Catholic bioethical perspectives on Ontario’s HPV vaccination

On 17 October 2007 a Catholic school board in northern Ontario — the Huron-Superior Catholic District School Board (H-SCDSB) — voted 5 to 4 to disallow within their schools the human papillomavirus vaccination programs for grade 8 girls that were being led by local public health units. As this was the only school board in Ontario to disallow the program (other school boards had close votes), the motivation and reasoning behind this decision have come under scrutiny and provoked debate.

The H-SCDSB’s decision rested on two concerns: that Gardasil (the only currently available HPV vaccine) might pose excessive medical risks, and that vaccinating girls against a sexually transmitted virus constituted “hypocrisy” in an educational system dedicated to teaching Catholic values, including sexual abstinence before marriage.¹ This decision meant that some Catholics in the region had to make alternative arrangements with the Algoma Public Health authority to obtain the vaccine for their daughters. Many families who commute to H-SCDSB schools do so from rural settings, and it is known that rural residence additionally challenges patients’ ability to participate in health care programs.² This has had the effect of reducing the potential reach of the vaccination program to the target population of grade 8 girls in the Sault Ste. Marie area.

Of broader concern is the fact that, even though H-SCDSB was the only school board to disallow an on-site vaccination program, various authorities have given moral direction against the vaccine in the name of Catholic beliefs. Foremost among these is the Ontario Conference of Catholic Bishops (OCCB), who in a letter to the province’s Catholic educators affirmed the right of parents to decide whether to vaccinate their daughters, but also made non-scientific linkages between the vaccination program and sexual sin and warned parents about what the OCCB deemed to be insufficient scientific knowledge about the vaccine.³ Thirty-two percent (or 674 970 students) of all Ontario’s primary and secondary school students attend publicly funded Catholic schools,⁴ and Ontario has so far seen an overall provincial participation rate in the vaccination program of less than 50% (and, in some regions, of only 28%⁵). The HPV vaccination effort is falling short of its potential reach, and misinformation regarding the vaccine may continue to hinder the program’s success.

Informed non-participation in any public health program by any individual or group is perfectly legitimate. My real concern is that Catholics are being told that their faith commitment precludes them from allowing their daughters to be vaccinated against HPV and that Catholic educational facilities have an obligation to prevent access to the vaccine. The irony here is that writings on Catholic health ethics do not prohibit the HPV vaccine, and actually make at least one strong point in favour of endorsing such a program. If we accept that the objections offered by the H-SCDSB — i.e., that participation in the HPV vaccination program is both immoral and unsafe — are familiar to many Ontario Catholics, as these objections are consistent with advice from the OCCB, then a discussion about the accuracy and justifications of such objections could serve as valuable input for the Catholic conscience.

Considering the health safety concern first, it is true that any vaccination poses some minimal but measurable risk to patients. However, the risk of serious adverse events after injection of the Gardasil vaccine is extraordinarily low (< 0.1%).⁶ In a systematic review of research, the few serious adverse events observed had little relationship to the vaccine itself.⁷ As such, the concerns regarding vaccine risk offered by the H-SCDSB and OCCB lack sufficient weight to preclude participation in the program.

Second, when it comes to moral decision-making in the context of health and medicine, Catholics are encouraged to operate from an informed-conscience perspective – they are obligated to reflect on the ethical and spiritual aspects of their decision and then to follow what they determine to be right.⁸ Two moral principles in Catholic bioethics are particularly relevant to this issue: double effect and legitimate cooperation.

When an action has a double effect — that is, when it has both beneficial and harmful consequences — Catholics are counselled that they may pursue the action provided that:

• the action is not intrinsically evil

• the intent of the actor is to achieve the beneficial effect

• the beneficial effect is not achieved by means of the harmful effect

• the beneficial effect is greater than the harmful effect.⁸

In the instance of HPV vaccination, neither the act of vaccination nor the prevention of infection is intrinsically evil; the intention of the health care practitioners is to benefit the patient; the benefit (absence of infection) is not achieved by means of harm (sexual immorality); and the established and evidenced beneficial effect of cervical cancer prevention is far greater than unsubstantiated fears of increased promiscuity.⁹

The second moral principle to consider is legitimate cooperation. Catholic doctrine teaches that when an action involves more than one person, it is unethical to cooperate formally (directly) with that action if it is immoral. However, it can be a moral duty for Catholics to participate materially (indirectly) in such an act if the intention of doing so is to produce a good effect and to avoid or reduce greater harms.¹⁰Even if one estimates that vaccines might interfere with the Catholic message that abstinence is best, one could also determine that the goal of the actor (the vaccinator) is to reduce occurrences of HPV, and that this goal is to reduce harm. By this reasoning, giving parents the opportunity to have their children vaccinated at school as part of an accessible health promotion project falls well within a morally principled Catholic value system.

It should also be considered that the promotion of social justice has been a strong vein within modern Catholic thought.¹⁰ It is well known that HPV infects both males and females. Men have a remote chance of developing cancers of the penis or throat as a result of HPV infections, and men who have sex with men carry an increased risk of anal cancer. However, women endure a much greater risk from the infection through the development of cervical dysplasia and cancer of the cervix.¹¹ School boards that create a barrier between girls and protection from cervical cancer do nothing to address the significant vulnerability that girls have in comparison with boys with regard to HPV-related cancers. The same infectious agent has a much greater impact on women than on men, and to erect barriers to obtaining protection against cancer for girls is deplorable and unethical.

These arguments lead us to the conclusion that the H-SCDSB’s decision is not in keeping with Catholic direction on ethical issues in human health or social justice. It is critical that decision-makers in the Catholic school boards meditate upon the fullest possible considerations of how morality may trump public health issues. After all, protection from HPV for teenage girls now can also one day afford protection within the monogamous sanctity of marriage.

Biography

Ken Kirkwood is Assistant Professor of Applied Health Ethics in the Health Sciences Program of the Faculty of Health Sciences, University of Western Ontario, London, Ont.