Raising Rates of Childhood Vaccination: The Trade-off Between Coercion and Trust

"...the approaches most likely to be effective are those that work to build rapport, empathy, and trust between healthcare providers and members of vaccine hesitant or resistant communities."

In an effort to increase vaccination rates, in 2016, Australia's government introduced "No Jab, No Pay", which involved removing certain tax and childcare benefits for non-vaccinators and formally disallowing conscientious objection to vaccination. The government has also raised the possibility of banning unvaccinated children from childcare centres ("No Jab, No Play"). While not discounting the role of the state in achieving the aims of public health, this article examines the impact, and questions the ethical justification, of such coercive approaches to childhood vaccination.

The paper begins with a look at state and federal jurisdictions in Australia, also examining the moral responsibilities of individuals and governments. The researchers distinguish the case of compulsory vaccination from other public health policies that enforce compliance through legislation, such as the wearing of seat belts in cars or helmets while riding bicycles. They stress that respect for the rights of individual patients to provide or decline consent to medical treatments is a fundamental precept of contemporary Western societies, arguing that undermining respect for this principle could pose significant dangers - most notably, the potential of an erosion of trust by the community in the medical profession and public agencies. In addition, coercive measures could lead to an ethically problematic isolation or stigmatisation of a population group on the basis of their behaviour. The refusal to treat families by some doctors who have a poor opinion of parents who object to vaccination, for example, amounts to another form of coercion, in their view.

The small but real risks associated with vaccination deserve attention in light of rare but catastrophic events such as the Cutter polio incident in 1955, which involved a contaminated batch of Salk vaccine causing polio infection in 40,000 school children. This and other examples provided in the paper demonstrate that "concerns about the risks associated with vaccination should not be dismissed as unreasonable and that vaccine programmes must be delivered with full transparency about the possibility of unexpected serious adverse events....The combination of a large-scale safety problem (such as the Cutter incident) and a coercive policy may seriously damage trust in the integrity of the medical system in general and the public health system in particular."

Communication comes into play in these ethics-based arguments; centrally: "Where the full details of a treatment have been openly and transparently discussed with a patient - including the risks and potential benefits to themselves and others, no matter how unlikely - and a free and uncoerced decision is made to proceed, it is possible to accept whatever ensues [e.g., an adverse event] without calling into question the integrity of the professional relationship, the authority of the public authorities, or of caring relationships in general. Where governments mandate certain treatments and override the capacity of individuals to make decisions about their own welfare or those of their children all of these basic assumptions may be put at risk."

The article looks at "No Jab, No Pay"/"No Jab, No Play" policies in more detail, pointing to unintended consequences exposed in the media, with reports of anti-vaccination parents seeking out a fringe medical practitioner who was willing to sign medical ineligibility forms fraudulently. In response, Australian experts in vaccination policy have noted that retaining non-medical exemptions that require ongoing conversation with doctors would be preferable. Other unintended consequences of these policies raise concerns about equity - e.g., "the alienation of non-vaccinating families will extend beyond the single procedure of vaccination to exclusion from healthcare services more broadly, with resulting damage both to the families involved and the wider community."

The researchers also argue that the policies can backfire in terms of health education and dialogue in the community. Scholars they cite have underlined the importance of healthcare professionals in shaping parents' decisions on vaccination, suggesting that we should not use them to impose coercive measures that would alienate their patients. These personnel are, it has been observed, well suited to make recommendations, tailoring education and information to each family's needs, background, and context. They are the ones who can engender trust and provide reassurance regarding any perceived and actual risks. For the researchers, this role is threatened by a policy that requires them to be adversarial at times: "a common theme...is that persuasion and education should prevail first and foremost and should only be overruled by paternalism or compulsion in the extreme circumstances in which these approaches do not work and where time constraints could pose a real threat to the child and/or society."

Having considered further issues around public health ethics and coercion, the researchers conclude that the evidence does not support a move to an increasingly mandatory approach that could only be delivered through paternalistic, punitive practices.