Search Results
Five thousand, two hundred and thirty-one publications were returned by the searches (see Figure 1). Eight hundred and twenty-two duplicates were removed in the first instance, leaving 4409 records to be screened by title and abstract. During this screening process 4058 records were excluded, leaving 351 full text publications to be assessed. Of these a further 230 records were excluded (due to not meeting the inclusion criteria, previously unidentified duplicates, or inability to source the full text), leaving 121 publications for inclusion in the review. These included 117 journal articles, three theses and one book.
[Insert Figure 1 here]
Literature Source Type.
Analysis of the ANZSRC Field of Research codes of the source journals of included articles revealed three main areas, or a combination of them (Figure 2). Around half were coded to medicine (63%); of these, just over half were dual coded to ethics (20%) or another code (9%). Twenty one percent of articles were from the philosophy or ethics literature alone; another 25% were from ethics and medicine or ethics and law. Law was the least dominant discipline, with only 12% of articles being coded to law (alone or in combination with other disciplines). This pattern suggests active concern within medicine regarding non-vaccination, but also widespread overlap in concern between medicine, ethics, and law.
[Insert Figure 2 here]
Main Themes Found in the Literature
Articles addressed two central questions (see Table 1):
- Whether vaccine refusal was justified (henceforth ‘refusal’ arguments)
- Whether various policy or practice responses to those who reject vaccines are justified (henceforth ‘response’ arguments)
Descriptive Analysis of Content
The literature was dominated by papers focused on ‘response’ arguments (61%). A smaller group of papers address ‘refusal’ arguments (19%), and about 18% considered both ‘refusal’ and ‘response’, usually making normative arguments about vaccine refusal as background to arguments regarding ‘response’ (See Figure 3). Less than 2% of papers had a different focus.
[Insert Figure 3 here]
‘Response’ arguments were more common in the medical and health sciences literature (ERA FoR code 11, see Figure 4). Although the ethics/philosophy (FoR code 22) and law literatures (FoR code 18) were also dominated by ‘response’ arguments, these journals—unlike medical journals—were more likely to include ‘refusal’ arguments.
[Insert Figure 4 here]
As would be expected, authors made ‘response’ and ‘refusal’ arguments in different ways. In the following sections we consider the detail of how arguments were made. We refer to each included article by its unique reference listed in Table 1.
Table 1. Papers included in the review
Reference
|
Author(s)
|
Year
|
Journal
|
Volume(issue), pages
|
1
|
J. Brennan
|
2018
|
Journal of Medical Ethics
|
44(1), 37-43
|
2
|
M. J. Walker, S. Clarke and A. Giubilini
|
2017
|
Bioethics
|
31(3), 155-161
|
3
|
M. C. Navin
|
2017
|
HEC Forum
|
29(1), 43-57
|
4
|
J. Flanigan
|
2017
|
Journal of Value Inquiry
|
51(1), 199-202
|
5
|
J. J. Delaney
|
2017
|
American Journal of Bioethics
|
17(4), 56-57
|
6
|
E. Parasidis and D. J. Opel
|
2017
|
American Journal of Public Health
|
107(1), 68-71
|
7
|
B. J. Christiaan
|
2017
|
Journal of Bioethical Inquiry
|
14(3), 375-384
|
8
|
P. J. Carson and A. T. Flood
|
2017
|
American Journal of Bioethics
|
17(4), 36-43
|
9
|
M. J. Deem
|
2017
|
Nursing
|
47(12), 11-14
|
10
|
D. J. Opel, J. L. Schwartz, S. B. Omer, R. Silverman, J. Duchin, E. Kodish, D. S. Diekema, E. K. Marcuse and W. Orenstein
|
2017
|
JAMA Pediatr
|
171(9), 893-896
|
11
|
K. R. W Matthews
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 172-173
|
12
|
T. Kuntz
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 168-172
|
13
|
B. L. Hausman
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 193-197
|
14
|
L. Parker
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 176-180
|
15
|
K. Haller
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 187-192
|
16
|
Josh and J. Mazer
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 173-176
|
17
|
K. Browne
|
2016
|
Cambridge Quarterly of Healthcare Ethics
|
25(3), 472-478
|
18
|
T. Ankeney
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 156-158
|
19
|
K. Kirkwood
|
2016
|
Narrative Inquiry in Bioethics
|
6(3), 163-166
|
20
|
Committee on practice and ambulatory medicine, committee on infectious diseases, committee on state government affairs, council on school health, section on administration and practice management
|
2016
|
Pediatrics
|
138(3)
|
21
|
S. Mann
|
2016
|
Journal of the Mississippi State Medical Association
|
57(7), 216-218
|
22
|
J. K. Billington and S. B. Omer
|
2016
|
American Journal of Public Health
|
106(2), 269-270
|
23
|
K. S. Hendrix, L. A. Sturm, G. D. Zimet and E. M. Meslin
|
2016
|
American Journal of Public Health
|
106(2), 273-278
|
24
|
M. Unterreiner
|
2016
|
Journal of Practical Ethics
|
4(1)
|
25
|
R. Griffith
|
2016
|
British journal of nursing
|
25(19), 1076-1077
|
26
|
K. Alexander, T. A. Lacy, A. L. Myers and J. D. Lantos
|
2016
|
Pediatrics
|
138(4), 1-6
|
27
|
American Academy of Pediatrics
|
2016
|
Pediatrics
|
138(3), 2145
|
28
|
K. Stewart
|
2016
|
Thesis (Florida Atlantic University)
|
|
29
|
B. Gray
|
2016
|
Clinical Research and Bioethics
|
7(1), 1000256
|
30
|
A. L. Caplan and D. R. Curry
|
2015
|
Journal of Medical Ethics
|
41(3), 276-277
|
31
|
D. S. Diekema
|
2015
|
Journal of Law, Medicine & Ethics
|
43(3), 654-660
|
32
|
J. C. Bester
|
2015
|
Journal of Bioethical Inquiry
|
12(4), 555-559
|
33
|
M. J. Smith
|
2015
|
Infectious Disease Clinics of North America
|
29(4), 759-769
|
34
|
A. S. Cunningham
|
2015
|
BMJ
|
251, h4576
|
35
|
J. M. Glanz, C. R. Kraus and M. F. Daley
|
2015
|
Plos Biology
|
13(8), e1002227
|
36
|
L. O. Gostin
|
2015
|
JAMA
|
29(2), 121-130
|
37
|
M. Navin
|
2015
|
Book: Values and Vaccine Refusal: Hard Questions in Ethics, Epistemology, and Health Care
|
|
38
|
J. Berlin
|
2015
|
Texas medicine
|
111(9), 22-30
|
39
|
R. H. Jeffery
|
2015
|
Australian family physician
|
44(11), 849-852
|
40
|
S. L. Block
|
2015
|
Journal of Law, Medicine & Ethics
|
43(3), 648-653
|
41
|
H. Y. Lawrence, B. L. Hausman and C. J. Dannenberg
|
2014
|
Journal of Medical Humanities
|
35(2), 111-129
|
42
|
T. Dare
|
2014
|
HEC Forum
|
26(1), 43-57
|
43
|
J. Flanigan
|
2014
|
HEC Forum
|
26(1), 5-25
|
44
|
C. Constable, N. R. Blank and A. L. Caplan
|
2014
|
Vaccine
|
32(16), 1793-7
|
45
|
D. J. Opel, K. A. Feemster, S. B. Omer, W. A. Orenstein, M. Richter and J. D. Lantos
|
2014
|
Pediatrics
|
133(3), 526-30
|
46
|
R. Rhodes and I. R. Holzman
|
2014
|
Pediatrics
|
134(Suppl 2), S121-9
|
47
|
M. Wicclair
|
2013
|
Cambridge Quarterly of Healthcare Ethics
|
22(3), 308-18
|
48
|
M. Navin
|
2013
|
Public Affairs Quarterly
|
27(1), 69-85
|
49
|
J. L. Schwartz
|
2013
|
Human vaccines & Immunotherapeutics
|
9(12), 2663-5
|
50
|
C. A. Rentmeester
|
2013
|
Human vaccines & Immunotherapeutics
|
9(8), 1812-4
|
51
|
R. Grifith
|
2013
|
Br J Community Nurs
|
18(11), 545-7
|
52
|
D. S. Diekema
|
2013
|
Hum Vaccin Immunotherapeutics
|
9(12), 2661-2
|
53
|
J. Blignaut
|
2013
|
Thesis: University of Cape Town
|
|
54
|
D. Ropeik
|
2013
|
Human Vaccines & Immunotherapeutics
|
9(8), 1815-1818
|
55
|
A. Caplan
|
2013
|
Human Vaccines & Immunotherapeutics
|
9(12), 2666-7
|
56
|
Anonymous author
|
2012
|
Medical Ethics Advisor
|
9
|
57
|
K. Insel
|
2012
|
The Virtual Mentor
|
14(1), 17-22
|
58
|
A. L. Caplan, D. Hoke, N. J. Diamond and V. Karshenboyem
|
2012
|
Journal of Law, Medicine & Ethics
|
40(3), 606-11
|
59
|
T. Newman
|
2012
|
Minnesota Medicine
|
95(8), 24-25
|
60
|
D. Isaacs
|
2012
|
New South Wales Public Health Bulletin
|
23(5), 111-115
|
61
|
J. D. Lantos, M. A. Jackson and C. J. Harrison
|
2012
|
Journal of Health Politics, Policy & Law
|
37(1), 131-140
|
62
|
D. J. Opel and D. S. Diekema
|
2012
|
Journal of Health Politics, Policy & Law
|
37(1), 141-7
|
63
|
D. Nulty
|
2011
|
JONA's Healthcare Law, Ethics, & Regulation
|
13(4), 122-4
|
64
|
J. L. Schwartz and A. L. Caplan
|
2011
|
Primary Care; Clinics in Office Practice
|
38(4), 717-28
|
65
|
J. Gilmour, C. Harrison, L. Asadi, M. H. Cohen and S. Vohra
|
2011
|
Pediatrics
|
128(4), S167-74
|
66
|
M. Poreda
|
2011
|
Seton Hall Law Review
|
41(2), 765-811
|
67
|
D. Isaacs, H. A. Kilham, S. Alexander, N. Wood, A. Buckmaster and J. Royle
|
2011
|
Vaccine
|
29(37), 6159-62
|
68
|
A. Finn and J. Savulescu
|
2011
|
Lancet
|
378(9790) 465-8
|
69
|
D. S. Diekema
|
2011
|
J Clin Ethics
|
22(2), 128-33
|
70
|
A. Chatterjee and C. O'Keefe
|
2010
|
Expert Review of Vaccines
|
9(5), 497-502
|
71
|
J. D. Lantos, M. A. Jackson, D. J. Opel, E. K. Marcuse, A. L. Myers and B. L. Connelly
|
2010
|
Current Problems in Pediatric & Adolescent Health Care
|
40(3), 38-58
|
72
|
S. Kling
|
2009
|
Current Allergy and Clinical Immunology
|
22(4), 178-180
|
73
|
D. Khalili and A. Caplan
|
2007
|
The Journal of Law, Medicine & Ethics
|
35(3), 471-7
|
74
|
B. Halperin, R. Melnychuk, J. Downie and N. Macdonald
|
2007
|
Paediatrics & Child Health
|
12(10), 843-5
|
75
|
A. Lyren and E. Leonard
|
2006
|
Clin Pediatr (Phila)
|
45(5), 399-404
|
76
|
J. D. Blum and N. Talib
|
2006
|
Medicine and Law
|
25(2), 273-81
|
77
|
M. Wharton, R. Hogan, P. Segal-Freeman and A. Hinman
|
2005
|
The Journal of Law, Medicine & Ethics
|
33(4), 34-37
|
78
|
A. Dawson
|
2005
|
Bioethics
|
19(1), 72-89
|
79
|
D. S. Diekema and the Committee on Bioethics
|
2005
|
Pediatrics
|
115(5), 1428-31
|
80
|
J. Wood-Harper
|
2005
|
Nursing Ethics
|
12(1), 43-58
|
81
|
E. J. Furton
|
2005
|
Ethics and medics
|
30(12), 1-2
|
82
|
T. May and R. D. Silverman
|
2005
|
Human Vaccines
|
1(1), 12-15
|
83
|
S. P. Calandrillo
|
2004
|
University of Michigan Journal of Law Reform
|
37(2), 353-440
|
84
|
E. J. Furton
|
2004
|
The National Catholic Bioethics Quarterly
|
4(1), 53-62
|
85
|
H. Baker
|
2004
|
Camb Law J
|
63(1), 49-52
|
86
|
P. N. Goldwater, A. J. Braunack-Mayer, R. G. Power, P. H. Henning, M. S. Gold, T. G. Donald, J. N. Jureidini and C. F. Finlay
|
2003
|
Medical Journal of Australia
|
178(4), 175-7
|
87
|
P. McIntyre, A. Williams and J. Leask
|
2003
|
Medical Journal of Australia
|
178(4), 150-151
|
88
|
A. R. Hinman, W. A. Orenstein, D. E. Williamson and D. Darrington
|
2002
|
Journal of Law, Medicine & Ethics
|
30(3), 122-7
|
89
|
J. Froome and K. Badcock
|
2002
|
Nursing Times
|
98(12), 16
|
90
|
D. A. Salmon and A. W. Siegel
|
2001
|
Public Health Reports
|
116(4), 289-95
|
91
|
R. D. Silverman and T. May
|
2001
|
Margins
|
1(2), 505-21
|
92
|
R. Swan
|
2000
|
The Humanist
|
60(6), 11
|
93
|
S. Pywell
|
2000
|
Medical Law International
|
4(3), 223-43
|
94
|
P. Bradley
|
1999
|
Journal of Medical Ethics
|
25(4), 330-4
|
95
|
T. Dare
|
1998
|
Bioethics
|
12(2), 125-149
|
96
|
A. Rogers and D. Pilgrim
|
1995
|
Health Care Analysis
|
3(2), 99-107
|
97
|
N. J. Ngcobo
|
2009
|
Thesis
|
|
98
|
A. Fernbach
|
2011
|
Journal of the American Academy of Nurse Practitioners
|
23(7), 336-45
|
99
|
Deem, M. J., Navin, M. C., & Lantos, J. D.
|
2018
|
JAMA Pediatrics
|
172(6), 514-516
|
100
|
Rossi, R., Rellosa, N., Miller, R., Schultz, C. L., Miller, J. M., Berman, L., & Miller, E. G.
|
2020
|
Pediatrics,
|
146(4), e20200768
|
101
|
Bester, J. C.
|
2018
|
Clinical pediatrics
|
57(5), 505-508
|
102
|
Hadjipanayis, A., Dornbusch, H. J., Grossman, Z., Theophilou, L., & Brierley, J.
|
2020
|
European Journal of Pediatrics
|
179, 683–687
|
103
|
Kennedy, J.
|
2020
|
Perspectives in public health
|
140(1), 23-24
|
104
|
Kling, S
|
2020
|
Current Allergy and Clinical Immunology,
|
33(1), 48-51
|
105
|
Aorora, K. S., Morris, J., & Jacobs, A. J.
|
2018
|
Journal of Clinical Ethics
|
29(3), 206–216
|
106
|
Giubilini, A., Caviola, L., Maslen, H., Douglas, T., Nussberger, A. M., Faber, N., . . . Savulescu, J.
|
2019
|
HEC Forum
|
31(4), 325-344
|
107
|
Zagaja, A., Patryn, R., Pawlikowski, J., & Sak, J.
|
2018
|
Medical Science Monitor
|
24, 8506–8509
|
108
|
Blunden, C. T.
|
2019
|
BMJ
|
45, 71-74
|
109
|
Bock, G. L.
|
2020
|
Journal of Medical Ethics
|
46, 114-117.
|
110
|
Horan, R. A.
|
2019
|
Awards for Excellence in Student Research and Creative Activity – Documents. 7
|
|
111
|
Pierik, R.
|
2018
|
Journal of applied philosophy
|
35(2), 381-398
|
112
|
Navin, M. C., & Attwell, K.
|
2019
|
Bioethics
|
33(9), 1042-49
|
113
|
Haire, B., Komesaroff, P., Leontini, R., & MacIntyre, C. R.
|
2018
|
Bioethical Inquiry
|
15(2), 199-209
|
114
|
Williamson, L., & Glaab, H
|
2018
|
BMC Medical Ethics
|
19, 84
|
115
|
Giubilini, A., Douglas, T., & Savulescu, J.
|
2018
|
Medicine, Health Care and Philosophy
|
21(4), 547-560
|
116
|
MacDonald, N. E., Harmon, S., Dube, E., Taylor, B., Steenbeek, A., Crowcroft, N., & Graham, J.
|
2018
|
Paediatr Child Health,
|
24(2), 92-97
|
117
|
Weithorn, L. A., & Reiss, D. R.
|
2018
|
Human vaccines and immunotherapeutics
|
14(7), 1610-17
|
118
|
Tomsick, E.
|
2020
|
Journal of Law and Health
|
34(1), 129-154
|
119
|
Rus, M., & Groselj, U.
|
2021
|
Vaccines
|
9(2), 113
|
120
|
Bernstein, J.
|
2021
|
Kennedy Institute of Ethics Journal
|
31(1), 17-52
|
121
|
O'Neil, J.
|
2020
|
Journal of medical ethics
|
46, 108-111
|
‘Refusal’ arguments: whether or not vaccine rejection by individual parents is justifiable
Arguments about whether vaccine refusal by individual parents is justifiable included consideration of parents’ rights, the interests of the child (including the legal ‘best interests of the child standard’), the value of herd immunity, the epistemic basis for ethical claims, and the relevance of religious views. Our sampling period included a special issue of Narrative Inquiry in Bioethics which published narratives written by parents to communicate their normative positions on vaccination. Most of these were written by non-vaccinating parents, and they make up over one third of all arguments in the identified literature that support refusal. On balance, most of the literature argues that it is not justifiable for parents to refuse routine vaccination for their children.
Some arguments within the literature were absolute in their position on whether vaccine rejection is justifiable; others weighed competing values in a situation-specific approach. Irrespective of the arguments used to justify a position, most of the literature frames the question of whether vaccine rejection is justifiable based on three key areas of concern: (i) Respect for autonomy, the doctrine of informed consent and the value of liberty, (ii) Consequences for the child and others, and/or (iii) The normative significance of parental trust, distrust, and uncertainty. We explore the main arguments within these concepts below. As the discussion shows, these concepts are not discrete – they are often weighed against one another, linked by causal claims, or held in tension in the arguments made. Figure 5 represents proportionally the ’refusal’ arguments made in the reviewed literature.
[Insert Figure 5 here]
Respect for autonomy, the doctrine of informed consent and the value of liberty
Fifteen papers from this sample present arguments that vaccine refusal is justified based on respect for parental autonomy, rights, or liberties (21, 23, 25, 31, 32, 35, 36, 39, 68, 71, 75, 80, 94, 100, 121). Some argue that vaccine refusal is justified on the basis of preserving legal rights (31, 80) or expression of religious freedom (23). Opposing positions (including from four of the authors who also offer arguments justifying refusal) argue that, on balance, considerations regarding respect for autonomy are, or can be, outweighed by the potential harm caused to the child and others by not vaccinating though the increased risk of vaccine preventable diseases (21, 36, 20, 23, 110). This includes legal perspectives arguing that the freedom to choose is not unfettered (25) and that courts can override parental autonomy if this is in the child’s best interest (75, 85), as well as arguments from religious perspectives that the freedom to exercise religious beliefs needs to be weighed against harm caused to others (21,91). Those who argue that vaccine refusal is justified counter that disrespecting parental autonomy can also cause harm to the child through loss of trust and possible disengagement of the child from the healthcare system (100), and that the increased risk of disease is a price worth paying to ensure that political values are preserved (71). Of note: non-vaccinating parents also assert a right to make choices for their children in support of their refusal (14,18), but unlike others, their arguments are based primarily on epistemic claims about vaccine effectiveness, necessity and safety rather than moral or ethical positions. However, they assert that these doubts necessitate respect for their decision.
Consequences for others and the child
Most of the literature argues for or against the justifiability of vaccine refusal based on consequences. These include potential harms from vaccine preventable diseases or vaccines themselves, or conversely, potential benefits from herd immunity. The concept of herd immunity is deployed in different ways. Those justifying vaccine refusal in certain circumstances argue that in settings where there is a high level of herd immunity, the risk posed by an unvaccinated child is not great enough to override respect for parental autonomy (62, 65, 94, 98), and that the benefits of community protection do not justify the individual risk posed by the vaccine and borne by the child who is already protected through herd immunity (72, 96, 97, 17, 93, 108). Perspectives of non-vaccinators echo these ideas by asserting that some diseases are not harmful enough to proscribe vaccine refusal (14) and that vaccine injury contributes to and justifies refusal (16).
In contrast, those who argue that refusal is not justifiable propose a duty to contribute to herd immunity because it is a public good (7,80, 19,120, 33, 48, 68,115), or that free-riding (allowing one’s child to enjoy the benefits of herd immunity provided by others, while avoiding the risk of vaccinating) is unfair (37,46, 48). On this account, the vaccine refusal of a few may undermine herd immunity and thus cause harm to the many by increasing disease risks (9, 11, 26, 37, 59, 76, 81, 86); further, these risks are borne by the most vulnerable (43). These arguments about harm to others include those made by authors writing from religious perspectives (8, 81, 84, 92, 98). Finally, an account by a vaccinating parent suggests that harms resulting from non-vaccination are blameworthy because they are an intentional act of aggression against vaccinated children (19).
The concept of the child’s interests arises frequently in these publications. Pursuing or protecting these interests generally combines concern about the consequences of non-vaccination for the child with concern for autonomy, in the broad sense of being able to direct one’s life in accordance with one’s values or aims. Authors write about the interests of the child in both a general sense (i.e. the interests of the child outside of a legal context) and in a legal sense (the formal ‘best interests of the child standard’). The legal construction is used both to support (31, 6, 93) and to oppose vaccine refusal. Arguments that receiving a vaccine is in the legal ‘best interests of the child’ (21,39) posit that any deviation from a widely accepted legal view of the interests of a child should weigh the risk of harm to the child (68) irrespective of the parent’s beliefs (78), or that non-vaccination constitutes negligence or child endangerment (28). On the other hand, some authors argue that, from a legal perspective, parents have the right to consent to or refuse vaccination ostensibly using the ‘child’s best interests standard’(93) and that there is insufficient legal precedent to argue that non-vaccination constitutes medical neglect (6).
Arguing from distrust and uncertainty
As previously noted, the sample included a set of papers written from the perspective of non-vaccinating parents. Most of these contributions seek to justify vaccine refusal, and many justifications were grounded in distrust. They call into question vaccine safety and effectiveness (12,13, 14,18), and the accuracy of the reporting of adverse events following immunization (96). They claim financial conflicts, constructing clinicians, clinical medicine, and/or regulatory agencies as untrustworthy or non-credible (12,14,16). They cite empirical studies of non-vaccinators to support parental preferences for natural infection over a vaccine (97). Non-vaccinating parents were not the only authors to make arguments in this vein. Some other authors cite the lack of absolute certainty of vaccine safety as justification for parents refusing vaccines in the interests of their children (28,76), especially regarding newer vaccines for which efficacy is not well-established (34). This line of argument depicts vaccine proponents as driven by commercial interests, thus justifying parental mistrust and refusal (34). Contra this, one paper asserts that refusal on the grounds of mistrust of government or medicine is not justifiable, as it is inconsistent with the scientific evidence and the well-established regulatory processes in place, such as the rigorous clinical testing required to develop and approve vaccines, and the systems established to report adverse events and ensure safety (8).
‘Response’ arguments: claims regarding the justifiability of different responses to non-vaccination
The literature examines four main responses to non-vaccination (i) government mandate policies (such as legal ramifications for refusing vaccination and vaccination as a school entry requirement), and other coercive policies, (ii) exemptions to mandate policies, (iii) individual practitioner and medical practice responses (including patient dismissal from practice for vaccine refusal, vaccinating against parents’ will, and nudging), and (iv) withholding health resources. The literature includes authors who argue that these responses are justifiable and others who argue that they are not. Much like the refusal arguments, some response arguments are absolute in their position, while others advocate weighing competing values in a context -specific way. Like refusal arguments, most arguments for and against particular responses to non-vaccinating parents draw from respect for autonomy, the doctrine of informed consent and the value of liberty, as well as considering consequences for the child and others. Other concepts appearing in these arguments include inequity, and the duties of governments and practitioners. Figure 6 represents proportionally the ’response’ arguments made in the reviewed literature.
[Insert Figure 6 here]
Respect for autonomy, the doctrine of informed consent and the value of liberty
As in the literature on refusal, many arguments about policy or practice responses to non-vaccinating parents depend on the interrelated concepts of respect for autonomy, informed consent and liberty. Five papers engage with the issue of practitioners vaccinating against parents’ will with respect to these concepts. They argue that forced vaccination by healthcare providers violates parents’ autonomy and/or the ethical requirement for informed consent, because vaccination carries risks (80,119), and clinicians have legal obligations to obtain valid consent for procedures (94). Some authors propose alternatives to forced vaccination, including focusing on rebuilding trust (rather than violating negative liberty) (32), and accepting that views on vaccination derive from plural and culturally-specific values (29). On the other hand, proponents of forced vaccination do not engage with these concepts, instead deploying the harm principle and the legal ‘best interests of the child standard’ to justify their position. We explore this argument in the following section “Consequences for the child and others”.
Another set of papers make arguments about vaccine mandates that also draw on autonomy or liberty justifications, often weighing these against harm or risk of harm. Arguments justifying mandates are often legal in nature and use, for example, the harm principle or case law to argue that the freedom or liberty to choose not to vaccinate is limited by the risk of ill health and/or death to the child or others in the community, including vulnerable persons (83,91). One author argues that legal actions should be brought against those who harm others by refusing vaccination, as this would both discourage refusal and, in the case of any successful claims, compensate victims (55). Some authors argue that mandates are justifiable if the exercise of liberty rights poses a threat to public health (53,82,83,91,119). While those arguing that mandates are not justifiable sometimes rely on arguments about risk of harm—i.e. that in a low-incidence (and therefore low-risk) setting mandates cannot be justified (45, 87,104)—most make their arguments from autonomy, informed consent, and personal liberty and do not weigh these against the potential for harm (12,16,61,82,89,107,114). One author argues that even if mandates improve vaccination rates, they damage trust with parents and make refusers more steadfast in their decision (121), so are not sustainable. Finally, some authors present middle-ground positions that—in their view—are more autonomy- or liberty-preserving, including persuasion (121) or weakly enforced mandates (71), or argue that policy responses should take the least coercive approach that is feasible and effective to balance the needs of the individual with public health (117).
Those supporting conscientious objection to mandates argue that such provisions contribute to the collective good of a culture of respect for autonomy (82), or reflect the “American ideal” of personal freedom (66). Contra this, those opposed to conscientious objection provisions argue that challenges to mandates based in religious freedom have failed in case law, as the right to practice religion freely does not include the liberty to expose children or communities to disease (20,92). One author provides a qualified view of conscientious objection on religious grounds, arguing that such liberties could be justified only while high vaccination rates are maintained (109).
Authors disagree about whether certain policy or practice responses do, or do not, respect autonomy or uphold important liberties. For example, authors disagree on the effect of both nudges and conscientious objection policies on parental autonomy or liberty. With respect to nudges, some argue they are autonomy-preserving because they steer parents in a certain direction while allowing choice (106), do not override or challenge the strong views of deeply opposed opponents (42, 44) and uphold informed consent (121). Some supporters of nudging weigh multiple normative considerations, arguing that nudges that appeal to social responsibilities in a medical practice setting are justified because they appropriately balance parental autonomy against the practitioner’s responsibility to promote trust and collective benefits (3,80). Those opposed to nudges for vaccination decisions argue that the invasive nature of immunization increases the need for independent and informed decision making (60,113). These authors argue against a presumptive consultation style in general practice, proposing participatory clinical encounters (114), and using persuasion (42), as alternatives to more coercive approaches.
Consequences for the child and others
Many of the arguments in this literature consider individual and collective consequences—benefits, harms, burdens, and costs to society — and propose that these may override other normative considerations. The risk and prevention of harm is particularly pertinent here. For example, a parental decision can be overruled in cases where there is a significant risk of harm to the child (78), or nudges become more justifiable when the risk of harm to others is higher (3, 75).
Arguments about mandates often include concern about consequences, since it is inherent in a vaccine mandate that there will be some costs associated with non-vaccination. Mandate proponents argue that mandates ensure high vaccination rates, thus preventing disease outbreaks (39) and associated harms (97), so are in the best interest of individual children (28, 73, 111) and serve the greater good (4,28,73,79). Some justify mandates by proposing a duty to contribute to herd immunity, including under the “clean hands principle”, that is, an obligation not to participate in collectively harmful activities (1,5). Conversely, some authors argue that mandates are not necessary to achieve high levels of population immunity, so state coercion is unjustified at a collective level or at the level of the individual child because each child receives limited benefit (94). Those opposing mandates also argue that vaccine safety is not absolute (88) and that mandates are a disutility, carrying associated costs with surveillance and enforcement (95). Other authors sought to balance these kinds of consequences against other normative considerations with respect to mandates, including the level of herd immunity, the risks of non-vaccination to the child and/or society, and respect for parental autonomy (32,53,88,119). One author argues that mandates protect ‘victims’ of the anti-vaccination movement from harms so long as certain conditions are met (43): that the vaccine can prevent infection and transmission, that individuals minimize their risk of exposure, and that the right of self-defense is preserved (e.g. in the case of allergy to vaccines).
Consequences are also important to arguments about conscientious objection, but here it is generally concerns about the impact on the collective. Some argue that exemptions should not be allowed because they may increase rates of disease or undermine individual or community health (20, 87, 118); others argue that if disease risk is low, exemptions are justified because those few individuals with exemptions do not pose a risk to others or herd immunity (20, 82, 105).
Consequences to the child and others are used to justify whether responses should be applied in general practice settings. As mentioned in the previous section, some authors justify healthcare workers vaccinating against a parent’s will using both the harm principle (69) and the legal ‘best interests of the child standard’ (25); others suggest it is against the legal best interests of an older child to be forcibly vaccinated, as this may have a more detrimental impact than being unvaccinated (25,51). The best interests of the child are also invoked extensively to argue that non-vaccinating families should not be dismissed from medical practices (98,104, 26, 75). Here authors note that an unvaccinated child is more vulnerable to vaccine preventable diseases (9, 49), practice dismissal limits opportunities to access health care (31,52, 56,79,116) and the increased risk of harm from vaccine preventable diseases is transferred to other practices (9,47,49). One paper makes an argument about the consequences of treating non-vaccinating families for general practitioners, suggesting that practices caring for unvaccinated children should disclose this to other patients to minimize medicolegal risks, and should receive legal protection to account for the increased liability and risk of caring for these patients (40).
A small body of literature employs claims about who is responsible for the consequences of non-vaccination to make arguments about responses to non-vaccination. For example, one article seeks to justify discriminating against unvaccinated children with a vaccine preventable disease by limiting their access to health resources, relying on precedents such as coronary bypass surgery being withheld from obese people and smokers, and arguing that those who contribute to their own ill-health (in this case by not vaccinating) do not deserve healthcare (80). A related argument focuses on managing refugee camps during outbreaks that pose a direct and imminent threat of harm, proposing that the state is justified in withholding humanitarian aid from non-vaccinating refugees because the state is responsible for setting conditions that provide protection to (or prevent harm to) aid givers and public health (30).
Inequity
Some critiques of policy or practice responses to non-vaccination emphasise that these responses can have inequitable effects and argue that this is unjustifiable. Exemption policies are a key focus here. Five papers argue against exemptions to vaccine mandates on the grounds that these unevenly distribute the risks and benefits of vaccinations (27,61,66, 73,118). These authors propose that the inaction of a few compromises the health of the most vulnerable community members (118) and disenfranchises those with medical contraindications for vaccines (27). One author particularly focuses on home-schooled children, arguing that exempting them from vaccine mandates exposes both those children and society to harm, and that it is in the interests of these children and society that they be protected through vaccination (73). Some authors suggest that policy exemptions could be made justifiable by imposing conditions that offset potential inequities. On this view, exemptions could be justified so long as the refuser is prepared to make a financial or other contribution to help offset the potential financial burden of the diseases they may cause, or to otherwise contribute to social good (2, 22).
Similarly, some opponents of coercive mandates or practice dismissal for non-vaccination critique these responses for having inequitable effects. It is argued that coercion risks creating a group of disenfranchised people (113) and that different people have different capacities to resist coercive policies (114). Similarly, dismissal leaves vulnerable children without advocacy (64), leads to patients not being treated equally (63) and marginalizes children from health care (74). One paper argues that family dismissal should be strongly discouraged, and an alternative mutually beneficial solution sought after considering the interests of the patient, physician, family, community, and society at large (74).
The duty of practitioners and the state
Some papers address the duties of practitioners and the duties of the state to respond to non-vaccination, in ways that go beyond simply weighing up consequences, implications for autonomy or freedom, or equity of impacts.
A variety of duties of practitioners are proposed. The first of these is to protect a child from their parent's beliefs if those beliefs are likely to cause significant harm, which is used to justify initiating child protection proceedings to vaccinate against a parent’s will (67). Another is to protect patients in the waiting room from the risks posed by non-vaccinating patients, which is used to justify dismissing non-vaccinating patients from practice (9,26,38, 40,45). Counter-obligations are used to argue against practice dismissal. These include a health professional’s obligation to provide healthcare in the best interest of the child despite the parent’s decisions, and to deal with infectious disease as a part of their role (9,26,45,47, 56,101). Authors also argue that physicians’ obligations exclude enforcing parental accountability through dismissal, especially if that means the child is held accountable for the actions of their parents (47), and that continuing to provide care to a non-vaccinating family does not make the physician complicit in their decision (116).
It is sometimes asserted that the state is obliged to discourage non-vaccination on a number of grounds. This includes a fundamental duty of states to protect society (21), a responsibility of states to protect herd immunity as a common good or to reduce social and financial burdens and costs (53,119), and the state’s role to protect the common good in the face of risks to public health and the fallibility of individuals’ risk perception (54). Some of these arguments focus on exemptions from mandatory vaccination policies, proposing that states can not justify such exemptions because the government’s interest in protecting society outweighs the individual's interest (21) or because vaccination is a social and moral good owed by a society to its children (118).