The Vaccine Blog

Republication from the blog of the American Philosophical Association- The Ethical Complexity of Vaccine Hesitancy

You may not necessarily think about ethics until some ethical question becomes relevant to you. Generally speaking, ethics comprises the standards of conduct that determine “right” and “wrong” behavior as well as the logical reasoning that justifies our moral judgments. More specifically, ethics examines the moral decisions of individuals, who are not just individuals, but are interacting with each other and with society. Nowhere is that more present than in the question of vaccine hesitancy.

Why are people hesitant to get vaccinated? The answer to this will vary hugely between people, cultures, and regions. Western societies have a hyper-individualized culture, which is reflected in the issues we emphasize. For this reason, in Western societies, the single largest issue is the conflict between the freedom of the individual and the responsibility they have to society. That means that, generally, patients are free to delay or reject vaccination. However, this places others at risk of contracting disease, making the issue of patient autonomy in vaccination decisions unique when compared with other medical decisions. 

Patient autonomy is a core principle of medicine and medical ethics. It places the patient at the center of decision-making and recognizes that they are the key stakeholder in decisions that affect them. No serious healthcare professional would dispute that. However, there’s a key phrase worth focusing on: “in decisions that affect them.” In medical decisions that affect the patient alone, the patient is generally free to exercise their autonomy fully. However, when decisions involve other people, especially vulnerable patients like children or the elderly—there can be a conflict of values. 

Daniel Salmon and Saad Omer eloquently take the point a bit further: “A divergence between individual and community benefits may also exist when there are ideological beliefs incongruent with vaccination or individuals are unaware of or do not accept available scientific evidence.” In other words, some ideologies prioritize individual autonomy over social responsibility. These ideologies may lead their adherents to reject or ignore scientific evidence. Consequently, some communities refuse to access available resources that contain the best scientific information. Alternatively, if individuals belong to those communities in which other members restrict the availability of vaccines, they may wish to be vaccinated but lack access to these procedures.

There are diverse reasons why people hold to ideological beliefs that make them hesitant about vaccines. There is, indeed, a subculture of mistrust of vaccines and of scientific and healthcare institutions more broadly. Such beliefs include the view that triple-dose measles-mumps-rubella (MMR) vaccination is linked with autism spectrum disorder (which has been disproven), the idea that HPV vaccination causes fertility issues, and the fear that the side effects of vaccines are disproportionately riskier than those of infectious disease. But why do people form and maintain these beliefs? 

One way to answer this is to consider vaccine hesitancy in a framework of interlinked issues. Consider someone who was born in a community that emphasizes a natural living lifestyle. This lifestyle may include a rejection of vaccination. This individual has spent their whole life within such a community, forming fulfilling personal and professional relationships. Perhaps they have married and had children within the group. It is difficult to revise one’s ethical convictions once one has integrated themselves into a community to this extent. In other communities, such as some ethnic minority communities, individuals remain affected by historical trauma with healthcare institutions. These communities may already have ingrained mistrust toward vaccines as a result of these traumas and ongoing experiences of racial or ethnic prejudice in the healthcare system. If community members feel they have been repeatedly mistreated, further mistrust will grow. Finally, for some vaccine-hesitant people, all of the above scenarios apply. Vaccine hesitancy does not simply exist in a vacuum.

When it comes to parents making vaccination decisions for young children, parental autonomy still applies. Much of the time, we can assume that “respecting [parents’] decisions is respecting their [children’s] wellbeing.” However, this is not always the case. Maybe a child has a condition that means that abstaining from vaccination is dangerous for them. Perhaps there’s an outbreak, epidemic, or even a pandemic that could be life-threatening, such as COVID-19 that exacerbates the danger. In extreme cases like these, the state may override parental autonomy on the basis of medical neglect. These cases are morally and legally controversial for the parents and communities involved.

Overriding individual choice for the sake of the collective good closely links parents’ autonomy with the issue of vaccine mandates. Few things spark controversy in healthcare more than mandating vaccines. The COVID-19 pandemic has intensified this controversy. Vaccine mandates may not necessarily be about the vaccine itself but about freedom and government involvement in personal healthcare decisions. There is a distinction between being against vaccines themselves and being against mandates. Indeed, the issue of vaccine hesitancy can serve as a cover for other, non-medical issues, such as political beliefs, poverty, personal autonomy, and the relationship between the individual and the state. 

A good example of the complexity of vaccine hesitancy is the polio vaccination boycott in Nigeria from February 2003 to July 2004. Following the 9-11 attacks in the U.S. and the American wars in Afghanistan and Iraq, many Muslim communities were increasingly suspicious about anything originating from the West. In northern Nigeria in 2003, political and religious leaders of Kano, Zamfara, and Kaduna states brought the immunization campaign to a halt by calling on parents not to allow their children to be immunized. They argued that the vaccine could be contaminated with antifertility agents (estradiol hormone), HIV, and cancerous agents. The resulting reduction in vaccination rates had devastating consequences. By 2008, Nigeria accounted for 86% of all the polio cases on the continent; Nigeria has struggled to be polio-free since then. The impact that this boycott had on the polio vaccination campaigns highlights how powerfully cultural beliefs—and geopolitical events—can affect vaccine mandates and compliance.  

Unvaccinated and under-vaccinated populations can cause issues outside of public healthcare. Vaccine hesitancy must be seen as a framework of interlinked issues—not just one issue in a vacuum. As with many other ethical questions, there is not a perfect or easy answer to the problem of vaccine hesitancy. It is unrealistic to achieve a single solution to vaccine hesitancy when there are many factors contributing to it along with different cultural varieties of it.