Vaccination, and Policies for Enforcement

Rob Crilly reported in the Telegraph a couple of days ago that Pakistan is to pursue a policy of fining people who do not have their children vaccinated against polio.  Now, at the time I write this, I can’t find this story or anything like it replicated elsewhere – Dawn, which is Pakistan’s biggest English-language newspaper and has carried 15 stories on polio so far this year (and which is supportive of mass vaccination), doesn’t mention it; nor does al-Jazeera – but let’s allow for the sake of the argument that the story is true, and that fines are to be imposed on parents who fail to get their children vaccinated (or that they’re being at least considered).  I’m in two minds about such a policy.

Obviously, the prevailing attitude in anglophone bioethics is to be suspicious of mandatory interventions into health decisions: it’s hard to get away from the Georgetown Mantra.

On the other hand, polio is very nasty indeed, and Pakistan is one of the three remaining countries in the world where it exists.  (The others are Afghanistan and Nigeria; in all three cases, there have been active campaigns against vaccination on the grounds that it’s “un-Islamic” – which I suppose is true, but only inasmuch as that it has nothing whatsoever to do with Islam – and suspicion of vaccination workers has grown in Pakistan over the last year because they’re seen as potential CIA operatives.)  Vaccination is much less nasty than polio, and Pakistan is already implementing a number of policies (such as offering it free at toll-booths) to increase vaccination.

There seem to be two questions that need to be addressed.  First, is a policy of mandatory vaccination permissible?  Second, is a fine the right way to enforce it?

The main argument against the permissibility of mandatory vaccination is that governments have no business interfering with the private affairs of individuals or families.  But we can accept this as a rule of thumb without having to be dogmatic about it – and there’re plenty of instances in which intervention is not only acceptable, but desirable.  For example, we tend to expect governments to set minimum standards for education and to coerce parents into providing for the education of their children; and the idea that social services overstep the moral line when they intervene in cases of forced child marriage is risible.  At least sometimes, the state intervening in family life is acceptable.

I suppose that there might be a rejoinder to this to the extent that there’s a difference between acting to promote the child’s best interests, and acting to negate things contrary to the child’s interests.  Being married off young is contrary to your interests; but not being married off young does not promote them, so much as leave them as they would have been all else being equal.  Similarly, I don’t promote your mobility by refraining from breaking your leg or stopping others from doing so.  Vaccination, it might be thought, is different, because not being vaccinated does not make you worse off – it just leaves you as you would have been; and there’s nothing wrong with leaving people how they would have been.

Well, yeah.  But that argument can easily be met, on the grounds that we don’t normally think that it’s sufficient for parents to refrain from harming their kids: we tend to think that there should be something more positive going on as well.  But if parents are refusing to discharge that role, then it might well fall to the state to make good at least some of what’s been neglected.  (There would be limits to this: I don’t think that the state has any duty to make good consistently poor birthday presents, but you get the picture.)

So: vaccination might be just another instance of the state intervening in loco parentis for the sake of the people living within its borders.  Polio is bad; it’s better for children to be vaccinated.  It’s better for child B that child A be vaccinated, too, because of herd immunity.  Parents who refuse to vaccinate their children are not perhaps positively endangering them, but they are allowing them to remain in an endangered state, and to act as a reservoir for the illness thereby putting others at risk, when it would be possible to eliminate the danger – and that seems to be blameable to allow that to happen.  Note, to, that child B does not have to be co-existent with A: B could in fact be A’s child.  In the case of polio, this is because the virus is particularly adapted to humans; so once you’ve managed to eradicate it from one generation, you have eradicated it from all generations in the future.

Bluntly, it’s quite possible that there’s a duty to vaccinate, and that the state may enforce this duty.  At the very least, that’s not an obviously lunatic position to adopt.

As to whether fines are the best way to enforce any such duty…  The thing is, it’s already the least-educated who’re most likely to avoid vaccination, and they’re the poorest.  So a financial penalty may not be all that plausible.  Some places refuse to accept children into public schools without proof of vaccination – but this just penalises the child, and makes it more likely that the poor education and poverty in which vaccine suspicion thrives will be perpetuated.

This is where the problem gets hard: even if you think that vaccination should be mandatory, and that the state can enforce it, the question of how it should do so remains open.  Public education is great, but slow.  Freebies at tollbooths might actually turn out to be the best option.