The Right for Autonomy, the Duty of Disclosure and Public Health Considerations - The 2013 Polio Crisis in Israel as a Case Study

Vaccinations often create an ethical and legal conflict between the community interest in health and the individual right to autonomy. The 2013 Polio crisis in Israel provides an example of such a conflict. Aware of this challenge, the Minister of Health articulated and implemented an extensive communication strategy, which is the focus of this law review article. More specifically, the paper addresses several questions: What ethical and legal conflict did the Ministry of Health face? How did the Ministry of Health resolve this conflict? What were the characteristics of the Ministry of Health's communication strategy - specifically, in terms of the nature and content of the information provided to the public? Did the Ministry of Health's communication strategy comply with Israeli law?

To describe the crisis in brief, at the end of May 2013, during a routine environmental surveillance of poliovirus in the sewage system, wild-type poliovirus 1 (WPV1) was detected in several facilities in southern Israel. Several weeks later, a continuous circulation of WPV1 was detected in other parts of Israel. In August 2013, the Israeli Ministry of Health conducted a supplemental immunisation activity (SIA) in the southern region of the country. Two weeks later, based on newly discovered findings indicating the continuous circulation of WPV1 - and notwithstanding the absence of paralytic polio cases - a decision was made to extend SIAs to the entire country. According to the decision, all children who were born after January 1 2004 and who received at least one dose of inactivated poliovirus vaccine (IPV) but not oral polio vaccine (OPV) would receive bivalent OPV (bOPV). The benefit of bOPV to IPV-vaccinated children was marginal; the main purpose of administering bOPV was to protect groups at special risk from being infected with WPV1 and becoming sick. The decision whether to vaccinate a child with bOPV was left to the parents and was not declared mandatory.

The paper consists of 5 parts. After context and an introduction to the case,

• Part II presents the alleged conflict between parents' right to make an autonomous decision regarding their children and the interest of public health, as manifested in the general context of vaccinations and in the specific case of the 2013 polio crisis. The discussion focuses on parents' right to information, the equivalent duty of disclosure, and the issue of understanding. Special attention is given to informational manipulation as endangering parents' understanding of the situation and thus their right to make autonomous decisions regarding vaccinations.
• Part III explores how this conflict was resolved by the Israeli Ministry of Health. For this purpose, an empirical analysis of the communication strategy adopted by the Ministry of Health, and of the information that was delivered to the public following this strategy, is presented. Some key points:
  • The objective of the communication strategy was to achieve a high level of public cooperation and thus high vaccination rates. To achieve this goal, the aim was to build and maintain public trust and create a supportive public atmosphere regarding the decision. An important tool in building and maintaining public trust was transparency to avoid a potential accusation of concealing information. Therefore, it was decided that the public should receive full information from an official health authority.
  • Information was delivered to the public by using various communication channels. The Ministry of Health created an official polio website, which included information regarding the disease and the vaccine, updates concerning new locations where the virus was detected, the number of vaccinated children, a FAQ page, and informational videos. A preexisting national call centre ("The Voice of Health") was reinforced by Ministry of Health staff for several weeks. Parents received informational pamphlets prior to the vaccination, and they were invited to direct questions to public health professionals through an existing Ministry of Health official Facebook interface and live chats. Information was also delivered to the public through interviews with Ministry of Health officials. Print media (national and regional) and online journalism, including various social networks, forums, and blogs, were additional channels for delivering information to the public. Phone calls and short messaging service (SMS) messages to parents who did not vaccinate their children were used to provide information as needed.
  • The main slogan chosen for the campaign was "Just two drops and the family is protected from the risk of Polio." The theme that bOPV protects family members - and not just individuals or "society" - from the risk of polio was repeated in various ways in the information that was delivered to the public. Stressing the benefits of the vaccine to family members and close friends was intended to address the possibility that parents would decide not to pursue vaccination with bOPV because their child had already been vaccinated with IPV, rendering the child protected from paralysis in the event of exposure to WPV1. Calls for the public to show social responsibility or to demonstrate altruism were rare. Moreover, these motives were presented only as a response to claims made by opponents of the vaccine. Only by thoroughly reading all the published information would parents understand that the vaccine provided only a negligible benefit to vaccinated children.
  • As reported here, although the information provided to the public did not include untrue statements, manipulation of information was part of the Ministry of Health's strategy to increase vaccination rates. For example, the fact that the vaccine was not expected to make a real contribution to an IPV-vaccinated child, which carries a negative or at least a neutral connotation, was rarely mentioned. This claim is explained in depth in the context of "informational manipulation".
• Part IV observes whether parents' right to make autonomous decisions applies to vaccinations according to Israeli law and whether this right may be restricted based on public health considerations.
• Part V offers a critical analysis of the communication strategy adopted by the Israeli Ministry of Health during the 2013 polio crisis, exploring implications of informational manipulation (e.g., in the absence of complete information, parents may obtain inaccurate information based on anecdotal stories, rumours, and the activity of anti-vaccination groups or individuals, which could exacerbate distrust - in the long run posing a real danger to public health, which requires cooperation). This section addresses two questions: Did the adopted communication strategy infringe upon parents' constitutional right to autonomy? This question is answered in the affirmative. Was infringing parents' constitutional right to autonomy justified under Israeli law? In short (see the paper for the full analysis), no, it was not: "even if withholding information from parents was expected to increase vaccination rates, any expected benefit was not proportional to the severity of the infringement of parents' right to make an autonomous decision regarding the vaccination of their child." The argument here is that other, less injurious measures could and should have been used.
• Part VI presents conclusions. Here is an excerpt: "providing parents with partial information and using other forms of informational manipulation infringed upon their right to make autonomous decisions, which is considered a constitutional right according to Israeli law. This conclusion, it should be emphasized, holds even though some parents may have understood that the vaccine provided only a marginal benefit to vaccinated children, even though an extensive amount of information was provided to parents, and even though parents were not directly misled through the presentation of false information. The social nature of the vaccine and its mere marginal benefit to vaccinated children compose part of the information that described the nature of bOPV and its purpose. As such, this information was substantial, and providing this information fully, clearly and understandably to parents was crucial for their ability to make an autonomous decision regarding the vaccination of their children.... Depriving parents of material information regarding the social nature of the vaccine and its marginal benefit to IPV-vaccinated children severely hindered parents' ability to understand the nature and consequences of vaccinating their child, and thus, their right to make an autonomous decision was severely restricted. Such harm was greater in scope than the expected benefit to public health....The conclusion from this analysis is that although the information provided to parents was wide in scope and although parents were not directly misled, the Ministry of Health's communication strategy during the 2013 Polio Crisis was not consistent with Israeli law."

The author suggests that this conclusion applies to contexts beyond the 2013 Israeli polio crisis, because all childhood vaccinations against infectious diseases raise the same questions regarding the issue of disclosure discussed in this article. The takeaway is that "describing the severe damage to parents' constitutional right to make autonomous decisions involved in informational manipulation and presenting less injurious measures are expected to contribute to future discussions regarding the issue of disclosure in the context of vaccinations and the communication strategy that should be adopted in crisis situations."