In our article, we argued that Inconvenience is ethically preferable to Eliminationism because it preserves parental liberty and substantially decreases exemption rates. Giubilini, Douglas and Savulescu respond that it is ‘at least doubtful that Inconvenience is ethically preferable to Eliminationism’ because both involve a trade-off of important values: Eliminationism achieves greater fairness at a cost to liberty; Inconvenience protects greater liberty at a cost to fairness (2017: 3). Giubilini, Douglas and Savulescu believe Eliminationism achieves greater fairness than Inconvenience because they think more people will vaccinate their children—and, therefore ‘contribute’ to herd immunity—under Eliminationism than under Inconvenience. However, Inconvenience substantially decreases waiver rates and increases immunization rates. Accordingly, Inconvenience may promote fairness more than Giubilini, Douglas and Savulescu suppose. More importantly, Giubilini, Douglas and Savulescu seem to equate the moral value of a marginal change in fairness (i.e. whether a few percent more children contribute to herd immunity) with the moral value of an absolute change in liberty (i.e. whether all parents have a meaningful right to refuse childhood vaccines). Only someone who places a very low relative moral weight on parental liberty would think it ‘doubtful’ whether Inconvenience was ethically preferable to Eliminationism. Purchasing Liberty? Giubilini, Douglas and Savulescu argue that Contribution is ‘a variant, or a refinement’ of Inconvenience, the type of policy we advocate, because both kinds of policies impose burdens on parents (2017: 3). For example, Giubilini, Douglas and Savulescu suggest parents who receive NMEs could be required to ‘prepar[e] healthy school meals’ in lieu of vaccinating their children (2017: 4). But, Contribution is not a type of Inconvenience. Inconvenience takes for granted that parents have the right to receive NMEs. The purpose of the burdens in Inconvenience-type NME policies is pragmatic, not moral. The burdens should be only as onerous as is necessary to decrease the waiver rate to the level required to maintain sufficiently high vaccination rates. In contrast, Contribution implies that parents must purchase their right to refuse vaccines by making an ‘alternative contribution that in some roughly comparable way and to some roughly comparable degree benefits society’ as does childhood vaccination (Giubilini, Douglas, and Savulescu, 2017: 5). According to this view, the purpose of the burdens in NME policies is moral: they ensure that parents pay the appropriate price for their rights. We reject this transactional account of parental rights to NMEs. Parents do not need to earn their right to make medical decisions for their children through acts of good citizenship. Education and Parental Autonomy In our article, we highlighted a kind of Inconvenience NME policy recently implemented in Michigan, where parents must now attend an education session at a local health department before they can exercise their right to a NME. The immunization waiver educator is required to present parents with information about ‘the risks of not receiving the vaccines being waived and the benefits of vaccination to the individual and the community’ (Michigan Administrative Code, 2014). Like all instances of Inconvenience, Michigan’s model (which we call Education) takes parental rights for granted, and it decreases waiver rates by making it more difficult to access otherwise available goods (in this case, state-recognized day-care centers and any organized public, private, charter or online school). This is what distinguishes Inconvenience from Contribution, which requires parents to purchase their right to refuse vaccines through acts of public service that are comparable in moral importance to childhood vaccination. So, Education is preferable to Contribution for the same reason that all instances of Inconvenience are preferable to Contribution. There is another reason to prefer Education to Contribution: the burdens Education imposes on parents can help them better exercise the very liberty that this kind of NME policy protects. This is not because parents will change their minds when they receive information about the risks of vaccine-preventable diseases and the benefits of vaccination, though they sometimes do. Rather, it is because providing parents with this information promotes their informed consent to vaccine refusal. Just as the informed consent process in medical contexts promotes patient autonomy, so too do the burdens of Education-type NME policies promote the autonomy of parents. We support the Education model because NME policies should not only protect parental freedom, but they should also promote it. The Contribution model fails on both of these counts. Conclusion We have defended the moral primacy of parental liberty in NME policies. Of course, this liberty is not unlimited. In cases of ongoing outbreaks—when refusal would cause ‘serious risk of serious harm’—it may be reasonable to suspend parental liberty to refuse vaccines. Under normal circumstances, however, an appropriate respect for parental liberty (and children’s right to bodily integrity) requires that NME policies prioritize civil liberties, even at some cost to other values, including fairness. Too often, public health efforts have failed to adequately protect civil liberties and have historically caused both moral harms and diminished public trust in public health. An Inconvenience model for NME policies—and especially its Education variant—aims to promote public health while also protecting civil liberties and public trust, something that neither Eliminationism nor Contribution can do. Conflict of Interest None declared. References AAP Committee on Bioethics . ( 2013 ). Reaffirmation: Responding to Parents Who Refuse Immunization for Their Children . Pediatrics , 131 , e1696 . Crossref Search ADS WorldCat AAP Committee on Bioethics . ( 2016 ). Informed Consent in Decision-Making in Pediatric Practice . Pediatrics , 138 , e20161484 . Crossref Search ADS PubMed WorldCat AMA . ( 2015 ). AMA Supports Tighter Limitations on Immunization Opt Outs. Available from http://www.ama-assn.org/ama/pub/news/news/2015/2015-06-08-tighter-limitations-immunization-opt-outs.page [accessed 9 September 2017]. Giubilini A. , Douglas T., Savulescu J. ( 2017 ). Liberty, Fairness and the "Contribution Model" for Non-Medical Vaccine Exemption Policies: A Reply to Navin and Largent. Public Health Ethics, 10 , 235 – 240 . Largent M. A. ( 2011 ). Breeding Contempt: The History of Coerced Sterilization in the United States , Reprint edition. New Brunswick, NJ : Rutgers University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Largent M. A. ( 2012 ). Vaccine: The Debate in Modern America . Baltimore, MD: Johns Hopkins University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Michigan Administrative Code . (2014). Available from http://w3.lara.state.mi.us/orr/Files/AdminCode/1472_2014-073CH_AdminCode.pdf [accessed 9 September 2017]. Navin M. C. ( 2015 ). Values and Vaccine Refusal: Hard Questions in Ethics, Epistemology and Health Care . New York, NY : Routledge . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Navin M. C. , Largent M. A. ( 2017 ). Improving Nonmedical Vaccine Exemption Policies: Three Case Studies. Public Health Ethics, 10 , 225 – 234 . Navin M. C. , Wasserman J. A. (forthcoming). Reasons to Amplify the Role of Parental Permission in Pediatric Treatment. American Journal of Bioethics. © The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Prioritizing Parental Liberty in Non-medical Vaccine Exemption Policies: A Response to Giubilini, Douglas and Savulescu

Navin, Mark, C; Largent, Mark, A
Public Health Ethics , Volume 10 (3) – Nov 1, 2017
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Oxford University Press
Copyright
© The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
ISSN
1754-9973
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1754-9981
DOI
10.1093/phe/phx015
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Abstract

Abstract In a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions (NMEs) to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and Savulescu give insufficient weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally. Introduction We place primary importance on liberty in health care decision-making (Largent, 2011), including the liberty of parents to make decisions for their children (Largent, 2012; Navin, 2015; Navin and Wasserman, forthcoming). We agree with the American Academy of Pediatrics (AAP) that parents should be free to refuse medical interventions (including vaccines) for their children when doing so does not place children at ‘significant risk of serious harm’ (AAP Committee on Bioethics, 2016), something that vaccine refusal does not cause under normal conditions (AAP Committee on Bioethics, 2013). In the USA, childhood immunization requirements usually apply to almost all forms of childcare and schooling, including state-recognized day-care centers and all schools (public, private, charter or online). Many parents rely on day care, and few parents are able to homeschool their children. In this context, parents who do not have access to non-medical exemptions (NMEs) to immunization requirements do not have a meaningful liberty to make decisions about their children’s vaccination status. We have argued for a type of reform to NME policies that takes parental liberty for granted and imposes burdens on parents who wish to access social goods, in this case state-regulated schools and day cares (Navin and Largent, 2017). In what we call an Inconvenience model for NME policies, parents who are not strongly committed to refuse vaccines will choose to vaccinate rather than bear a burden of some sort. Giubilini, Douglas and Savulescu (2017) claim we have given short shrift to the value of fairness. They argue for a type of NME policy they call Contribution, according to which parents must purchase their liberty to refuse vaccines by contributing to valuable public health goods. Inconvenience vs. Eliminationism California has recently abolished NMEs (this is an instance of what we call Eliminationism), and the American Medical Association (AMA) urges all the US states to do likewise (AMA, 2015). In our article, we argued that Inconvenience is ethically preferable to Eliminationism because it preserves parental liberty and substantially decreases exemption rates. Giubilini, Douglas and Savulescu respond that it is ‘at least doubtful that Inconvenience is ethically preferable to Eliminationism’ because both involve a trade-off of important values: Eliminationism achieves greater fairness at a cost to liberty; Inconvenience protects greater liberty at a cost to fairness (2017: 3). Giubilini, Douglas and Savulescu believe Eliminationism achieves greater fairness than Inconvenience because they think more people will vaccinate their children—and, therefore ‘contribute’ to herd immunity—under Eliminationism than under Inconvenience. However, Inconvenience substantially decreases waiver rates and increases immunization rates. Accordingly, Inconvenience may promote fairness more than Giubilini, Douglas and Savulescu suppose. More importantly, Giubilini, Douglas and Savulescu seem to equate the moral value of a marginal change in fairness (i.e. whether a few percent more children contribute to herd immunity) with the moral value of an absolute change in liberty (i.e. whether all parents have a meaningful right to refuse childhood vaccines). Only someone who places a very low relative moral weight on parental liberty would think it ‘doubtful’ whether Inconvenience was ethically preferable to Eliminationism. Purchasing Liberty? Giubilini, Douglas and Savulescu argue that Contribution is ‘a variant, or a refinement’ of Inconvenience, the type of policy we advocate, because both kinds of policies impose burdens on parents (2017: 3). For example, Giubilini, Douglas and Savulescu suggest parents who receive NMEs could be required to ‘prepar[e] healthy school meals’ in lieu of vaccinating their children (2017: 4). But, Contribution is not a type of Inconvenience. Inconvenience takes for granted that parents have the right to receive NMEs. The purpose of the burdens in Inconvenience-type NME policies is pragmatic, not moral. The burdens should be only as onerous as is necessary to decrease the waiver rate to the level required to maintain sufficiently high vaccination rates. In contrast, Contribution implies that parents must purchase their right to refuse vaccines by making an ‘alternative contribution that in some roughly comparable way and to some roughly comparable degree benefits society’ as does childhood vaccination (Giubilini, Douglas, and Savulescu, 2017: 5). According to this view, the purpose of the burdens in NME policies is moral: they ensure that parents pay the appropriate price for their rights. We reject this transactional account of parental rights to NMEs. Parents do not need to earn their right to make medical decisions for their children through acts of good citizenship. Education and Parental Autonomy In our article, we highlighted a kind of Inconvenience NME policy recently implemented in Michigan, where parents must now attend an education session at a local health department before they can exercise their right to a NME. The immunization waiver educator is required to present parents with information about ‘the risks of not receiving the vaccines being waived and the benefits of vaccination to the individual and the community’ (Michigan Administrative Code, 2014). Like all instances of Inconvenience, Michigan’s model (which we call Education) takes parental rights for granted, and it decreases waiver rates by making it more difficult to access otherwise available goods (in this case, state-recognized day-care centers and any organized public, private, charter or online school). This is what distinguishes Inconvenience from Contribution, which requires parents to purchase their right to refuse vaccines through acts of public service that are comparable in moral importance to childhood vaccination. So, Education is preferable to Contribution for the same reason that all instances of Inconvenience are preferable to Contribution. There is another reason to prefer Education to Contribution: the burdens Education imposes on parents can help them better exercise the very liberty that this kind of NME policy protects. This is not because parents will change their minds when they receive information about the risks of vaccine-preventable diseases and the benefits of vaccination, though they sometimes do. Rather, it is because providing parents with this information promotes their informed consent to vaccine refusal. Just as the informed consent process in medical contexts promotes patient autonomy, so too do the burdens of Education-type NME policies promote the autonomy of parents. We support the Education model because NME policies should not only protect parental freedom, but they should also promote it. The Contribution model fails on both of these counts. Conclusion We have defended the moral primacy of parental liberty in NME policies. Of course, this liberty is not unlimited. In cases of ongoing outbreaks—when refusal would cause ‘serious risk of serious harm’—it may be reasonable to suspend parental liberty to refuse vaccines. Under normal circumstances, however, an appropriate respect for parental liberty (and children’s right to bodily integrity) requires that NME policies prioritize civil liberties, even at some cost to other values, including fairness. Too often, public health efforts have failed to adequately protect civil liberties and have historically caused both moral harms and diminished public trust in public health. An Inconvenience model for NME policies—and especially its Education variant—aims to promote public health while also protecting civil liberties and public trust, something that neither Eliminationism nor Contribution can do. Conflict of Interest None declared. References AAP Committee on Bioethics . ( 2013 ). Reaffirmation: Responding to Parents Who Refuse Immunization for Their Children . Pediatrics , 131 , e1696 . Crossref Search ADS WorldCat AAP Committee on Bioethics . ( 2016 ). Informed Consent in Decision-Making in Pediatric Practice . Pediatrics , 138 , e20161484 . Crossref Search ADS PubMed WorldCat AMA . ( 2015 ). AMA Supports Tighter Limitations on Immunization Opt Outs. Available from http://www.ama-assn.org/ama/pub/news/news/2015/2015-06-08-tighter-limitations-immunization-opt-outs.page [accessed 9 September 2017]. Giubilini A. , Douglas T., Savulescu J. ( 2017 ). Liberty, Fairness and the "Contribution Model" for Non-Medical Vaccine Exemption Policies: A Reply to Navin and Largent. Public Health Ethics, 10 , 235 – 240 . Largent M. A. ( 2011 ). Breeding Contempt: The History of Coerced Sterilization in the United States , Reprint edition. New Brunswick, NJ : Rutgers University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Largent M. A. ( 2012 ). Vaccine: The Debate in Modern America . Baltimore, MD: Johns Hopkins University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Michigan Administrative Code . (2014). Available from http://w3.lara.state.mi.us/orr/Files/AdminCode/1472_2014-073CH_AdminCode.pdf [accessed 9 September 2017]. Navin M. C. ( 2015 ). Values and Vaccine Refusal: Hard Questions in Ethics, Epistemology and Health Care . New York, NY : Routledge . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Navin M. C. , Largent M. A. ( 2017 ). Improving Nonmedical Vaccine Exemption Policies: Three Case Studies. Public Health Ethics, 10 , 225 – 234 . Navin M. C. , Wasserman J. A. (forthcoming). Reasons to Amplify the Role of Parental Permission in Pediatric Treatment. American Journal of Bioethics. © The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org

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Public Health Ethics – Oxford University Press

Published: Nov 1, 2017

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