The ethics of vaccination: individual, collective, and institutional responsibilities

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This book talk is co-organised with the Oxford Martin Programme on Collective Responsibility for Infectious Disease

Vaccination raises ethical issues about the responsibilities of individuals, communities, and states in preventing serious and potentially life-threatening infectious diseases. Such responsibilities are typically taken to be about minimising risks for those who are vaccinated and for those around them. However, there are other ethical considerations that matter when defining the responsibilities of different actors with regard to vaccination. Such ethical considerations are not often given due considerations in the debate on vaccination ethics and policy.

Thus, in this talk Dr Alberto Giubilini aims at offering a defence of compulsory vaccination taking into account not only the importance of preventing the harms of infectious diseases, but also the value of fairness in the distribution of the burdens entailed by the obligation to protect people from infectious diseases. He will offer a philosophical account of the key notions involved in the ethical debate on vaccination, of the types of responsibilities involved, of the possible types of vaccination policies ranked from the least to the most restrictive, and of the reasons why compulsory vaccination is, from an ethical point of view, the best policy available, as it is the most likely to guarantee not only protection from infectious diseases, but also a fair distribution of the burdens and responsibilities involved.

About the speaker

Alberto Giubilini is a Postdoctoral Research Fellow on the Oxford Martin Programme on Collective Responsibility for Infectious Disease. He has a PhD in Philosophy from the University of Milan (2010), and prior to joining the Uehiro Centre he worked in Australia at Monash University, University of Melbourne and Charles Sturt University.

He has published on different topics in bioethics and philosophy, including the ethics of procreative choices, end of life decisions, organ donations, conscientious objection in healthcare, the concept of conscience, human enhancement, and the role of intuitions and of moral disgust in ethical arguments. He has published a book in Italian on the ethics of end of life decisions (Morals in the Time of Bioethics, Le Lettere 2011) and co-edited a book on The Ethics of Human Enhancement (Oxford University Press 2016) together with Julian Savulescu, Steve Clarke, Tony Coady and Sagar Sanyal. His most recent book is The Ethics of Vaccination and is available via Open Access by clicking here.

About the book

This open access book, The Ethics of Vaccination, discusses individual, collective, and institutional responsibilities with regard to vaccination from the perspective of philosophy and public health ethics. It addresses the issue of what it means for a collective to be morally responsible for the realisation of herd immunity and what the implications of collective responsibility are for individual and institutional responsibilities.

The first chapter introduces some key concepts in the vaccination debate, such as ‘herd immunity’, ‘public goods’, and ‘vaccine refusal’; and explains why failure to vaccinate raises certain ethical issues. The second chapter analyses, from a philosophical perspective, the relationship between individual, collective, and institutional responsibilities with regard to the realisation of herd immunity. The third chapter is about the principle of least restrictive alternative in public health ethics and its implications for vaccination policies. Finally, the fourth chapter presents an ethical argument for unqualified compulsory vaccination, i.e. for compulsory vaccination that does not allow for any conscientious objection.

The book would appeal to both philosophers interested in public health ethics and the general public interested in the philosophical underpinning of different arguments about our moral obligations with regard to vaccination.

Oxford Martin School,
University of Oxford


Speak Kindly says:

Rotavirus? Nope, no herd immunity there either…
“We document here the occurrence of vaccine-derived rotavirus (RotaTeq [Merck and Co, Whitehouse Station, NJ]) transmission from a vaccinated infant to an older, unvaccinated sibling, resulting in symptomatic rotavirus gastroenteritis that required emergency department care. Results of our investigation suggest that reassortment between vaccine component strains of genotypes P7[5]G1 and P1A[8]G6 occurred during replication either in the vaccinated infant or in the older sibling, raising the possibility that this reassortment may have increased the virulence of the vaccine-derived virus.”

“In fact, transmission of these two rotavirus vaccines or vaccine-reassortment strains to unvaccinated contacts has been detected, even in the absence of symptoms.”

Rotateq vaccine strain reassortment and subsequent gastoenteritis infection in vaccine recipients was also observed in a 2012 study in 61 infants.

widespread introduction of the vaccine strain has altered the genetic makeup of wild-type rotavirus that now infects exposed populations.

Speak Kindly says:

Vaccine derived herd immunity from measles has been complete fantasy..
Measles vaccine can not prevent outbreaks. During the 1989-1991 U.S. outbreaks, 20 per cent to 40 per cent of those affected had received one to two doses, "over 50 per cent of the 98 individuals had received two doses of measles vaccine. However, even with two documented doses of measles vaccine, our laboratory demonstrated that 8.9% of 763 healthy children immunized a mean of 7.4 years earlier lacked protective levels of circulating measles-specific neutralizing antibodies, suggesting that even two doses of the current vaccine may be insufficient at the population level." – “The re-emergence of measles in developed countries: Time to develop the next-generation measles vaccines?”

“During the measles outbreak in California in 2015, a large number of suspected cases occurred in recent vaccinees. Of the 194 measles virus sequences obtained in the United States in 2015, 73 were identified as vaccine sequences.” About 38 percent of suspected measles cases in the 2015 Disneyland measles cases in California were actually vaccine-related and not caused by transmission of wild-type measles.” “Rapid Identification of Measles Virus Vaccine Genotype by Real-Time PCR”

“This measles outbreak occurred in an adult population with high 2-dose measles vaccination coverage. The primary patient had documentation of receipt of 3 doses of measles-containing vaccine, one each at ages 1, 2, and 6 years, per the vaccination schedule in Ukraine.” All 9 infected subjects were vaccinated and had modified measles symptoms. 163 unvaccinated contacts were not infected with measles. This study demonstrates that modified measles infection common in vaccinated people is likely misdiagnosed in the lack of an identified outbreak, that measles vaccine provides only temporary protection against symptoms of infection, and that post-vaccination..individuals exposed to wild virus can transmit infection to others even when the symptoms of infection is modified by vaccination.
“Measles Outbreak in a Highly Vaccinated Population”

Fever occurring subsequent to measles vaccination is related to the replication of the live attenuated vaccine virus. In the case presented here, the vaccine virus was isolated in the throat, showing that subcutaneous injection of an attenuated measles strain can result in respiratory excretion of this virus.

This is the first report of measles transmission from a twice vaccinated individual. The clinical presentation and laboratory data of the index were typical of measles in a naïve individual….Of 88 contacts, four secondary cases were confirmed that had either two doses of measles-containing vaccine or a past positive measles IgG antibody. All cases had laboratory confirmation of measles infection….This outbreak underscores the need for thorough epidemiologic and laboratory investigation of suspected measles cases regardless of vaccination status.

“We report a case of measles inclusion-body encephalitis (MIBE) occurring in an apparently healthy 21-month-old boy 8.5 months after measles-mumps-rubella vaccination. He had no prior evidence of immune deficiency and no history of measles exposure or clinical disease.” – “Measles Inclusion-Body Encephalitis Caused by the Vaccine Strain of Measles Virus.”

Measles inclusion body encephalitis is inevitably fatal….The latencies between vaccination and the development of measles inclusion body encephalitis in the publications described were 4 and 9 months. Evidence convincingly supports a causal relationship between MMR vaccine and measles inclusion body encephalitis in individuals with demonstrated immunodeficiencies.

“The reported coverage of the measles-rubella (MR) or measles-mumps-rubella (MMR) vaccine is greater than 99.0% in Zhejiang province. However, the incidence of measles, mumps, and rubella remains high.” – “ Difficulties in eliminating measles and controlling rubella and mumps: a cross sectional study of a first measles and rubella vaccination and a second measles, mumps, and rubella vaccination.“

“The number of measles cases reported in the first 10 months of 2013 – was three times the number reported in the whole of 2012. This is all the more odd considering that since 2009…the first dose of measles-virus-containing vaccine has reached more than 90% of the target population. One would expect with increasing measles vaccine uptake there would result in a decrease in measles incidence.” – “Monitoring progress towards the elimination of measles in China: an analysis of measles surveillance data”.

Excretion of vaccine strain measles virus in urine and pharyngeal secretions of a child with vaccine associated febrile rash illness, Croatia, March 2010

“Detection of vaccine-strain measles virus in urine by polymerase chain reaction confirmed the diagnosis of a vaccine reaction rather than wild-type measles.”
“What is the cause of a rash after measles-mumps-rubella vaccination?”

“Detection of measles virus RNA in urine specimens from vaccine recipients.”

“We conclude that outbreaks of measles can occur in secondary schools, even when more than 99 percent of the students have been vaccinated and more than 95 percent are immune.”
“Measles outbreak in a fully immunized secondary-school population.”

“Vaccination coverage for the total population was 99.0%. Incomplete vaccination coverage is not a valid explanation for the Quebec City measles outbreak.”
“Major measles epidemic in the region of Quebec despite a 99% vaccine coverage”.

“Late Onset of Vaccine-associated Measles in an Adult with Severe Clinical Symptoms: A Case Report”.

“Even though 95% of the children had measles antibodies after vaccination, vaccine efficacy was not more than 68%.” – “Measles incidence, vaccine efficacy, and mortality in two urban African areas with high vaccination coverage.”

“Overall, 20.7% (6 of 29) of persons known to have received measles vaccine had non-protective titers.” – “Measles-specific neutralizing antibodies in rural Mozambique: seroprevalence and presence in breast milk.”

“Vaccination status was known for 127 studied cases and 76.4% of them had received measles vaccine. The history of previous vaccination did not diminish the number of complications of the cases studied.” – “Clinical and epidemiological findings during a measles outbreak occurring in a population with a high vaccination coverage.”

“in recent years, the new vaccination regime, too, has been failing, with widespread outbreaks again occurring, including among those who have received the recommended dose and especially among infants too young to be vaccinated, and thus unprotected because their mothers had been vaccinated. Now health experts, scrambling to find solutions, are suggesting numerous reforms, including earlier child vaccinations and second doses for adults. Clearly, the science is not settled.” (Financial Post, 2014)

“The epidemiology of measles in Cape Town has thus changed as evinced in this epidemic, with an increase in the number of cases occurring in older, previously vaccinated children. The possible reasons for this include both primary and secondary vaccine failure.” – “The 1992 measles epidemic in Cape Town–a changing epidemiological pattern.”

“Acute encephalopathy followed by permanent brain damage or death associated with further attenuated measles vaccines”. (Moraten strain currently used today, ie: Mor(e) at(tenuated) en(ders) strain).

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