in the abstract establishment of a vaccine mandate may be seen as trust damaging, that measles vaccination mandates are evidence-based and transparent insofar as the objectives and outcomes sought from the program is trust enhancing. Furthermore, the action is not a broad, sweeping, all-vaccines policy, but rather a targeted, healthenhancing measure, which also should foster goodwill.

12. Yang YT, Silverman RD. Legislative prescriptions for controlling nonmedical vaccine exemptions. JAMA. 2015;313(3):247-248.

Conclusions

16. Carabin H, Edmunds WJ, Gyldmark M, et al. The cost of measles in industrialised countries. Vaccine. 2003;21(27-30):4167-4177.

Implementing and enforcing a measles vaccination mandate ensures that, over time, an entire population will be maximally protected from this infectious, dangerous, and disruptive illness through the use of an effective, safe, and readily available public health intervention. Although it would be preferable to not need mandates because everyone trusts in vaccination for protecting not only themselves and their children but also society at large, unfortunately this is not the case in all settings, thereby necessitating the implementation of such mandates.

17. Sugerman DE, Barskey AE, Delea MG, et al. Measles outbreak in a highly vaccinated population, San Diego, 2008: role of the intentionally undervaccinated. Pediatrics. 2010;125(4):747-755.

13. Omer SB, Pan WK, Halsey NA, et al. Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA. 2006;296(14): 1757-1763. 14. Prince v. Massachusetts, 321 US 158, at 166-67 (1944):166-167. 15. Mariner WK, Annas GJ, Glantz LH. Jacobson v Massachusetts: it’s not your great-great-grandfather’s public health law. Am J Public Health. 2005;95(4):581-590.

18. Carabin H, Edmunds WJ, Kou U, van den Hof S, Nguyen VH. The average cost of measles cases and adverse events following vaccination in industrialised countries. BMC Public Health. 2002;2:22. 19. Ozawa S, Mirelman A, Stack ML, Walker DG, Levine OS. Cost-effectiveness and economic benefits of vaccines in low- and middle-income countries: a systematic review. Vaccine. 2012;31(1): 96-108. 20. Zhou F, Shefer A, Wenger J, et al. Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics. 2014;133(4):577-585.

COUNTERPOINT:

Acknowledgments Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

References 1. Measles and rubella weekly monitoring report: week 10, 2015: March 08 to March 14, 2015. Public Health Agency of Canada website. http://phac-aspc.gc.ca/mrwr-rhrr/2015/w10/index-eng. php. Published March 25, 2015. Accessed March 30, 2015. 2. California Department of Public Health, Immunization Branch. California measles surveillance update. California Department of Public Health website. http://www.cdph.ca.gov/HealthInfo/discond/ Documents/Measles_update_3-27-2015_public.pdf. Published March 27, 2015. Accessed April 1, 2015. 3. Wynia MK. Mandating vaccination: what counts as a “mandate” in public health and when should they be used? Am J Bioeth. 2007; 7(12):2-6. 4. Measles (Rubeola). Centers for Disease Control and Prevention website. http://www.cdc.gov/measles/index.html. Accessed March 18, 2015. 5. Rubio PP. Is the basic reproductive number (R0) for measles viruses observed in recent outbreaks lower than in the pre-vaccination era? Eurosurveillance. 2012;17(31):5. 6. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014;133(4):e835-e842. 7. Hendrix KS, Finnell SM, Zimet GD, Sturm LA, Lane KA, Downs SM. Vaccine message framing and parents’ intent to immunize their infants for MMR. Pediatrics. 2014;134(3):e675-e683. 8. Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11):1776-1782. 9. Committee to Review Adverse Effects of Vaccines Board on Population Health and Public Health Practice. Adverse Effects of Vaccines: Evidence and Causality. Washington, DC: Institute of Medicine; 2015. 10. Rashid H, Khandaker G, Booy R. Vaccination and herd immunity: what more do we know? Curr Opin Infect Dis. 2012;25(3):243-249. 11. May T, Silverman RD. Free-riding, fairness and the rights of minority groups in exemption from mandatory childhood vaccination. Hum Vaccin. 2005;1(1):12-15.

854 Point and Counterpoint

Should Childhood Vaccination Against Measles Be a Mandatory Requirement for Attending School? No Peter Schröder-Bäck, PhD; Kyriakos Martakis, MD; Maastricht, The Netherlands

We have no doubt that childhood measles immunization programs aimed at achieving or maintaining herd immunity are justified from both a public health and an ethical perspective. The minor risks that may be associated with the vaccination far outweigh the burden of disease that measles outbreaks produce.1 AFFILIATIONS: From the Department of International Health (Drs Schröder-Bäck and Martakis), CAPHRI—School of Public Health and Primary Care, Faculty of Health, Medicine, and Life Sciences, Maastricht University; the Faculty for Human and Health Sciences (Dr SchröderBäck), University of Bremen, Bremen, Germany; and the Children’s and Adolescents’ Hospital, University Hospital of Cologne (Dr Martakis), Cologne, Germany. CONFLICT OF INTEREST: None declared. CORRESPONDENCE TO: Peter Schröder-Bäck, PhD, Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care (CAPHRI), Department of International Health, Postbox 616, 6200 MD Maastricht, The Netherlands; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.15-1162

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Although the effectiveness of a policy imposing a mandatory childhood vaccination prior to enrollment in school (usually including exemptions because of religious or so-called philosophical reasons)2 may look self-evident, we would doubt that this measure is necessary or sufficient for herd immunity. In fact, the vaccination coverage of local populations where measles outbreaks have occurred is as low as 50%3 and is often the result of nonvaccinated adults.4 Thus, it is reasonable to develop or strengthen policies to approach every unvaccinated candidate, including adults. Here, we have considered mandatory vaccination at school entry from an ethical perspective. In our ethical analysis we have taken into account values such as avoiding harm, autonomy, social justice, and health maximization.5 We are convinced that it is essential to use as little compulsion as possible for successful and justifiable immunization programs.6 Allowing school enrollment only if the child is immunized is a form of compulsion. It is de facto compulsion for many parents, because private alternatives to school like home schooling might be difficult to afford or to accomplish for many parents. Pragmatically, many parents need supervision of their children while they go to work. Thus, not allowing children to attend school is, for many parents, no option. What are the most relevant ethical arguments from our point of view in the context of this issue? It may be argued that the decision of not having one’s child immunized against measles is a matter of liberty or autonomy.7 Our arguments are in fact a clear departure from this perception. John Stuart Mill said that the liberty of individuals shall be protected as long as the exercise of their liberty does not pose harm to others.7 This classic “harm principle” points out that parents who deliberately do not immunize their own child put the community at risk. Potential victims include the parents’ children themselves, nonvaccinated children (including infants too young to be immunized), immigrant children from countries with no access to measles vaccine, and individuals for whom measles vaccination is contraindicated, such as patients with immune deficiencies. Thus, the libertarian argument of self-responsibility—that prevention is one’s individual decision and infection would be one’s own fault—is not convincing. Similarly, the autonomy argument that deciding against immunization is an autonomous act worthy of protection is flawed. It is at least flawed if we understand “autonomy” in the tradition of Immanuel Kant. Immanuel Kant describes acting autonomously as acting on a journal.publications.chestnet.org

maxim on which everyone else could act as well. Yet, if the actual goal of a parent was to free ride on the positive immunization status of others, this would not work out if nobody immunized.8 If a parent were to argue for an autonomous decision of accepting the risk of a measles infection rather than immunizing their child, this decision could be argued to be in conflict with the child’s developing autonomy.9 If we are convinced one should immunize oneself and one’s children against measles, why are we arguing against a positive mandatory measles immunization status for attending school? Such a policy would also seemingly find support from a social ethics perspective: One could argue for forcing all children to be immunized out of fairness, because the benefits and burden of immunization would be equally distributed. In turn, free riders—who are often people of high socioeconomic status who manage to receive exemptions2—would be eradicated. Such fairness is certainly appealing. Yet, along with other authors,2,10 we prefer that incentives and nudges be used to achieve herd immunity to avoid compulsion. Our societies can afford incentives and should explore these possibilities first before turning to compulsion. Examples for incentives could be financial: incentive payments for immunization, lower (health) insurance premiums, or tax exemptions.2 Among the possible “nudges” could be a choice architecture that makes measles immunization the default option (eg, in the pediatrician or family practitioner’s consultations).10 These incentives and nudges could also focus on nonimmunized adults. Although this might entail substantial financial investment, it is certainly affordable for the society. Our main argument against a mandatory positive vaccination status for school and in favor of incentives and nudges is derived from our understanding of social justice. The aim of social justice is to protect the wellbeing of everyone in our societies. We agree with Powers and Faden11 that well-being has certain morally significant, irreducible dimensions (irreducible meaning one dimension may not be traded off or compensated against another). Among these are health and development of capacities for reasoning. In our understanding, the latter is best achieved through state-controlled school education, which offers children equal opportunities to participate in society. Thus, to exclude children from decent school education for health would violate the convincing postulate that both dimensions—education and health—should be irreducible. Although in liberal societies adults may choose to do tradeoffs between 855

dimensions of well-being or other goods, in this context we are talking about the state and parents making an ethically unconvincing tradeoff with the well-being of children. Such a tradeoff would be intended by the policy if school can only be attended when vaccinated. This tradeoff would be a burden to a particularly vulnerable group that needs any society’s best attention: children. Rather than allowing tradeoffs of essential dimensions of well-being by policy design, more energy and resources have to be spent so that children get both: measles immunization and decent school education. No doubt, during a local measles outbreak it may be necessary to close schools temporarily or, arguably, exclude nonimmunized children. Such eventualities must be followed by efforts to limit the resulting educational setback. Also, access to cinemas, amusement parks, or concert halls could be limited for nonimmunized people. Yet, to prevent children from attending school is ethically questionable, potentially discriminating against those of lower sociodemographic status who cannot organize adequate alternative education or receive exemptions. From an ethical perspective, we conclude that herd immunity to protect against measles outbreaks is the right public health goal. However, when it comes to achieving herd immunity we are doubtful that immunization should be a prerequisite for attending school. We remain unconvinced that this is a necessary or a sufficiently effective intervention; it may be more effective to focus on other interventions that include all nonimmunized individuals, including adults. We also see ethical reasons against this unjust policy—not only because wealthier parents might de facto still be able to receive exemptions from immunization. With such a policy the state trades off, in principle, the right to decent education with the right to health. Yet both education and health present irreducible dimensions of well-being. Instead, we should strive to realize both—the right to health and the right to decent education—for everyone.

References 1. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2012;2(2):CD004407. 2. Constable C, Blank NR , Caplan AL. Rising rates of vaccine exemptions: problems with current policy and more promising remedies. Vaccine. 2014;32(16):1793-1797. 3. Majumder MS, Cohn EL, Mekaru SR, Huston JE, Brownstein JS. Substandard vaccination compliance and the 2015 measles outbreak. JAMA Pediatr. 2015;169(5):494-495. 4. Robert Koch Institute. Measles: on the measles outbreaks in Berlin and Bosnia Herzegovina [in German]. Epidemiologisches Bulletin. 2015;5:37.

856 Point and Counterpoint

5. Schröder-Bäck P, Duncan P, Sherlaw W, Brall C, Czabanowska K. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Med Ethics. 2014;15:73. 6. Schröder-Bäck P, Brand H, Escamilla I, et al. Ethical evaluation of compulsory measles immunisation as a benchmark for good health management in the European Union. Cent Eur J Public Health. 2009;17(4):183-186. 7. Nuffield Council on Bioethics. Public Health: Ethical Issues. London, England: Nuffield Council on Bioethics; 2007. 8. O’Neill O. Public health or clinical ethics: thinking beyond borders. Ethics Int Aff. 2002;16(2):35-45. 9. Komrad MS. A defence of medical paternalism: maximising patients’ autonomy. J Med Ethics. 1983;9(1):38-44. 10. Gostin LO. Law, ethics, and public health in the vaccination debates: politics of the measles outbreak. JAMA. 2015;313(11):1099-1100. 11. Powers M, Faden R. Social Justice: The Moral Foundations of Public Health and Health Policy. New York, NY: Oxford University Press; 2006.

Rebuttal From Prof Silverman and Dr Hendrix Ross D. Silverman, JD, MPH; Kristin S. Hendrix, PhD; Indianapolis, IN

We agree with much of what Drs Schröder-Bäck and Martakis1 argue in their counterpoint editorial. The benefits of vaccination outweigh any individual and societal risks accrued by remaining unvaccinated. Ethical arguments in favor of mandating measles vaccination may outweigh appeals to liberty or individual or parental autonomy. Furthermore, mandates would minimize free-riding and maximize public fairness by appropriately imposing shared burdens across society. Where we largely diverge is how we AFFILIATIONS: From the Indiana University Fairbanks School of Public Health (Prof Silverman); the McKinney School of Law (Prof Silverman); Children’s Health Services Research (Dr Hendrix), Department of Pediatrics, Indiana University School of Medicine; Indiana University Center for Bioethics (Dr Hendrix); and The Regenstrief Institute, Inc (Dr Hendrix). FUNDING/SUPPORT: Dr Hendrix is supported by the National Institutes of Health [Grant K01AI110525]. CONFLICT OF INTEREST: R. D. S. has, in the past 3 years, received funding for his work as a mentor in a Robert Wood Johnson Foundation/ Georgia State University program on public health law education and has spoken publicly on the issue of vaccine law, policy, and ethics. K. S. H. has received grant funding from the National Institutes of Health and The Indiana University Clinical and Translational Sciences Institute Pediatric Project Development Team to study vaccine attitudes and decision-making. She has also been quoted by various public news and media outlets on the topic of childhood immunization and parental attitudes. CORRESPONDENCE TO: Ross D. Silverman, JD, MPH, Indiana University Fairbanks School of Public Health, and McKinney School of Law, 714 N Senate Ave, EF250, Indianapolis, IN 46202; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.15-1164

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