The COVID-19 pandemic and the surprising increase in measles outbreaks in recent years has challenged health professionals to address once more the public health concern of infectious diseases that were thought to be eradicated. Increasing numbers of parents, especially in wealthy and highly educated areas of the United States, fear that vaccines are unsafe and refuse to immunize their children (LaVito, 2019). The American Academy of Pediatrics has stated that during a one-year period, 74% of pediatricians reported encountering a parent who refused or delayed vaccination for their child (Balestra, 2016). Although, the refusal rate nationally is only 3.3%, even this small percentage represents a public health concern. Additionally, in some areas of the country the refusal rate is as high as 14.25% (LaVito, 2019). The stellar development of a vaccine for COVID-19 has brought hope in the midst of hundreds of thousands of deaths from the virus, yet 21% of Americans state that they do not intend to get a coronavirus vaccine and are “pretty certain” more information will not change their mind (Funk & Tyson, 2020).
Vaccinations protect individuals and the public from diseases that are preventable and possibly life-threatening. The first vaccination requirements for school entry were enacted in the 1850s to prevent smallpox. By the 1990s, students in all 50 states were required to have specific immunizations (College of Physicians of Philadelphia, 2018). It is important for parents to understand that vaccines receive extensive research and monitoring before they are added to children’s immunization schedules. Each state then uses this data to devise mandates for vaccinations.
Data from the Centers for Disease Control and Prevention (CDC) suggest that vaccinations given to children between 1994 and 2013 may have saved as many as 732,000 lives, as well as prevented 322 million illnesses and 21 million hospitalizations over the course of the children’s lives (Balestra, 2016). Additionally, vaccination is an important factor in containing healthcare and societal costs, saving an estimated $295 billion in healthcare costs and $1.38 trillion over all, through prevention of diseases, such as smallpox, polio, and measles (Balestra, 2016). In-spite-of these impressive benefits, however, vaccinations have long been the focus of ethical controversies. In 2019, anti-vaccine concerns were identified as one of the five most important ethical issues in nursing (American Mobile, n.d.).
The American Nurses Association (ANA) has served as an important voice in establishing guiding policies related to vaccination. The 2015 ANA Position Statement reads:
To protect the health of the public, all individuals should be immunized against vaccine-preventable diseases according to the best and most current evidence outlined by the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP). All health care personnel (HCP), including registered nurses (RNs), should be vaccinated according to current recommendations for immunization of HCP by the CDC and Association for Professionals in Infection Control and Epidemiology (APIC) (ANA, 2015).
This 2015 ANA position statement that supported exemptions from immunization for medical contraindications and religious beliefs is currently under revision. The increased number of cases of measles and other vaccine-preventable illnesses in recent years has intensified concern over non-immunized children. ANA (2019) no longer supports exemptions for religious reasons, noting that to protect the health of the public, unless there are medical contraindications, all individuals should be immunized against vaccine-preventable diseases.
Social media, such as Facebook, Twitter, and YouTube, have been important factors in the dissemination of false information about the safety of vaccines. One study of YouTube videos about immunizations found that 32% of the videos opposed vaccination and had more views and higher ratings than videos promoting vaccination (Hussain et al., 2018). Another study focused on whether individuals effectively assessed the accuracy of online medical information about vaccines. Results showed that although 59% of study participants believed that information on the sites was completely accurate, only 18 of the 40 Internet sites in the study were actually accurate (Hussain et al., 2018).
Surprisingly, false information about vaccinations is often spread by health professionals. Melody Anne Butler, an RN and infection preventionist, found that nurses were involved in spreading false information about vaccines online. This led her to found Nurses Who Vaccinate (n.d.), a nonprofit organization that provides nurses and other health professionals with current, evidence-based information about immunizations (Charles & Gussone, 2019; Nurses Who Vaccinate, n.d.). Butler stated that one of the most common concerns by anti-vaccine proponents is that vaccines cause autism. Yet a recent large-scale study found that children who did not receive any vaccines were more likely to be diagnosed with autism than children who received recommended vaccinations (Reuters, 2019). Butler emphasized the importance of the CDC and other evidence-based resources in providing critical information to debunk myths related to vaccines.
A lack of trust in the safety of the COVID-19 vaccine has been a factor in reluctance to get vaccinated, especially among Black Americans, who may mistrust the vaccine and medical advances due to a history of racism and exploitation, including, most famously, the Tuskegee Syphilis Study and the treatment of Henrietta Lacks, and due to evidence of ongoing racism in current medical practice (Kum, 2020). Only 42% of Black adults say they would consider getting the COVID-19 vaccine, as compared to 63% of Hispanic and 61% of White adults (Funk & Tyson, 2020).
Parents may refuse vaccinations for their children because of religious or philosophical beliefs that conflict with school mandates for immunizations or because they question the safety of vaccines. Religious exemptions are supported by 48 states, and 20 states allow exemptions for philosophical reasons. Vaccination exemptions for medical contraindications are allowed by all 50 states (College of Physicians of Philadelphia, 2018). Parents who refuse vaccinations based on religious and/or philosophical exemptions, however, incur increased risk of illness not only for their child, but also their communities (College of Physicians of Philadelphia, 2018). Thus, it is important for nurses and other health professionals to find ways to implement vaccine regulations to protect the greatest number of people without infringing on individual autonomy.
When an ethical situation is complicated, it is important for a moral agent to be familiar with ethical frameworks and know how to apply them. For a nurse faced with resistance to vaccination, the two primary considerations that are difficult to balance are the individual’s right to autonomy and the nurse’s obligation to non-maleficence, i.e., avoiding harm for patients and society (Hussain et al., 2018). These two considerations parallel closely the ethical frameworks of Immanuel Kant and John Stuart Mill. Kant’s deontological ethics emphasizes respect for persons as autonomous agents with their own free will (Kant, 1785/1993). Mill’s utilitarian ethics favors making decisions that are likely to result in the greatest happiness for the greatest number of people (Mill, 1861/2001).
In the case of vaccination-resisting individuals, as in many complex dilemmas, these two ethical frameworks may at first seem to point in different directions – deontological ethics would seem to point to leaving the individuals to make their own decisions, utilitarian ethics would seem to point to requiring vaccination for the good of society. However, it is common for these two frameworks to appear to be in disagreement when in fact they are not; often, they merely promote different rationales that then arrive at the same decision. In order to make an ethical decision with confidence, it is best to seek a solution that can be seen as moral under both frameworks.
Kant argues that an act is good if the principle behind it is in accord with the categorical imperative, a moral law that holds in all circumstances. One of the major formulations of this categorical imperative states that we must always behave in such a way that we treat any rational being, whether ourselves or others, as an end in themselves and never merely as a means (Kant, 1785/1993, p. 35). Following this guideline, neither a healthcare provider nor the law should coerce an individual, even though it might seem to be for the good of society, because that would be subverting the individual’s will and treating them as a means to a better end for the child, in the case of a parent, and for society. But respecting the autonomy of parents and other adults would not mean simply allowing them to follow their wishes unquestioned. To respect another person as an end in themselves is to recognize their ability to make decisions and form their own good will (Kant, 1785/1993). One way of showing that respect would be to help them be an informed free agent. Thus, initiating a conversation with those who oppose vaccination about the reasons behind their wishes can help to create a dialogue to understand why they object to vaccination, clear up misinformation, and share the evidence science provides in favor of vaccinations.
From the utilitarian side, protection for children and for society are paramount, so it might seem that coercion is called for. And in fact, Mill’s Harm Principle does allow for interference with personal liberties, if the purpose of the interference is to prevent harm to others (Mill, 1859/1978). But Mill’s ethics emphasize the larger picture of good for a society. In an immediate sense, taking away parents’ say over vaccination would help protect a society from preventable illnesses. On the other hand, such a policy would mean creating a society where individuals’ and parents’ rights could be overcalled by the law or institutions or pressured through social coercion. That in itself is bad for society, which is why Mill emphasized individual liberty as part of utility (Mill, 1859/1978). Thus, pressuring or coercing a parent in this situation might fail to promote the greater good for society in this bigger-picture sense.
After considering the complexities of these two moral frameworks, we find that Kant and Mill are largely in accord about the importance of respecting individual freedom, and that respect for persons means treating them as intelligent, independent adults capable of making their own moral decisions. Providing evidence-based information and countering misinformation helps individuals, including parents, to be autonomous moral agents, more empowered to do the right thing for themselves, their children, and for society.
In conclusion, health professionals struggle to maintain an ethical balance between respect for individual beliefs and ensuring the community’s health. Americans struggle to understand the often-conflicting information in the media about whether vaccines are safe for themselves and their children. Research suggests that even parents who support vaccinations are often confused with conflicting information that causes them to question their decisions (Hussain et al., 2018). Nurses can help foster moral agency by providing sound information, explaining the source of misinformation, and creating a dialogue that considers the importance of both individual autonomy and the health of the community.
Christine Sorrell Dinkins, PhD
Jeanne Merkle Sorrell, PhD, RN, FAAN