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Ethical dilemmas of vaccination

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How relevant are gender and age when making policies about vaccination and does this leave governments open to claims of discrimination? Dr Jeroen Luyten from LSE’s Department of Social Policy says it’s time we had the debate.

Each year, more than 527,000 women are diagnosed with cervical cancer worldwide and about half that number dies from the disease, the majority in developing countries.

The cancer is caused by the spread of the human papillomavirus virus (HPV), one of the most common sexually transmitted infections in adults.

To combat this disease, HPV vaccination for girls aged 12-13 was introduced in the UK in 2008, along with many other countries, including the US, Canada, Australia and Europe.

People may ask why boys are not vaccinated. Does the virus not constitute a health risk for them? If they are vaccinated, won’t they also indirectly protect girls? And given the infection is spread sexually, don’t we all have a strong moral reason to become vaccinated?

The answer to all three questions is ‘yes’, according to Dr Jeroen Luyten from LSE’s Department of Social Policy.

“As with most policy decisions, ethical arguments must be balanced against costs and value for money, but it is essential that the ethical side is considered,” Dr Luyten argues.

“This moral question of vaccination can be complex, it has a much larger social dimension than most other medical interventions,” he adds. 

In the case of cervical cancer, the HPV vaccine is one of the most expensive around – about £300 per individual, hence governments opting for the most affordable and cost-effective prevention strategy. But while the biggest share of HPV deaths is due to cervical cancer, adding weight to the policy decision, the virus is also responsible for an estimated 50,000 cancers in men, including penile, anal, throat, neck and tongue cancers.

Girls are obviously a priority because of cervical cancer, but alienating boys from the vaccination schedule could be seen to be discriminatory – from both sides.

“You could argue that targeting women for vaccination actually reinforces a belief that it is a ‘female problem’ and boys have nothing to do with the spread of the virus, whereas clearly both sexes transmit the virus and both could be argued to have to carry the burden of prevention,” Dr Luyten says.

“From boys’ perspective, general estimates of the risks for boys do not reflect intragroup differences in the male gender. More sexually active boys could be a higher risk group for HPV than less-active girls.”

Another example can be found in the prevention of the varicella-zoster virus, causing both chickenpox and its adult version, shingles.

Vaccination of children reduces exposure to chickenpox in the general population but this could lead to an increase in the prevalence of shingles in adults because the latter may need regular exposure to chickenpox in order to preserve immunity against shingles.

Shingles is far more painful and severe for the elderly than chickenpox is for children. If you vaccinate children, adults lose out, but is there an ethical solution? Should we put the health of children before adults, particularly the elderly? How should we make these trade-offs between generations?

Evidence from the US, where chickenpox vaccination is universal, shows that hospitalisation among children has reduced by 88 per cent and deaths by 74 per cent. But studies from the UK  that account for the indirect effect on older generations (e.g. Edmunds and Brisson|) also show how these benefits are offset by an overall increase in shingles cases.

Dr Luyten says it’s time that society started to debate these moral and ethical issues in vaccination policy.

 “On which moral grounds can selective vaccination for one gender or age group be justified? How should policy makers balance opposing health interests? Should children not have the right to protect their own health instead of protecting that of others? And should parents take into account other people when deciding whether or not to have their children vaccinated? Where does freedom of choice and the obligation to cause no harm to others sit within these policy frameworks?

“There are many complex trade-offs involved, to which no final answers exist, and more discussion would be welcome,” he says.

Additional notes

Dr Luyten’s paper on the Ethics of VZV Vaccination| is now available online in the journal Vaccine| : http://www.sciencedirect.com/science/article/pii/S0264410X14013760|

The Sexual Ethics of HPV Vaccination for Boys| is available at: http://eprints.lse.ac.uk/59727/|

Dr Jeroen Luyten| joined the London School of Economics and Political Science in September 2014 as a Fellow in Health Economics and Health Policy in the Department of Social Policy. He holds a master's degree in economics from the University of Antwerp and a master's degree in philosophy from the Catholic University of Leuven.

7 November 2014

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