PoPulationand Public HealtH etHics

policy
in the “anti-cancer vaccine” marketed to females, or instead to communitarian
and/or utilitarian * attempts to reduce illness rates across populations, as
implied by expanding the “anti-stI vaccine” to both sexes.
Who are identified as the primary stakeholders, and what information would
be relevant under each ethical model? An autonomy-based, self-protection
model allows at-risk individuals (or their parents) to “opt-in” to vaccine use;
this requires significant patient/consumer education about individual risks of
exposure, risks and complications of the vaccine, its effectiveness and limitations
(this product prevents only certain HPV strains, does not prevent other
stIs, and may require boosters) and other options to prevent HPV infection.
Communal and utilitarian models would focus less on individual choices than
on epidemiological data about the threshold of herd immunity needed to reduce
cervical cancer rates, the emergence of other HPV strains and economic
comparisons of various strategies to reduce HPV’s impact; achieving public
health targets often requires an “opt-out” approach to routine vaccination.
Policy considerations
When is it appropriate for governments or public health experts to move from
an autonomy-based model of offering people means to protect themselves,
to a routine (or even coercive) program to protect the common good? The
1905 U.S. Supreme Court case Jacobson v. Massachusetts outlined four tests
necessary to justify public health measures such as mandatory smallpox vaccination:
an avoidable harm to public health must be at stake; the method
must have “real or substantial relation” to ensuring protection; any burdens
must not be disproportionate to the expected benefits; and the measures must
not pose undue health risks. 1 These principles have been updated in recent
years for broader public health interventions: James Childress et al. suggest
principles of effectiveness, proportionality, necessity, least infringement and
public justification; 2 Canadian Ross Upshur offers a harm principle, least restrictive
means, reciprocity and transparency. 3
The harms of cervical cancer and other HPV-related conditions justify making
a vaccine available, but HPV does not pose the same extent of public
* Communitarians value groups as more than the sum of their parts, and seek interdependent
thriving; utilitarians seek the “greatest good for the greatest number”, tabulating individual
benefits and harms for a collective net benefit.
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