PoPulationand Public HealtH etHics

policy
adults may choose for themselves and/or their children, like vaccines for influenza,
chicken pox or hepatitis A/B?
Fair allocation: Public health programs typically emphasize one of three
competing visions of distributive justice: equality, need or utility. It is sometimes
possible to maximize two of the three, but it is usually impossible to
maximize all three at the same time; something always has to be sacrificed.
The equality, or egalitarian, model extends access to everyone. This approach
is often unnecessarily expensive, as some recipients may not have needed the
intervention, while ensuring equal access in remote areas may be difficult.
The high cost of the vaccine and the varying cancer risk across different socioeconomic
groups makes an egalitarian approach economically unappealing.
Because the vaccine was targeted to 8th graders, however, leaving out other
age groups, equality was only partly emphasized in the Ontario HPV program.
Targeting the program to those in greatest need would, in this case, focus on
vaccine delivery to girls in lower socio-economic strata. The initial emphasis
on prevention of cervical cancer, which is more common than HPV-related
anal and throat cancers and more serious than genital warts, reflects a partly
need-based approach in the Ontario program, although one might also argue
that health risks for men — especially gay men — are ignored. However,
while the need-based model reduces unnecessary interventions, it also risks
(re)stigmatizing the recipients, as noted in the case scenario. When a distributive
justice approach aiming to reduce disparate outcomes inadvertently
reinforces the social injustices that create and perpetuate those disparities,
the appropriate response is to reframe our questions: the issue is not merely
whether to provide this vaccine and to whom, but how to address the underlying
determinants of health that increase vulnerability.
The utilitarian model of distributive justice seeks to achieve the greatest possible
good for the greatest number, within the available resources. Since three
doses of this HPV vaccine are required to ensure immunity, and boosters are
likely needed to maintain it, utilitarians would consider it unreasonable to
offer the intervention to those with a low likelihood of completing the series.
Since the HPV vaccine will not prevent other stIs, a “safer sex” campaign
may be more beneficial overall at much lower cost. Socio-economic determinants
of health must be considered in a voluntary-access program: those at
greatest risk of serious health problems are also most likely to face barriers
in accessing options to protect themselves; targeted deployment to higher-risk
PoPulation anD Public HealtH etHics
110