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Conscientious Objection to Vaccination

Conscientious Objection to Vaccination bs_bs_banner Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12326 Volume 31 Number 3 2017 pp 155–161 STEVE CLARKE, ALBERTO GIUBILINI AND MARY JEAN WALKER Keywords conscientious objection, ABSTRACT vaccination, Vaccine refusal occurs for a variety of reasons. In this article we examine herd immunity, vaccine refusals that are made on conscientious grounds; that is, for reli- public health gious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases (either for themselves or for their children); sec- ond, if so, to what constraints or requirements should conscientious objection (CO) to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. We argue that conscientious objectors to vaccination should make an appropriate con- tribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease(s), its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribu- tion required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly con- tagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. vaccinate out of a selfish desire to free-ride on the INTRODUCTION herd immunity achieved by the vaccinations of others (Navin 2013b; May 2005). Still others refuse to People refuse vaccines for themselves or for their take vaccines or to vaccinate their dependants on con- dependants for a variety of reasons. These include the scientious grounds. Our focus in this paper is on vac- beliefs that vaccines cause health problems, that they cine refusal on conscientious grounds. Conscientious are not really effective, that they are manufactured in objection (CO) to vaccination may be based on reli- unsafe ways, and that diseases are better dealt with by gious, moral, or philosophical convictions, such as other means. There are also people who decide not to the conviction that health and disease should not be For detailed discussions of reasons for vaccine refusal or hesitancy see, controlled by vaccination, or that governments e.g. Department of Health and Ageing (DOHA) 2013. Myths and Real- th should not coerce citizens into receiving medical inter- ities: Responding to arguments against vaccination,5 edn. Canberra: ventions. Vaccine refusals on grounds of conscience are Commonwealth of Australia; J. Leask, S. Chapman, & S.C.C. Robbins. All manner of ills: The features of serious diseases attributed to vacci- explicitly sanctioned in some legislations; for example, nation, Vaccine 2010; 28:3066–70; N.E. Moran et al. 2006. Are compul- in Australia parents can refuse vaccinations for their sory immunisation and incentives to immunise effective ways to achieve children by filling in an Immunisation Exemption herd immunity in Europe?, in M. Selgelid, M. Battin, and C. Smith (eds) Ethics and Infectious Disease. Blackwell: Malden, MA:115–131; S.B. Omer et al. Vaccine refusal, mandatory immunisation, and the risks of vaccine-preventable diseases, New Engl J Med 2009; 360(19):1981–8; R.M. Wolfe, L.K. Sharp. Anti-vaccinationists past and present, BMJ M. Navin. Resisting moral permissiveness about vaccine refusal, Publ 2002; 325(7361):430–32. For historical discussion of anti-vaccination Aff Q 2013; 27(1):69–85; T. May. Public communication, risk perception, movements see S. Blume. Anti-vaccination movements and their inter- and the viability of preventive vaccination against communicable dis- pretations, Soc Sci Med 2006;62:628–2 9. eases, Bioethics 2005; 19(4):407–421. Address for correspondence: Dr Mary Jean Walker, Philosophy Department, School of Philosophical, Historical and International Studies, Building 11, Monash University VIC 3800, Australia. Tel: +61 (3) 9905 0319. Email: mary.walker@monash.edu 2016 The Authors Bioethics Published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. 156 Steve Clarke, Alberto Giubilini and Mary Jean Walker Conscientious Objection Form in which they declare or harmful. But this is not the subject of our that they hold a personal, philosophical, religious or article. medical belief involving a conviction that vaccination We will focus on two questions: first, whether people under the National Immunisation Program should not should be entitled to conscientiously object to vaccina- take place. tion against contagious diseases (either for themselves or It may well be that some conscientious objectors for their children); second, if so, to what constraints or requirements should CO to vaccination be subject. to vaccination also have non-conscientious reasons to Countries differ in whether mass vaccination is compul- refuse vaccines, and that they would want to refuse sory or voluntary, and whether provision is made for vaccines on these other grounds even if they were CO. While there has been philosophical discussion of denied the opportunity to conscientiously object. We various ethical questions surrounding vaccination, as think that the other reasons that have so far been well as some discussion of epistemic questions raised by advanced for vaccine rejection are spurious. While it the disagreement surrounding it, there has been little is important that particular vaccination programs, discussion focusing specifically on the permissibility and like other medical practices, are evidence-based, sci- treatment of CO to vaccination. CO has been discussed entific evidence has repeatedly demonstrated that extensively in other contexts, including military service vaccination can offer a safe, effective way to achieve (e.g. conscientious objection to conscription) and provi- individual immunity from serious diseases, and pre- sion of certain healthcare services (e.g. conscientious vents very significant morbidity and mortality. When practised on a large scale through a mass vac- cination program, it enables herd immunity to pro- tect those who cannot be vaccinated, and even the eradication of diseases. There is much that could be T. Dare. Disagreement over vaccination programmes: Deep or merely complex and why does it matter? HEC Forum 2014; 26:43–57; A. Kata said, and has been said, about the misguided reason- Anti-vaccine activists, Web 2.0, and the postmodern paradigm – An ing of those who think that vaccination is dangerous overview of tactics and tropes used online by the anti-vaccination move- ment. Vaccine 2012; 30:3778–89; J. Leask & S. Chapman. An attempt to swindle nature: press anti-immunisation reportage 1993–1997. Austra- lian and New Zealand J Publ Health 1998; 22(1):17–26; Leask, Chapman & Robbins. op. cit. note 1; M. Navin. Competing epistemic spaces: How The form can be found at http://www.nevdgp.org.au/info/immunisa- social epistemology helps explain and evaluate vaccine denialism. Soc tion/conscientious-objection-form.pdf [Accessed 10 May 2016]. This Theory Pract 2013; 39(2):241–264; S.Tafuri et al. Addressing the anti- form may fall into disuse in Australia following the removal of a CO vaccination movement and the role of HCWs. Vaccine 2014; 32:4860–65. exemption which previously allowed non-vaccinating families to access It might be argued that those who refuse vaccines on this basis are certain financial benefits, see M. Klapdor. Social Services Legislation conscientious refusers, in the sense that it is their beliefs coupled with Amendment (No Jab, No Pay) Bill, 2015. Bills Digest (2015–2016) 36. their aim of not harming their children (or themselves) that lies behind Available at http://www.aph.gov.au/Parliamentary_Business/Bills_ the refusal, and this aim is a moral or conscientious one. While this raises Legislation/bd/bd1516a/6bd036. interesting questions about the role of beliefs about empirical, rather E.g., E.S. Bar-On et al. Combined DTP-HBV-HIB vaccine versus than religious or moral, matters in conscientious objection, we will not separately administered DTP-HBV and HIB vaccines for primary seek to address those questions here. If these refusals were to be consid- prevention of diphtheria, tetanus, pertussis, hepatitis B and Haemo- ered conscientious, however, we would take our arguments below to philus influenzae B (HIB) (Review). Cochrane Database Syst Rev apply. 2012(4). DOI: 10.1002/14651858.CD005530.pub3; M.P. Curran & Our focus here is only on diseases that are contagious, i.e. that can be K.L. Goa. DTPa-HBV-IPV/Hib vaccine. Drugs 2003; 63(7):673–682; transmitted from person to person, and not on non-contagious diseases M.G. Lucero et al. Pneumococcal conjugate vaccines for preventing (e.g. tetanus), where the risk of being infected does not depend on how vaccine-type invasive pneumococcal disease and X-ray defined many people around us are vaccinated. pneumonia in children less that two years of age (Review). For discussion of ethical questions, see, e.g. L. Asveld. Cochrane Database Syst Rev 2009(4). DOI: 10.1002/ Mass-vaccination programmes and the value of respect for autonomy, 14651858.CD004977.pub2; V. Demicheli et al. Vaccines for measles, Bioethics 2008; 22(5):245–57; A. Dawson. The determination of best mumps and rubella in children (Review). Cochrane Database Syst interests in relation to childhood vaccinations, Bioethics 2005; Rev 2012(2). DOI: 10.1002/14651858.CD004407.pub3; K. Soares- 19(2):188–205; J. Flanigan. A defense of compulsory vaccination, HEC Weiser et al. Vaccines for preventing rotavirus diarrheoa: Vaccines Forum 2014; 26:5–25; J. Harris & S. Holm. Is there a moral obligation in use (Review) Cochrane Database Syst Rev 2012(11). DOI: not to infect others? BMJ 1995; 311(7014):1215–17; M. Navin. Resisting 10.1002/14651858.CD008521.pub3. moral permissiveness about vaccine refusal, Public Aff Q 2013; Smallpox is an example of an eradicated disease, see M. Verweij, 27(1):69–85; M. Verweij, 2006. Obligatory precautions against infection, 2013. Vaccination policies. In The International Encyclopedia of in Ethics and Infectious Disease. M. Selgelid, M. Battin, & C. Smith, eds. Ethics. H. La Follette, ed. Blackwell: Malden, MA:. 5279–82; and Blackwell: Malden, MA: 70–82. For discussion of some epistemic ques- polio has almost been eradicated thanks to vaccines, see Global tions see T. Dare. Disagreement over vaccination programmes: Deep or Polio Eradication Initiative, 2015, Data and Monitoring: Polio cases merely complex and why does it matter? HEC Forum 2014; 26:43–57; M. worldwide, 2015. Available at http://www.polioeradication.org/Data- Navin. Competing epistemic spaces: How social epistemology helps andmonitoring/Poliothisweek/Poliocasesworldwide.aspx [Accessed 1 explain and evaluate vaccine denialism, Soc Theory Pract 2013; Feb 2016]. 39(2):241–64. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd Conscientious objection to vaccination 157 objection to abortion). CO in relation to military severe or highly contagious diseases, if the population service in particular has received quite extensive discus- rate of CO becomes high enough to threaten herd immu- sion by legal thinkers, human rights activists, and philos- nity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de ophers. It is accepted in many countries and recognized facto impermissible. as a human right in various national and international charters and instruments. To address the two questions above, we consider an ETHICAL REASONING UNDERPINNING analogy between CO to vaccination and CO to military RIGHTS AND DUTIES OF service. As thinking about CO to military service is com- CONSCIENTIOUS OBJECTORS TO paratively well-developed, the policies and practices for MILITARY SERVICE responding to CO in that area are a useful resource for considering CO to vaccination. Although in some places In Australia, the UK and the USA, recent policies sur- conscientious objectors to military service face imprison- rounding CO have enabled conscientious objectors to ment or other serious consequences, in many countries, military service and to active participation in war to be including the USA, Canada, Australia, and many assigned other duties. Either they have been assigned non- European countries, policies have been developed that combatant roles within their nations military services, or recognise the rights of objectors, while balancing these civic roles that do not directly assist the military services against the military needs and interests of the state. In of their nation, but which contribute to the well-being of many of these countries, CO to military service is their society (e.g. serving in public libraries, healthcare granted, sometimes upon satisfactorily meeting certain institutions, etc.). The alternative service is generally for requirements (or has been when conscription or compul- at least the same duration, but can be up to twice as sory national service in those countries was in place). long, as conscripts to the military are expected to serve. Conscientious objectors are typically required to dem- Whether and to what extent the same kind of policy onstrate that their objection is genuine. Objectors rea- should be adopted in the case of vaccination depends, soning is commonly subjected to the assessment of a inter alia, on whether and to what extent CO to vaccina- tribunal. For example, in the UK an Advisory Commit- tion is relevantly similar to CO to military service. tee on Conscientious Objectors (ACCO) assesses cases of We examine the ethical reasoning underpinning the CO which have been rejected by the relevant service treatment of conscientious objectors to military service authorities, and in Australia, a Conscientious Objection in Section 1. In Section 2 we consider the analogy Tribunal assesses cases of CO during wartime. Usually, between CO to military service and CO to vaccination in the tribunal aims to test sincerity (i.e. whether the objec- some detail. In Section 3, we explore some key implica- tor truly holds beliefs inconsistent with participating in tions of the analogy for vaccination policies. We argue military service) rather than validity (the rationality or that conscientious objectors to vaccination should make reasonability of the explanation the objector provides). an appropriate contribution to society in lieu of being There are at least two ways to justify the requirement vaccinated. The contribution to be made will depend on that conscientious objectors to military service perform the severity of the relevant disease(s), on its morbidity, other tasks that benefit their society and that are roughly and also on the likelihood that vaccine refusal will lead commensurate with the efforts made by those who per- to harm. In particular, the contribution required will form military service. depend on whether the rate of CO in a given population The first is to argue that because there is a general threatens herd immunity to the disease in question: for duty to contribute to the upkeep of ones society, there is a special form of that duty to make extra contribu- For discussion of CO to military service, see e.g. C.A.J. Coady. Objecting morally, J Ethics 1997; 1(4):375–97; C. Cohen. Conscientious tions to the upkeep and preservation of ones society in objection, Ethics 1968; 78(4):269–79; K.W. Kemp. Conscientious objec- times of crisis. Arguably, there is a related special duty tion, Public Aff Q 1993; 7(4):303–24. For discussion of CO in healthcare to collaborate with others to try to prevent crises. On see, e.g. J. Savulescu. Conscientious objection in medicine, BMJ 2006; some occasions a society will come under threat from 332:94; M.R. Wicclair. 2011. Conscientious Objection in Health Care: An hostile military forces. Recognizing that threats to their Ethical Analysis. Cambridge: Cambridge University Press. United Nations. 2012. Conscientious Objection to Military Service. Geneva: United Nations Human Rights, Office of the High Commis- CPTI 2006, op. cit. note 12, pp. 121–23. sioner; 7–20. Available at http://www.ohchr.org/Documents/Publica- Advisory Committee on Conscientious Objectors (ACCO). 2016. tions/ConscientiousObjection_en.pdf [accessed 2 February 2016]. Advisory Committee on Conscientious Objectors, https://www.gov.uk/ Conscience and Peace Tax International (CTPI). 2006. Military government/organisations/advisory-committee-on-conscientious-objec- Recruitment and Conscientious Objection: A thematic global survey. tors [Accessed 1 February 2016]. Leuven: CTPI:89–104. Available at http://cpti.ws/cpti_docs/brett/ M. Coombs & L. Reyner. 2003. Conscientious Objection to military recruitment_and_co_A4.pdf [Accessed 1 February 2016]; United service in Australia. Department of the Parliamentary Library Research Nations. 2012. op. cit. note 11. Note, 31(2002–3). V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd 158 Steve Clarke, Alberto Giubilini and Mary Jean Walker preservation are liable to occur, most societies maintain been required to demonstrate that their objection is con- standing military forces to deter or repel such threats. sistent with their other beliefs, and consistent with their Forces may be maintained by voluntary enlistment actions. and/or by legislating a compulsory period of national service. When emerging threats are significant, military ANALOGIES AND DIFFERENCES forces may need to be expanded via conscription. Peo- BETWEEN CO TO MILITARY SERVICE ple may be understood to have a duty to serve in their AND TO VACCINATION: LIBERTY, RISK, societies standing military forces and/or to serve in AND UTILITY expanded military forces during time of crisis, and may be conscripted to do so. Those who have a conscien- Since infectious disease, like an invading military force, tious objection to military service may be permitted to can pose a severe potential threat to society – including avoid having to serve in the military, but their obligation threats to political stability and national security –it is to contribute to the upkeep and preservation of their arguable that, by analogy to their duty to contribute to society does not thereby disappear: hence our expecta- military forces, ordinary people have a duty to contribute tion that they perform commensurate roles that benefit to the effort to prevent infectious diseases. In fact, the their society. analogy between infectious diseases and war is quite The second line of justification for insisting that con- widespread in the public health ethics literature. This scientious objectors perform duties that are roughly duty to prevent contagion involves sub-duties regarding commensurate with active military service is that society behaviour during times at which there are outbreaks of needs to take steps to prevent free-riding. There is an diseases. For example, if people are instructed by a legiti- ongoing temptation for individuals to accept the bene- mate authority to quarantine themselves for a period of fits that spring from being part of a society without time, then they have a duty to follow this instruction. contributing to the upkeep and preservation of that They also have a duty to help prevent the outbreak of society. Generally, societies can survive when there are a diseases. This involves, inter alia, a duty to receive vacci- few free-riders, who do not pay taxes, observe laws, nations so as to contribute to herd immunity when the refrain from damaging public property, and so on. disease is communicable. However, if the number of free riders becomes too high, Infectious diseases are analogous to the threat of inva- the future of that society itself is undermined, as it sion by hostile military forces in that in both cases the struggles to maintain itself under the weight of unpro- upkeep and preservation of society can be threatened. It ductive and counterproductive free-riders. An additional is arguable that infectious disease has actually been more problem is that if non-free riders are aware that there of a threat to the upkeep of society than war. Somewhere are significantly many free-riders in their society, then between one-quarter and one-third of the population of their own commitment to contribute to that society can Europe – and up to three-quarters of the population in be undermined by resentment towards free-riders, which some areas – are thought to have died of plague in the makes it more likely that they themselves will become th mid-14 Century, which is a far more significant rate of free-riders. Participation in military forces is often thought to be an onerous duty, so there is a strong temptation to avoid that duty. If the appeal to CO were to enable one to H. Feldbaum et al. Global health and national security: the need for avoid that duty, and not acquire some commensurate critical engagement, Med Conflict Surviv 2006; 22(3):192–198; A.T. Price-Smith. 2002. The health of nations: infectious disease, environmen- duty, then it would enable free-riding. Potential free tal change, and their effects on national security and developments.New riders would seek to present themselves as sincere consci- York: MIT Press. entious objectors in order to avoid military service, while 17 This duty may be grounded in the status of public health (or herd still benefiting from the protection that military forces immunity) as a public good, shared in the community in which one lives provide. If we ensure that conscientious objectors to mili- (A. Dawson. The determination of “best interests” in relation to child- hood vaccinations, Bioethics 2005; 19(2):188–205; M. Navin. Resisting tary service make a contribution to society that is equiva- moral permissiveness about vaccine refusal, Pub Aff Q 2013; 27(1):69– lent to military service, such as providing community 85; S.B. Omer et al. Vaccine refusal, mandatory immunisation, and the services for a length of time roughly equal to the period risks of vaccine-preventable diseases. New Engl J Med 2009; that conscripts are required to provide military service, 360(19):1981–8); or based on the duty to avoid harming others: J. Harris we discourage free-riders from seeking to present them- and S. Holm S. Is there a moral obligation not to infect others? BMJ 1995; 311(7014):1215–17; M. Verweij. 2006. Obligatory precautions selves as sincere conscientious objectors. The possibility against infection, in Ethics and Infectious Disease. M. Selgelid, M. Bat- that free-riders might present themselves as genuine con- tin, and C. Smith (eds). Blackwell: Malden, MA: 70–82. These different scientious objectors also underpins the obligation of con- ways of understanding the duty do not affect our argument here. scientious objectors to provide a demonstration of G. De Grandis. On the analogy between infectious diseases and wars: sincerity. Objectors to military service have generally how to use it and not to use it. Public Health Ethics 2011; 4(1):70–83. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd Conscientious objection to vaccination 159 death than during any war that has ever been fought in they were denied the right to object, the aforementioned Europe. It is estimated that 80% of the indigenous pop- costs need to be balanced against the prospective benefits ulation of Mexico died of viral hemorrhagic fever in the to be gained by these individuals. It seems that individual th mid-16 Century, which is a much greater rate of mor- benefit is higher in the case of vaccination, since the vac- tality than that caused by the Spanish Conquistadors or cinated individual benefits by obtaining immunity to dis- any other military force in Mexico. ease and there is no corresponding benefit obtained by In cases of both vaccination and conscription, a duty military service. There are, of course, individual benefits is imposed on individuals and is justified by appeal to a that military conscripts may enjoy. Military conscripts public good: national security from external military are, almost invariably, paid for their service and can threats in one case, and group immunity to some infec- receive specialist training that can benefit them later on tious diseases (which is also relevant to national security) in civilian life. Some can also go on to enjoy successful in the other. In both cases, the duty entails three types of careers in the military itself. costs for the individual: a liberty cost, personal risk, and Considering analogies and differences with the military a utility cost in terms of time and energies required of case in terms of liberty, risk, and utility costs, it seems the individual. that in the case of CO to vaccination there are at least The liberty cost is roughly the same in both cases of equally strong, if not stronger, reasons for compelling vaccination and the military, because in both cases an conscientious objectors to make commensurate efforts to individual is asked to do something they might not do help prevent the outbreak of infectious disease and/or to voluntarily. In both cases, CO can be claimed by appeal- contribute to the welfare of the community in general. ing to a principle of liberty. They have a duty to make these commensurate efforts The risk for the individual is higher in the case of and, as our earlier discussion of free-riding shows, we as military conscription, at least during wartime, than a society have strong reasons to seek to ensure that they vaccination, because fighting in war entails a risk to make such commensurate efforts. the life of soldiers, whilst the vaccines that are approved by therapeutic goods regulators and used IMPLICATIONS OF THE ANALOGY FOR today are very safe. Side effects occur, but are rare and CO TO VACCINATION for the most part negligible. In peacetime, the risk of military service is low, although the possibility that a On the basis of the analogy to CO to military service we conflict may happen during ones military service can draw two broad policy implications for CO to vaccina- should be factored in when assessing the risk associated tion. First, it is legitimate to expect those conscientiously with conscription. objecting to vaccination to supply evidence of their sincer- The utility cost is much higher in the case of military ity. Second, those who conscientiously object have an obli- conscription than vaccination, since conscripts are gation to contribute to the upkeep of their society. required to spend considerable time in the army training Sincerity can be assessed by testing the consistency of for combat. By contrast, vaccines only entail the small the claimed CO with the persons other beliefs, and with utility costs involved in attending a medical appointment, their actions. This may be assessed through personal inter- since the procedure (a simple injection) is usually quick views and/or written applications to tribunals, boards, or and relatively painless. A further cost of undertaking 24 committees, which may be civil or military in makeup. either military service or vaccination, when doing so Current practices surrounding CO to vaccination do goes against ones conscience, might be called a cost of not generally require objectors to state reasons for their psychological, or moral, distress. objection. In Australia, for example, all conscientious In order to appreciate the severity of the burden that objectors have had to do, in the past, was to sign a form would-be conscientious objectors would have to bear if stating that they have a conscientious objection and to have this form signed by a practitioner to certify that a Encyclopaedia Britannica. 2016. “plague.” Britannica Academic. healthcare professional had discussed the benefits of vac- Web. 31 Jan. 2016. Available at http://academic.eb.com/EBchecked/ topic/462675/plague [Accessed 1 February 2016]. cination with them. In the US, most states that allow a R. Acuna-Soto, L.C. Romero & J.H. Maguire. Large epidemics of hemorrhagic fevers in Mexico 1545–1815, Am J Trop Med Hyg 2000; 62(6):733–39. United Nations, op. cit. note 11; C. Cohen. Conscientious objection, Ethics 1968; 78(4):269–79; K.W. Kemp. Conscientious objection. Public United Nations, op. cit. note 11; Conscience and Peace Tax Interna- Aff Q 1993; 7(4):303–324. tional (CTPI), op. cit. note 12. 22 25 Department of Health. 2015. The Australian Immunisation Hand- M. Klapdor. 2015. Social Services Legislation Amendment (No Jab, book, 10th edn. Canberra: Australian Government Department of No Pay) Bill 2015. Bills Digest (2015–2016) 36. Available at http://www. Health: ch.4. aph.gov.au/Parliamentary_Business/Bills_Legislation/bd/bd1516a/6bd036. C. Cohen. Conscientious objection, Ethics 1998; 78(4):269. [Accessed 1 February 2016]. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd 160 Steve Clarke, Alberto Giubilini and Mary Jean Walker parent to conscientiously object to their children being of a more direct or clearly commensurate way to dis- vaccinated merely require that parent to sign a form or a charge the obligation. notarised statement. However, we do need to be careful with the analogy at These practices may partly be explained by the con- this point. The withholding of some financial benefits sideration that it would be very difficult and very costly from families who refuse to vaccinate their children to assess the sincerity of conscientious beliefs surround- seems consistent with a similar policy in place in the case ing vaccination. For example, in Australia there are of CO to military conscription. Granted, the two types over 40,000 conscientious objectors to vaccination; any of policies are similar in that it is acknowledged that the procedure to assess the sincerity of Australian conscien- community bears a cost for the objection and objectors tious objections to vaccination with reasonable accu- are therefore asked to make up for such cost by provid- racy would require significant resources. Rather than ing the community with a relevantly similar utility sur- expending significant resources to assess sincerity, it plus – a public service in one case, a saving in the budget may therefore be preferable to test sincerity indirectly, that the State could use for other health measures in the by increasing the effort required to conscientiously other. However, denying objectors benefits to which object to vaccination, to a point where free-riders other citizens are entitled is in some relevant respects dif- would find the burdens of objecting to be more onerous ferent from requiring them to do something that other than vaccinating. For instance, objectors might be citizens are not required to do. In particular, it is differ- required to attend educational counselling about the ent in that withholding a benefit does not involve a util- risks and benefits of vaccination for their children and ity cost compared with a non-benefit baseline, whereas for the community (as Salmon and Siegel have sug- providing an alternative service does have a utility cost gested), to discuss vaccination with a medical profes- compared to the non-service baseline. sional (as in previous Australian practice), and so on. It is more difficult to find suitable options for an alter- In addition, CO can be made more burdensome by native contribution to being vaccinated than to military requiring objectors to make some other contribution to service. In times of war, society will not only need sol- societys upkeep. diers. It will require some to hold non-combatant mili- There are some requirements that can be placed on tary positions, and will continue to require people to conscientious objectors to limit the potential costs to undertake other kinds of (non-military) work. Thus society of accommodating their objection. For instance, those objecting to military service might still contribute objectors might be required not to travel to countries to the war effort, or they might contribute to societys where the relevant diseases are known to exist at levels, upkeep in other ways. Whilst such positions may involve or where the population is known to have low vaccina- less personal risk, they might involve similar utility and tion rates, such that the travel could pose a risk to the liberty costs, and they make a contribution to the same persons community upon return. They might also be overall aim. In the case of vaccination there is no obvi- obliged to undertake certain actions in the case of an ously comparable contribution that can be made, in outbreak, such as isolating themselves (or their children) terms of positive impact on herd immunity, or more gen- at home, or submitting to quarantine. erally to public health. While such requirements might lessen the threat posed What form of compensation is fair, then, in the case of to herd immunity from CO they would not discharge the conscientious objection to vaccination? One option is to obligation to contribute to the public good. Conscien- tious objectors might also be required to contribute to One issue with imposing financial penalties is that they may be seen as inequitable: such a system could result in a situation where those on societys upkeep in other ways. They might be made sub- higher incomes can afford to conscientiously object, while those on ject to financial penalties, denied access to financial ben- lower incomes cannot, or to put in another way, that some and not efits, or required to perform community service. The others are permitted to buy their way out of an obligation. While per- policy recently implemented in Australia to remove con- haps of concern (especially if vaccine refusal is associated with particular scientious objectors access to specific financial benefits groups, such that it contributes to the polarization of debate) this is in principle no more of an issue for vaccination than for other sorts of pen- could in this sense be considered justified, given the lack alties such as parking fines. We recognize, however, that the proposals here would limit but not eliminate free-riding. It seems arguable that those who object to participating in combat National Conference of State Legislatures (NCSL). 2016. States with might, as a result, be less able to contribute to it well, and thus allowing religious and philosophical exemptions to school immunization require- them to contribute in a different way benefits society as well as the objec- ments. Available at http://www.ncsl.org/research/health/school-immuni- tor. Although this is a disanalogy with the case of vaccination, since zation-exemption-state-laws.aspx [Accessed 2 February 2016]. ones attitude to vaccination makes no difference to its effect, it strength- D.A.Salmon & A.W. Seigel. Religious and Philosophical Exemptions ens our argument that conscientious objectors to vaccination can be from Vaccination Requirements and Lessons Learned from Conscien- required to make some other contribution, since the duty to contribute tious Objectors from Conscription, Public Health Rep 2001; 116:289–95, to the public good of herd immunity is not transferable in the same way p.293. as that of military service. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd Conscientious objection to vaccination 161 introduce an additional tax for conscientious objectors analysis of policy surrounding CO to military service, we to vaccines. This option raises questions about how we have argued that conscientious objectors have two obli- are to translate the risk involved in compromising herd gations when their objection prevents them from dis- immunity into a fair monetary amount. The risk of a charging a duty to contribute to the public good. These conscientious objector compromising herd immunity will are an obligation to demonstrate the sincerity of their vary for different diseases, as well as in relation to back- objection, and an obligation to make a commensurate ground conditions. Diseases differ significantly in their contribution to society. Imposing a requirement to dis- prevalence, contagiousness and the danger to ones charge some other duty will in many cases function as a health once one becomes infected. Thus, for instance, demonstration of sincerity, thus meeting both obligations CO to vaccination for a less serious infectious disease and enabling policy to side-step difficulties relating to the would pose a lower risk than CO to vaccination for a verification of sincerity. We have argued that in the case disease likely to be fatal to many people in the case of an of vaccination, though a commensurate contribution to outbreak. And in societies with a high overall rate of ones society is not available, objectors could discharge vaccination, cases of CO may pose little threat, while this duty by making a financial contribution to the state they would come to pose a higher threat where rates are (either via a penalty or lack of access to a benefit) that lower. reflects the degree of risk imposed on the community by These factors suggest that an estimate of what a fair their objection. As degree of risk includes the severity of compensation would consist in is not straightforward potential harms, and their probability, calculation of the and equal for all diseases. However, there is no apparent risk involved in not vaccinating will make reference to reason why the compensation required from conscien- the existing levels of vaccine coverage in the relevant tious objectors should not reflect these factors. Financial community. On such a system, the financial contribution penalties (in the form of either fines or the deprivation required of non-vaccinators will increase as overall vac- of benefits) might be developed that reflect the severity cine coverage lowers. When the risk of contagion is very of possible harms, and their probability of occurring. significant and the disease is sufficiently severe, this sys- Penalties for non-vaccination could thus be developed in tem would have to imply a financial compensation which a way that reflects both the potential severity of the haz- is too burdensome for almost anyone to be met. ards of contracting a disease, and the likelihood that not vaccinating for that disease could lead to an outbreak. Acknowledgement Penalties might even be worked out separately for differ- This research was supported by the Australian Research Council ent diseases: for instance, the potential harms from (DP150102068). Alberto Giubilinis research was supported by the chickenpox are generally lower than those from polio, Oxford Martin Program on Collective Responsibility for Infectious but one is less likely to contract polio than chickenpox. Disease. The authors made an equal contribution. This could also enable those who object only to some Steve Clarke is an Associate Professor in the School of Human- vaccines to pay a proportionate penalty. ities and Social Sciences at Charles Sturt University in Australia, On such a system, as vaccination rates decrease, penal- and a Senior Research Associate of the Uehiro Centre for Practi- ties increase, with the effect of not only preventing free cal Ethics at the University of Oxford. He has published over riding, but putting pressure on objectors to examine their seventy academic papers. He is also the author of The Justifica- beliefs. This would provide a way to ensure a balance is tion of Religious Violence (Wiley-Blackwell, 2014). reached between protecting societys interest in maintain- Alberto Giubilini is a Postdoctoral Research Fellow on the Oxford ing herd immunity, and allowing individuals to follow Martin Programme on Collective Responsibility for Infectious Dis- their consciences. ease at the University of Oxford. He has published on different topics in bioethics and philosophy, including the ethics of procrea- tive choices, end of life decisions, organ donations, conscientious CONCLUSION objection in healthcare, the concept of conscience, human enhancement, and the role of intuitions and of moral disgust in Our examination of the analogy between CO to military ethical arguments. service and CO to vaccination is useful for answering the Mary Jean Walker is a Postdoctoral Research Fellow in the ethics two questions with which we began: whether people program of the Australian Research Council Centre for Excellence should be entitled to conscientiously object to vaccina- in Electromaterials Science at Monash University in Australia. tion; and what constraints or requirements CO to vacci- Her research interests include ethical issues related to emerging health technologies, concepts of disease and health, surgical episte- nation should be subject to. In relation to the second mology, addiction, and narrative identity. question, drawing on moral considerations and an For instance, some object in particular to vaccines manufactured using cell lines derived from aborted foetuses, but not to other vaccines, see Department of Health and Ageing (DOHA), op. cit. note 1. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Bioethics Pubmed Central

Conscientious Objection to Vaccination

Bioethics , Volume 31 (3) – Dec 23, 2016

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© 2016 The Authors Bioethics Published by John Wiley & Sons Ltd
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bs_bs_banner Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12326 Volume 31 Number 3 2017 pp 155–161 STEVE CLARKE, ALBERTO GIUBILINI AND MARY JEAN WALKER Keywords conscientious objection, ABSTRACT vaccination, Vaccine refusal occurs for a variety of reasons. In this article we examine herd immunity, vaccine refusals that are made on conscientious grounds; that is, for reli- public health gious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases (either for themselves or for their children); sec- ond, if so, to what constraints or requirements should conscientious objection (CO) to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. We argue that conscientious objectors to vaccination should make an appropriate con- tribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease(s), its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribu- tion required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly con- tagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. vaccinate out of a selfish desire to free-ride on the INTRODUCTION herd immunity achieved by the vaccinations of others (Navin 2013b; May 2005). Still others refuse to People refuse vaccines for themselves or for their take vaccines or to vaccinate their dependants on con- dependants for a variety of reasons. These include the scientious grounds. Our focus in this paper is on vac- beliefs that vaccines cause health problems, that they cine refusal on conscientious grounds. Conscientious are not really effective, that they are manufactured in objection (CO) to vaccination may be based on reli- unsafe ways, and that diseases are better dealt with by gious, moral, or philosophical convictions, such as other means. There are also people who decide not to the conviction that health and disease should not be For detailed discussions of reasons for vaccine refusal or hesitancy see, controlled by vaccination, or that governments e.g. Department of Health and Ageing (DOHA) 2013. Myths and Real- th should not coerce citizens into receiving medical inter- ities: Responding to arguments against vaccination,5 edn. Canberra: ventions. Vaccine refusals on grounds of conscience are Commonwealth of Australia; J. Leask, S. Chapman, & S.C.C. Robbins. All manner of ills: The features of serious diseases attributed to vacci- explicitly sanctioned in some legislations; for example, nation, Vaccine 2010; 28:3066–70; N.E. Moran et al. 2006. Are compul- in Australia parents can refuse vaccinations for their sory immunisation and incentives to immunise effective ways to achieve children by filling in an Immunisation Exemption herd immunity in Europe?, in M. Selgelid, M. Battin, and C. Smith (eds) Ethics and Infectious Disease. Blackwell: Malden, MA:115–131; S.B. Omer et al. Vaccine refusal, mandatory immunisation, and the risks of vaccine-preventable diseases, New Engl J Med 2009; 360(19):1981–8; R.M. Wolfe, L.K. Sharp. Anti-vaccinationists past and present, BMJ M. Navin. Resisting moral permissiveness about vaccine refusal, Publ 2002; 325(7361):430–32. For historical discussion of anti-vaccination Aff Q 2013; 27(1):69–85; T. May. Public communication, risk perception, movements see S. Blume. Anti-vaccination movements and their inter- and the viability of preventive vaccination against communicable dis- pretations, Soc Sci Med 2006;62:628–2 9. eases, Bioethics 2005; 19(4):407–421. Address for correspondence: Dr Mary Jean Walker, Philosophy Department, School of Philosophical, Historical and International Studies, Building 11, Monash University VIC 3800, Australia. Tel: +61 (3) 9905 0319. Email: mary.walker@monash.edu 2016 The Authors Bioethics Published by John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. 156 Steve Clarke, Alberto Giubilini and Mary Jean Walker Conscientious Objection Form in which they declare or harmful. But this is not the subject of our that they hold a personal, philosophical, religious or article. medical belief involving a conviction that vaccination We will focus on two questions: first, whether people under the National Immunisation Program should not should be entitled to conscientiously object to vaccina- take place. tion against contagious diseases (either for themselves or It may well be that some conscientious objectors for their children); second, if so, to what constraints or requirements should CO to vaccination be subject. to vaccination also have non-conscientious reasons to Countries differ in whether mass vaccination is compul- refuse vaccines, and that they would want to refuse sory or voluntary, and whether provision is made for vaccines on these other grounds even if they were CO. While there has been philosophical discussion of denied the opportunity to conscientiously object. We various ethical questions surrounding vaccination, as think that the other reasons that have so far been well as some discussion of epistemic questions raised by advanced for vaccine rejection are spurious. While it the disagreement surrounding it, there has been little is important that particular vaccination programs, discussion focusing specifically on the permissibility and like other medical practices, are evidence-based, sci- treatment of CO to vaccination. CO has been discussed entific evidence has repeatedly demonstrated that extensively in other contexts, including military service vaccination can offer a safe, effective way to achieve (e.g. conscientious objection to conscription) and provi- individual immunity from serious diseases, and pre- sion of certain healthcare services (e.g. conscientious vents very significant morbidity and mortality. When practised on a large scale through a mass vac- cination program, it enables herd immunity to pro- tect those who cannot be vaccinated, and even the eradication of diseases. There is much that could be T. Dare. Disagreement over vaccination programmes: Deep or merely complex and why does it matter? HEC Forum 2014; 26:43–57; A. Kata said, and has been said, about the misguided reason- Anti-vaccine activists, Web 2.0, and the postmodern paradigm – An ing of those who think that vaccination is dangerous overview of tactics and tropes used online by the anti-vaccination move- ment. Vaccine 2012; 30:3778–89; J. Leask & S. Chapman. An attempt to swindle nature: press anti-immunisation reportage 1993–1997. Austra- lian and New Zealand J Publ Health 1998; 22(1):17–26; Leask, Chapman & Robbins. op. cit. note 1; M. Navin. Competing epistemic spaces: How The form can be found at http://www.nevdgp.org.au/info/immunisa- social epistemology helps explain and evaluate vaccine denialism. Soc tion/conscientious-objection-form.pdf [Accessed 10 May 2016]. This Theory Pract 2013; 39(2):241–264; S.Tafuri et al. Addressing the anti- form may fall into disuse in Australia following the removal of a CO vaccination movement and the role of HCWs. Vaccine 2014; 32:4860–65. exemption which previously allowed non-vaccinating families to access It might be argued that those who refuse vaccines on this basis are certain financial benefits, see M. Klapdor. Social Services Legislation conscientious refusers, in the sense that it is their beliefs coupled with Amendment (No Jab, No Pay) Bill, 2015. Bills Digest (2015–2016) 36. their aim of not harming their children (or themselves) that lies behind Available at http://www.aph.gov.au/Parliamentary_Business/Bills_ the refusal, and this aim is a moral or conscientious one. While this raises Legislation/bd/bd1516a/6bd036. interesting questions about the role of beliefs about empirical, rather E.g., E.S. Bar-On et al. Combined DTP-HBV-HIB vaccine versus than religious or moral, matters in conscientious objection, we will not separately administered DTP-HBV and HIB vaccines for primary seek to address those questions here. If these refusals were to be consid- prevention of diphtheria, tetanus, pertussis, hepatitis B and Haemo- ered conscientious, however, we would take our arguments below to philus influenzae B (HIB) (Review). Cochrane Database Syst Rev apply. 2012(4). DOI: 10.1002/14651858.CD005530.pub3; M.P. Curran & Our focus here is only on diseases that are contagious, i.e. that can be K.L. Goa. DTPa-HBV-IPV/Hib vaccine. Drugs 2003; 63(7):673–682; transmitted from person to person, and not on non-contagious diseases M.G. Lucero et al. Pneumococcal conjugate vaccines for preventing (e.g. tetanus), where the risk of being infected does not depend on how vaccine-type invasive pneumococcal disease and X-ray defined many people around us are vaccinated. pneumonia in children less that two years of age (Review). For discussion of ethical questions, see, e.g. L. Asveld. Cochrane Database Syst Rev 2009(4). DOI: 10.1002/ Mass-vaccination programmes and the value of respect for autonomy, 14651858.CD004977.pub2; V. Demicheli et al. Vaccines for measles, Bioethics 2008; 22(5):245–57; A. Dawson. The determination of best mumps and rubella in children (Review). Cochrane Database Syst interests in relation to childhood vaccinations, Bioethics 2005; Rev 2012(2). DOI: 10.1002/14651858.CD004407.pub3; K. Soares- 19(2):188–205; J. Flanigan. A defense of compulsory vaccination, HEC Weiser et al. Vaccines for preventing rotavirus diarrheoa: Vaccines Forum 2014; 26:5–25; J. Harris & S. Holm. Is there a moral obligation in use (Review) Cochrane Database Syst Rev 2012(11). DOI: not to infect others? BMJ 1995; 311(7014):1215–17; M. Navin. Resisting 10.1002/14651858.CD008521.pub3. moral permissiveness about vaccine refusal, Public Aff Q 2013; Smallpox is an example of an eradicated disease, see M. Verweij, 27(1):69–85; M. Verweij, 2006. Obligatory precautions against infection, 2013. Vaccination policies. In The International Encyclopedia of in Ethics and Infectious Disease. M. Selgelid, M. Battin, & C. Smith, eds. Ethics. H. La Follette, ed. Blackwell: Malden, MA:. 5279–82; and Blackwell: Malden, MA: 70–82. For discussion of some epistemic ques- polio has almost been eradicated thanks to vaccines, see Global tions see T. Dare. Disagreement over vaccination programmes: Deep or Polio Eradication Initiative, 2015, Data and Monitoring: Polio cases merely complex and why does it matter? HEC Forum 2014; 26:43–57; M. worldwide, 2015. Available at http://www.polioeradication.org/Data- Navin. Competing epistemic spaces: How social epistemology helps andmonitoring/Poliothisweek/Poliocasesworldwide.aspx [Accessed 1 explain and evaluate vaccine denialism, Soc Theory Pract 2013; Feb 2016]. 39(2):241–64. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd Conscientious objection to vaccination 157 objection to abortion). CO in relation to military severe or highly contagious diseases, if the population service in particular has received quite extensive discus- rate of CO becomes high enough to threaten herd immu- sion by legal thinkers, human rights activists, and philos- nity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de ophers. It is accepted in many countries and recognized facto impermissible. as a human right in various national and international charters and instruments. To address the two questions above, we consider an ETHICAL REASONING UNDERPINNING analogy between CO to vaccination and CO to military RIGHTS AND DUTIES OF service. As thinking about CO to military service is com- CONSCIENTIOUS OBJECTORS TO paratively well-developed, the policies and practices for MILITARY SERVICE responding to CO in that area are a useful resource for considering CO to vaccination. Although in some places In Australia, the UK and the USA, recent policies sur- conscientious objectors to military service face imprison- rounding CO have enabled conscientious objectors to ment or other serious consequences, in many countries, military service and to active participation in war to be including the USA, Canada, Australia, and many assigned other duties. Either they have been assigned non- European countries, policies have been developed that combatant roles within their nations military services, or recognise the rights of objectors, while balancing these civic roles that do not directly assist the military services against the military needs and interests of the state. In of their nation, but which contribute to the well-being of many of these countries, CO to military service is their society (e.g. serving in public libraries, healthcare granted, sometimes upon satisfactorily meeting certain institutions, etc.). The alternative service is generally for requirements (or has been when conscription or compul- at least the same duration, but can be up to twice as sory national service in those countries was in place). long, as conscripts to the military are expected to serve. Conscientious objectors are typically required to dem- Whether and to what extent the same kind of policy onstrate that their objection is genuine. Objectors rea- should be adopted in the case of vaccination depends, soning is commonly subjected to the assessment of a inter alia, on whether and to what extent CO to vaccina- tribunal. For example, in the UK an Advisory Commit- tion is relevantly similar to CO to military service. tee on Conscientious Objectors (ACCO) assesses cases of We examine the ethical reasoning underpinning the CO which have been rejected by the relevant service treatment of conscientious objectors to military service authorities, and in Australia, a Conscientious Objection in Section 1. In Section 2 we consider the analogy Tribunal assesses cases of CO during wartime. Usually, between CO to military service and CO to vaccination in the tribunal aims to test sincerity (i.e. whether the objec- some detail. In Section 3, we explore some key implica- tor truly holds beliefs inconsistent with participating in tions of the analogy for vaccination policies. We argue military service) rather than validity (the rationality or that conscientious objectors to vaccination should make reasonability of the explanation the objector provides). an appropriate contribution to society in lieu of being There are at least two ways to justify the requirement vaccinated. The contribution to be made will depend on that conscientious objectors to military service perform the severity of the relevant disease(s), on its morbidity, other tasks that benefit their society and that are roughly and also on the likelihood that vaccine refusal will lead commensurate with the efforts made by those who per- to harm. In particular, the contribution required will form military service. depend on whether the rate of CO in a given population The first is to argue that because there is a general threatens herd immunity to the disease in question: for duty to contribute to the upkeep of ones society, there is a special form of that duty to make extra contribu- For discussion of CO to military service, see e.g. C.A.J. Coady. Objecting morally, J Ethics 1997; 1(4):375–97; C. Cohen. Conscientious tions to the upkeep and preservation of ones society in objection, Ethics 1968; 78(4):269–79; K.W. Kemp. Conscientious objec- times of crisis. Arguably, there is a related special duty tion, Public Aff Q 1993; 7(4):303–24. For discussion of CO in healthcare to collaborate with others to try to prevent crises. On see, e.g. J. Savulescu. Conscientious objection in medicine, BMJ 2006; some occasions a society will come under threat from 332:94; M.R. Wicclair. 2011. Conscientious Objection in Health Care: An hostile military forces. Recognizing that threats to their Ethical Analysis. Cambridge: Cambridge University Press. United Nations. 2012. Conscientious Objection to Military Service. Geneva: United Nations Human Rights, Office of the High Commis- CPTI 2006, op. cit. note 12, pp. 121–23. sioner; 7–20. Available at http://www.ohchr.org/Documents/Publica- Advisory Committee on Conscientious Objectors (ACCO). 2016. tions/ConscientiousObjection_en.pdf [accessed 2 February 2016]. Advisory Committee on Conscientious Objectors, https://www.gov.uk/ Conscience and Peace Tax International (CTPI). 2006. Military government/organisations/advisory-committee-on-conscientious-objec- Recruitment and Conscientious Objection: A thematic global survey. tors [Accessed 1 February 2016]. Leuven: CTPI:89–104. Available at http://cpti.ws/cpti_docs/brett/ M. Coombs & L. Reyner. 2003. Conscientious Objection to military recruitment_and_co_A4.pdf [Accessed 1 February 2016]; United service in Australia. Department of the Parliamentary Library Research Nations. 2012. op. cit. note 11. Note, 31(2002–3). V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd 158 Steve Clarke, Alberto Giubilini and Mary Jean Walker preservation are liable to occur, most societies maintain been required to demonstrate that their objection is con- standing military forces to deter or repel such threats. sistent with their other beliefs, and consistent with their Forces may be maintained by voluntary enlistment actions. and/or by legislating a compulsory period of national service. When emerging threats are significant, military ANALOGIES AND DIFFERENCES forces may need to be expanded via conscription. Peo- BETWEEN CO TO MILITARY SERVICE ple may be understood to have a duty to serve in their AND TO VACCINATION: LIBERTY, RISK, societies standing military forces and/or to serve in AND UTILITY expanded military forces during time of crisis, and may be conscripted to do so. Those who have a conscien- Since infectious disease, like an invading military force, tious objection to military service may be permitted to can pose a severe potential threat to society – including avoid having to serve in the military, but their obligation threats to political stability and national security –it is to contribute to the upkeep and preservation of their arguable that, by analogy to their duty to contribute to society does not thereby disappear: hence our expecta- military forces, ordinary people have a duty to contribute tion that they perform commensurate roles that benefit to the effort to prevent infectious diseases. In fact, the their society. analogy between infectious diseases and war is quite The second line of justification for insisting that con- widespread in the public health ethics literature. This scientious objectors perform duties that are roughly duty to prevent contagion involves sub-duties regarding commensurate with active military service is that society behaviour during times at which there are outbreaks of needs to take steps to prevent free-riding. There is an diseases. For example, if people are instructed by a legiti- ongoing temptation for individuals to accept the bene- mate authority to quarantine themselves for a period of fits that spring from being part of a society without time, then they have a duty to follow this instruction. contributing to the upkeep and preservation of that They also have a duty to help prevent the outbreak of society. Generally, societies can survive when there are a diseases. This involves, inter alia, a duty to receive vacci- few free-riders, who do not pay taxes, observe laws, nations so as to contribute to herd immunity when the refrain from damaging public property, and so on. disease is communicable. However, if the number of free riders becomes too high, Infectious diseases are analogous to the threat of inva- the future of that society itself is undermined, as it sion by hostile military forces in that in both cases the struggles to maintain itself under the weight of unpro- upkeep and preservation of society can be threatened. It ductive and counterproductive free-riders. An additional is arguable that infectious disease has actually been more problem is that if non-free riders are aware that there of a threat to the upkeep of society than war. Somewhere are significantly many free-riders in their society, then between one-quarter and one-third of the population of their own commitment to contribute to that society can Europe – and up to three-quarters of the population in be undermined by resentment towards free-riders, which some areas – are thought to have died of plague in the makes it more likely that they themselves will become th mid-14 Century, which is a far more significant rate of free-riders. Participation in military forces is often thought to be an onerous duty, so there is a strong temptation to avoid that duty. If the appeal to CO were to enable one to H. Feldbaum et al. Global health and national security: the need for avoid that duty, and not acquire some commensurate critical engagement, Med Conflict Surviv 2006; 22(3):192–198; A.T. Price-Smith. 2002. The health of nations: infectious disease, environmen- duty, then it would enable free-riding. Potential free tal change, and their effects on national security and developments.New riders would seek to present themselves as sincere consci- York: MIT Press. entious objectors in order to avoid military service, while 17 This duty may be grounded in the status of public health (or herd still benefiting from the protection that military forces immunity) as a public good, shared in the community in which one lives provide. If we ensure that conscientious objectors to mili- (A. Dawson. The determination of “best interests” in relation to child- hood vaccinations, Bioethics 2005; 19(2):188–205; M. Navin. Resisting tary service make a contribution to society that is equiva- moral permissiveness about vaccine refusal, Pub Aff Q 2013; 27(1):69– lent to military service, such as providing community 85; S.B. Omer et al. Vaccine refusal, mandatory immunisation, and the services for a length of time roughly equal to the period risks of vaccine-preventable diseases. New Engl J Med 2009; that conscripts are required to provide military service, 360(19):1981–8); or based on the duty to avoid harming others: J. Harris we discourage free-riders from seeking to present them- and S. Holm S. Is there a moral obligation not to infect others? BMJ 1995; 311(7014):1215–17; M. Verweij. 2006. Obligatory precautions selves as sincere conscientious objectors. The possibility against infection, in Ethics and Infectious Disease. M. Selgelid, M. Bat- that free-riders might present themselves as genuine con- tin, and C. Smith (eds). Blackwell: Malden, MA: 70–82. These different scientious objectors also underpins the obligation of con- ways of understanding the duty do not affect our argument here. scientious objectors to provide a demonstration of G. De Grandis. On the analogy between infectious diseases and wars: sincerity. Objectors to military service have generally how to use it and not to use it. Public Health Ethics 2011; 4(1):70–83. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd Conscientious objection to vaccination 159 death than during any war that has ever been fought in they were denied the right to object, the aforementioned Europe. It is estimated that 80% of the indigenous pop- costs need to be balanced against the prospective benefits ulation of Mexico died of viral hemorrhagic fever in the to be gained by these individuals. It seems that individual th mid-16 Century, which is a much greater rate of mor- benefit is higher in the case of vaccination, since the vac- tality than that caused by the Spanish Conquistadors or cinated individual benefits by obtaining immunity to dis- any other military force in Mexico. ease and there is no corresponding benefit obtained by In cases of both vaccination and conscription, a duty military service. There are, of course, individual benefits is imposed on individuals and is justified by appeal to a that military conscripts may enjoy. Military conscripts public good: national security from external military are, almost invariably, paid for their service and can threats in one case, and group immunity to some infec- receive specialist training that can benefit them later on tious diseases (which is also relevant to national security) in civilian life. Some can also go on to enjoy successful in the other. In both cases, the duty entails three types of careers in the military itself. costs for the individual: a liberty cost, personal risk, and Considering analogies and differences with the military a utility cost in terms of time and energies required of case in terms of liberty, risk, and utility costs, it seems the individual. that in the case of CO to vaccination there are at least The liberty cost is roughly the same in both cases of equally strong, if not stronger, reasons for compelling vaccination and the military, because in both cases an conscientious objectors to make commensurate efforts to individual is asked to do something they might not do help prevent the outbreak of infectious disease and/or to voluntarily. In both cases, CO can be claimed by appeal- contribute to the welfare of the community in general. ing to a principle of liberty. They have a duty to make these commensurate efforts The risk for the individual is higher in the case of and, as our earlier discussion of free-riding shows, we as military conscription, at least during wartime, than a society have strong reasons to seek to ensure that they vaccination, because fighting in war entails a risk to make such commensurate efforts. the life of soldiers, whilst the vaccines that are approved by therapeutic goods regulators and used IMPLICATIONS OF THE ANALOGY FOR today are very safe. Side effects occur, but are rare and CO TO VACCINATION for the most part negligible. In peacetime, the risk of military service is low, although the possibility that a On the basis of the analogy to CO to military service we conflict may happen during ones military service can draw two broad policy implications for CO to vaccina- should be factored in when assessing the risk associated tion. First, it is legitimate to expect those conscientiously with conscription. objecting to vaccination to supply evidence of their sincer- The utility cost is much higher in the case of military ity. Second, those who conscientiously object have an obli- conscription than vaccination, since conscripts are gation to contribute to the upkeep of their society. required to spend considerable time in the army training Sincerity can be assessed by testing the consistency of for combat. By contrast, vaccines only entail the small the claimed CO with the persons other beliefs, and with utility costs involved in attending a medical appointment, their actions. This may be assessed through personal inter- since the procedure (a simple injection) is usually quick views and/or written applications to tribunals, boards, or and relatively painless. A further cost of undertaking 24 committees, which may be civil or military in makeup. either military service or vaccination, when doing so Current practices surrounding CO to vaccination do goes against ones conscience, might be called a cost of not generally require objectors to state reasons for their psychological, or moral, distress. objection. In Australia, for example, all conscientious In order to appreciate the severity of the burden that objectors have had to do, in the past, was to sign a form would-be conscientious objectors would have to bear if stating that they have a conscientious objection and to have this form signed by a practitioner to certify that a Encyclopaedia Britannica. 2016. “plague.” Britannica Academic. healthcare professional had discussed the benefits of vac- Web. 31 Jan. 2016. Available at http://academic.eb.com/EBchecked/ topic/462675/plague [Accessed 1 February 2016]. cination with them. In the US, most states that allow a R. Acuna-Soto, L.C. Romero & J.H. Maguire. Large epidemics of hemorrhagic fevers in Mexico 1545–1815, Am J Trop Med Hyg 2000; 62(6):733–39. United Nations, op. cit. note 11; C. Cohen. Conscientious objection, Ethics 1968; 78(4):269–79; K.W. Kemp. Conscientious objection. Public United Nations, op. cit. note 11; Conscience and Peace Tax Interna- Aff Q 1993; 7(4):303–324. tional (CTPI), op. cit. note 12. 22 25 Department of Health. 2015. The Australian Immunisation Hand- M. Klapdor. 2015. Social Services Legislation Amendment (No Jab, book, 10th edn. Canberra: Australian Government Department of No Pay) Bill 2015. Bills Digest (2015–2016) 36. Available at http://www. Health: ch.4. aph.gov.au/Parliamentary_Business/Bills_Legislation/bd/bd1516a/6bd036. C. Cohen. Conscientious objection, Ethics 1998; 78(4):269. [Accessed 1 February 2016]. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd 160 Steve Clarke, Alberto Giubilini and Mary Jean Walker parent to conscientiously object to their children being of a more direct or clearly commensurate way to dis- vaccinated merely require that parent to sign a form or a charge the obligation. notarised statement. However, we do need to be careful with the analogy at These practices may partly be explained by the con- this point. The withholding of some financial benefits sideration that it would be very difficult and very costly from families who refuse to vaccinate their children to assess the sincerity of conscientious beliefs surround- seems consistent with a similar policy in place in the case ing vaccination. For example, in Australia there are of CO to military conscription. Granted, the two types over 40,000 conscientious objectors to vaccination; any of policies are similar in that it is acknowledged that the procedure to assess the sincerity of Australian conscien- community bears a cost for the objection and objectors tious objections to vaccination with reasonable accu- are therefore asked to make up for such cost by provid- racy would require significant resources. Rather than ing the community with a relevantly similar utility sur- expending significant resources to assess sincerity, it plus – a public service in one case, a saving in the budget may therefore be preferable to test sincerity indirectly, that the State could use for other health measures in the by increasing the effort required to conscientiously other. However, denying objectors benefits to which object to vaccination, to a point where free-riders other citizens are entitled is in some relevant respects dif- would find the burdens of objecting to be more onerous ferent from requiring them to do something that other than vaccinating. For instance, objectors might be citizens are not required to do. In particular, it is differ- required to attend educational counselling about the ent in that withholding a benefit does not involve a util- risks and benefits of vaccination for their children and ity cost compared with a non-benefit baseline, whereas for the community (as Salmon and Siegel have sug- providing an alternative service does have a utility cost gested), to discuss vaccination with a medical profes- compared to the non-service baseline. sional (as in previous Australian practice), and so on. It is more difficult to find suitable options for an alter- In addition, CO can be made more burdensome by native contribution to being vaccinated than to military requiring objectors to make some other contribution to service. In times of war, society will not only need sol- societys upkeep. diers. It will require some to hold non-combatant mili- There are some requirements that can be placed on tary positions, and will continue to require people to conscientious objectors to limit the potential costs to undertake other kinds of (non-military) work. Thus society of accommodating their objection. For instance, those objecting to military service might still contribute objectors might be required not to travel to countries to the war effort, or they might contribute to societys where the relevant diseases are known to exist at levels, upkeep in other ways. Whilst such positions may involve or where the population is known to have low vaccina- less personal risk, they might involve similar utility and tion rates, such that the travel could pose a risk to the liberty costs, and they make a contribution to the same persons community upon return. They might also be overall aim. In the case of vaccination there is no obvi- obliged to undertake certain actions in the case of an ously comparable contribution that can be made, in outbreak, such as isolating themselves (or their children) terms of positive impact on herd immunity, or more gen- at home, or submitting to quarantine. erally to public health. While such requirements might lessen the threat posed What form of compensation is fair, then, in the case of to herd immunity from CO they would not discharge the conscientious objection to vaccination? One option is to obligation to contribute to the public good. Conscien- tious objectors might also be required to contribute to One issue with imposing financial penalties is that they may be seen as inequitable: such a system could result in a situation where those on societys upkeep in other ways. They might be made sub- higher incomes can afford to conscientiously object, while those on ject to financial penalties, denied access to financial ben- lower incomes cannot, or to put in another way, that some and not efits, or required to perform community service. The others are permitted to buy their way out of an obligation. While per- policy recently implemented in Australia to remove con- haps of concern (especially if vaccine refusal is associated with particular scientious objectors access to specific financial benefits groups, such that it contributes to the polarization of debate) this is in principle no more of an issue for vaccination than for other sorts of pen- could in this sense be considered justified, given the lack alties such as parking fines. We recognize, however, that the proposals here would limit but not eliminate free-riding. It seems arguable that those who object to participating in combat National Conference of State Legislatures (NCSL). 2016. States with might, as a result, be less able to contribute to it well, and thus allowing religious and philosophical exemptions to school immunization require- them to contribute in a different way benefits society as well as the objec- ments. Available at http://www.ncsl.org/research/health/school-immuni- tor. Although this is a disanalogy with the case of vaccination, since zation-exemption-state-laws.aspx [Accessed 2 February 2016]. ones attitude to vaccination makes no difference to its effect, it strength- D.A.Salmon & A.W. Seigel. Religious and Philosophical Exemptions ens our argument that conscientious objectors to vaccination can be from Vaccination Requirements and Lessons Learned from Conscien- required to make some other contribution, since the duty to contribute tious Objectors from Conscription, Public Health Rep 2001; 116:289–95, to the public good of herd immunity is not transferable in the same way p.293. as that of military service. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd Conscientious objection to vaccination 161 introduce an additional tax for conscientious objectors analysis of policy surrounding CO to military service, we to vaccines. This option raises questions about how we have argued that conscientious objectors have two obli- are to translate the risk involved in compromising herd gations when their objection prevents them from dis- immunity into a fair monetary amount. The risk of a charging a duty to contribute to the public good. These conscientious objector compromising herd immunity will are an obligation to demonstrate the sincerity of their vary for different diseases, as well as in relation to back- objection, and an obligation to make a commensurate ground conditions. Diseases differ significantly in their contribution to society. Imposing a requirement to dis- prevalence, contagiousness and the danger to ones charge some other duty will in many cases function as a health once one becomes infected. Thus, for instance, demonstration of sincerity, thus meeting both obligations CO to vaccination for a less serious infectious disease and enabling policy to side-step difficulties relating to the would pose a lower risk than CO to vaccination for a verification of sincerity. We have argued that in the case disease likely to be fatal to many people in the case of an of vaccination, though a commensurate contribution to outbreak. And in societies with a high overall rate of ones society is not available, objectors could discharge vaccination, cases of CO may pose little threat, while this duty by making a financial contribution to the state they would come to pose a higher threat where rates are (either via a penalty or lack of access to a benefit) that lower. reflects the degree of risk imposed on the community by These factors suggest that an estimate of what a fair their objection. As degree of risk includes the severity of compensation would consist in is not straightforward potential harms, and their probability, calculation of the and equal for all diseases. However, there is no apparent risk involved in not vaccinating will make reference to reason why the compensation required from conscien- the existing levels of vaccine coverage in the relevant tious objectors should not reflect these factors. Financial community. On such a system, the financial contribution penalties (in the form of either fines or the deprivation required of non-vaccinators will increase as overall vac- of benefits) might be developed that reflect the severity cine coverage lowers. When the risk of contagion is very of possible harms, and their probability of occurring. significant and the disease is sufficiently severe, this sys- Penalties for non-vaccination could thus be developed in tem would have to imply a financial compensation which a way that reflects both the potential severity of the haz- is too burdensome for almost anyone to be met. ards of contracting a disease, and the likelihood that not vaccinating for that disease could lead to an outbreak. Acknowledgement Penalties might even be worked out separately for differ- This research was supported by the Australian Research Council ent diseases: for instance, the potential harms from (DP150102068). Alberto Giubilinis research was supported by the chickenpox are generally lower than those from polio, Oxford Martin Program on Collective Responsibility for Infectious but one is less likely to contract polio than chickenpox. Disease. The authors made an equal contribution. This could also enable those who object only to some Steve Clarke is an Associate Professor in the School of Human- vaccines to pay a proportionate penalty. ities and Social Sciences at Charles Sturt University in Australia, On such a system, as vaccination rates decrease, penal- and a Senior Research Associate of the Uehiro Centre for Practi- ties increase, with the effect of not only preventing free cal Ethics at the University of Oxford. He has published over riding, but putting pressure on objectors to examine their seventy academic papers. He is also the author of The Justifica- beliefs. This would provide a way to ensure a balance is tion of Religious Violence (Wiley-Blackwell, 2014). reached between protecting societys interest in maintain- Alberto Giubilini is a Postdoctoral Research Fellow on the Oxford ing herd immunity, and allowing individuals to follow Martin Programme on Collective Responsibility for Infectious Dis- their consciences. ease at the University of Oxford. He has published on different topics in bioethics and philosophy, including the ethics of procrea- tive choices, end of life decisions, organ donations, conscientious CONCLUSION objection in healthcare, the concept of conscience, human enhancement, and the role of intuitions and of moral disgust in Our examination of the analogy between CO to military ethical arguments. service and CO to vaccination is useful for answering the Mary Jean Walker is a Postdoctoral Research Fellow in the ethics two questions with which we began: whether people program of the Australian Research Council Centre for Excellence should be entitled to conscientiously object to vaccina- in Electromaterials Science at Monash University in Australia. tion; and what constraints or requirements CO to vacci- Her research interests include ethical issues related to emerging health technologies, concepts of disease and health, surgical episte- nation should be subject to. In relation to the second mology, addiction, and narrative identity. question, drawing on moral considerations and an For instance, some object in particular to vaccines manufactured using cell lines derived from aborted foetuses, but not to other vaccines, see Department of Health and Ageing (DOHA), op. cit. note 1. V C 2016 The Authors Bioethics Published by John Wiley & Sons Ltd

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BioethicsPubmed Central

Published: Dec 23, 2016

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