Lay people's interpretation of ethical values related to mass vaccination; the case of A(H1N1) vaccination campaign in the province of Quebec (French Canada)

Abstract

Background

Pandemic influenza ethics frameworks are based on respect of values and principles such as regard for autonomy, responsibility, transparency, solidarity and social justice. However, very few studies have addressed the way in which the general population views these moral norms.

Objectives

(i) To analyse the receptiveness of the population of French‐speaking Quebecers to certain ethical principles promoted by public health authorities during the AH1N1 vaccination campaign. (ii) To add to the limited number of empirical studies that examine the population's perception of ethical values.

Design

Eight months after the end of the AH1N1 vaccination campaign in the Province of Quebec (Canada), 100 French‐speaking Quebecers were assembled in ten focus groups. Discussions focussed on the level of respect shown by public health authorities for individual autonomy, the limits of appeals for solidarity, the balance between vaccination efficiency and social justice towards non‐prioritized subpopulations, vaccination as a demonstration of civic duty and social responsibility.

Results

The population acknowledged a high level of individual responsibility towards family members and agreed to vaccination to protect children and ageing parents. However, the concepts of civic duty and solidarity did not elucidate unanimous support, despite the fact that social justice stood out as a dominant value of public morals.

Conclusion

The ethical principles promoted in influenza pandemic ethics frameworks are subject to reinterpretation by the population. An ethic of public health must consider their understanding of the fundamental values that legitimize mass vaccination.

Introduction and rationale

In the wake of the SARS episode in 2004 and H5N1 avian flu epidemic in 2005, several countries adopted contingency plans to protect their populations through vaccination campaigns. Although outwardly justified by solid epidemiological data, some of these interventions are at a high risk of infringing upon certain fundamental values. Influenza pandemic ethics frameworks1, 2, 3, 4, 5 suggest that consideration must be shown for values such as the protection of the public from harm, liberty, duty to provide, social justice, respect of autonomy, solidarity and trust to guarantee the ethical acceptance of a preventive vaccination campaign.

However, social acceptance of these principles and, therefore, popular receptiveness regarding massive vaccination campaigns depend on two factors. The first involves the level of actual respect of these principles by public health authorities during the implementation of preventive interventions during a crisis. The second concerns the population's perception of the merits of these principles. The present study explores the perception of Quebec citizens regarding these principles and their relevance a few months after the conclusion of the A(H1N1)¹ vaccination campaign.²

One of the conditions increasingly recognized as a guarantee of the ethical practice of public health is consideration of the population's opinion of ethical limits to preventive interventions. Participatory processes are gaining in popularity and acknowledged as very useful in issues regarding values espoused by the population.7 The field of public health is certainly no exception.8 The literature on pandemic planning recognizes the need to engage the public in the planning process to make ethically tenable decisions.9, 10, 11, 12, 13, 14 The public should be recognized as a credible source of expertise for pandemic communication planning15, 16, 17. Thus, it is relevant to invite the population to discuss their views of principles and values underlying any plan to fight a pandemic.18, 19

Four ethical principles at issue

Two influenza pandemic ethics frameworks in particular, had an impact on the analysis of ethical issues in Quebec and Canada. The first was proposed by the Quebec Public Health Ethics Committee (Comité d'éthique de santé publique CESP) which tabled an “Avis sur le volet santé publique” 20 of the Quebec ‘Pandemic influenza plan ‐ Health mission.’21 The second was produced by the University of Toronto Joint Center for Bioethics (UTJCB)1 and suggested ‘ethical considerations in preparedness planning for pandemic influenza.’ Amongst the ethical principles retained, four are of particular interest to us, namely responsibility, solidarity, social justice and public participation. Although the concept of social justice is explicitly apparent in the definition and tiering of at‐risk groups to prioritize for vaccination, the values of responsibility and solidarity are much more implicit in official messages to encourage vaccination. In the two latter cases, it was the insistence of public health authorities (relayed by mass media) on the need to ‘protect family and one's inner circle;’ ‘maximize vaccination coverage;’ and, ‘prevent the propagation of the virus and severe cases of infection’ that fostered public deliberation.

While acknowledging the importance of concern for the respect of personal and group autonomy, the notice produced by the ethics committee on public health of the Province of Quebec (CESPQ) “added [a concern for] responsibility and solidarity in order that measures to fight pandemics serve to protect populations more vulnerable to such situations” (translation).20 The notice referred to the responsibility of healthcare professionals to provide care, to the responsibility of public health authorities to protect the population and to the responsibility of employers towards their employees, but the notion of individual responsibility in response to vaccination was addressed indirectly only through the concept of ‘citizen engagement.’ Therefore, responsibility in this particular case was viewed as collective, rather than as individual.

Public health authorities also explicitly placed an emphasis on solidarity. In pandemic ethics frameworks, the solidarity at issue is that of society towards more vulnerable subgroups (in this case, subgroups more at risk of AH1N1). It refers to solidarity in cost sharing to guarantee universal access to the vaccine and respect of persons and social groups more affected by a pandemic (e.g. solidarity to fight the social stigmatization of members of the Chinese community in Canada during the SARS episode).22 Although the principle of solidarity is presented as unavoidable, it was initially designed as a form of group solidarity (cost sharing, equitable distribution of burdens related to vaccination) and not as a form of individual solidarity for the act of vaccination in itself. It is a community version of solidarity.

The notion of social justice was seen as a foil for this view of community solidarity. The CESPQ specified that “to be as efficient as possible in pandemic situations, measures retained must be embraced by the population. Amongst other things, popular acceptance is based on the perception of the justice/fairness of measures and a decision process perceived as being just (impartial, equitable) and transparent” (translation).20 Likewise, “to be equitable, access to measures must be unrelated to financial capacity, information or privileged contacts” (translation).20 The Toronto Joint Center for Bioethics suggested that “reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible”1 (principle of reciprocity).

Finally, concern for consideration of the population's opinion and popular consultation do not constitute an ethical principle as such. However, this value is of capital importance in ethics frameworks. The CESPQ acknowledged that “the trust of the people resides in large part […] in the ability of the state to […] be open to the contribution that the population may make and, thereby, encourage the inclusion of ‘people's expertise’ in decision making” (translation).20 Thus, for the CESPQ, “dialogue with the population and stakeholders was viewed as a participative approach that serves to reveal values at play, comprehend better the concerns of citizens and understand better the situation in which decisions will be made” (translation).20 For the UTJCB, an important component of the ethics framework was public participation or inclusivity, meaning “decisions should be made explicitly with stakeholder views in mind”, and there should be opportunities to engage stakeholders in the decision‐making process.1 Yet, the population had few opportunities to discuss fundamental values that guide public health decisions. Interesting exceptions included consultations of the allocation of scarce resources during a pandemic5, 11 or different target levels of preparedness of public health authorities in the planning of the mass vaccination program.12

These principles and values are subject to formal theoretical processing in influenza pandemic ethics frameworks. General public perception will be influenced by concrete vaccination interventions, the organization of the vaccination campaign and the communication strategy of both public institutions and the media. The present study will outline the position adopted by the French Canadian population regarding these principles in reaction to the direct experience of the 2009 mass vaccination campaign.

Methods

This research rests on a qualitative research design. In the fall of 2010, we convened ten focus groups for a total of 100 French‐language participants, including six groups from the Montréal metropolitan area and four from the Québec City area.³ Each group was formed of 9 to 11 adults and meetings lasted approximately 3 h. To increase the validity of our qualitative approach, and to limit the sampling bias, we used a non‐probability quota sample. Participants in each focus group were recruited on the basis of four socially significant criteria (quota): gender (50–50%), age (at least one participant from each of the six subgroups), education level (at least two for each of the three subgroups), AH1N1 vaccination status (50% vaccinated – 50% having refused vaccination). Participants were contacted by telephone by an independent survey enterprise through a random digit dialing method for each city until each focus group had reached its quota for each of the four criteria (global response rate 62%). Globally, the 100 participants were broken down as follows: gender (50 male, 50 female); age (18–24; n = 16), (25–34: n = 17), (35–44: n = 17), (45–54: n = 17), (55–64: n = 18), (65 + : n = 15); education (secondary: (n = 32), (some college: n = (34), (university: n = 32); vaccination (vaccinated: n = 51), (not vaccinated: n = 49).

Focus group participants were invited to debate the following questions related to values challenged through vaccination interventions as well as by the media and public health institution communications strategies:

• Q1: Did public healthcare messages on civic duty (devoir civique) disturb you or make you feel guilty?

• Q2: What did you think of the argument stating that those who refused the vaccination were not acting responsibly and were shifting the burden of protection to others who agreed to vaccination?

• Q3: Do you consider vaccination a civic duty?

• Q4: Some subgroups in the Canadian population were prioritized for vaccination owing to their high level of vulnerability. Did you view this as a form of injustice towards those who did not have access to the vaccine?

• Q5: Was it important that the public be consulted? Or, did you consider acceptable that this responsibility was delegated to paid professionals (policymakers, physicians, health system managers)?

Each focus group was hosted by two facilitators, members of the research team. Talks opened with a 10‐min discussion reviewing the steps and stages of the pandemic and the vaccination campaign. Facilitators made sure that each participant expressed himself freely on each theme. Focus group discussions were recorded and transcribed without identifying respondents within each group, an approach that does not allow complete breakdown of focus groups results. Textual data were codified by two members of the research team based on a mixed coding approach combining free and hierarchical codes23, 24, 25 using NVivo8. The data analysed involved the content of discussions related to each of the five questions (topics) and to the four ethics principles considered. The construction of conceptualizing categories was based on the premises of the grounded theory26, 27, compliance with validity criteria recognized for discussion groups28 and the strength of the consensus to emerge.17

Results

Based on this qualitative methodological approach, we were able to summarize the perceptions of our participants regarding the four ethical principles of responsibility, solidarity, social justice and public participation.

Individual responsibility and guilt

When invited to comment on phases of the vaccination promotion campaign implicitly or explicitly raising the issue of citizen responsibility, participants in the discussion groups first distinguished between two positions of responsibility, namely responsibility towards immediate family and members of the inner circle and responsibility towards the community at large (the state, department of health or society at large). The ‘meaning’ of responsibility was tempered largely by the nature of the issues facing each recipient and in particular by the degree of emotional involvement at play.

It was unanimously agreed that the primary and principal responsibility was towards the individual's immediate family. Participants reported that their main motivation for vaccination was rooted first and foremost in their concern to protect vulnerable family members, in particular children and ageing grandparents. This concern even led citizens profoundly opposed to vaccination to finally agree to it “in order not to contaminate my own children. I would never have forgiven myself for spreading AH1N1 to my children. I would have felt responsible and guilty for the rest of my life” (translation).

Debates within families were reported to be quite lively on occasion. Those against vaccination were sometimes viewed as irresponsible and/or selfish individuals who should feel guilty regarding the possible consequences of their decision on the health of their children. The debates also fuelled inter‐family conflict: the notion of responsibility raised by some conflicted with the freedom of choice and convictions of others who saw vaccination as pointless, ineffective and dangerous. Some decided to get vaccinated to avoid discourteous remarks from their social circle and not to feel guilty and judged. So, to a lesser extent, and over and above vulnerable loved ones, pressure from the social network was also a source of guilt and social judgment.

“(…) the pressure did not originate from the Premier or the Minister of Health speaking on television, it originated from the people around me. It was not so much the campaign [vaccination] itself that pressured me into deciding to get vaccinated” (translation).

The argument of responsibility towards others had a particular impact on parents responsible for at‐risk persons who felt like pawns in a conflict of values. They wanted what was right for their children while respecting their own values and beliefs regarding vaccination and, conversely, society was suggesting quite strongly that they trust public health authorities. Under pressure from official institutions and the implementation of a massive vaccination campaign (e.g. massive vaccination centres; school transportation of children to these centres), several reported feeling assailed by tremendous feelings of guilt.

On the other hand, responsibility towards the state was not viewed as an issue by participants. A fraction of the population turned a deaf ear to the appeal for responsibility. These were citizens who reported “always being against vaccination because of the danger of vaccines” or citizens who assigned no credibility to “alarmist government propaganda.” Likewise, those sensitive to the argument of responsibility and those who rejected it agreed in their questioning of all state propaganda on responsibility.

But the debates around the notion of responsibility appeared to have raised questions regarding the role of citizen, parents and friends. Collective values promoted by public health authorities came up against individual values obliging the citizen to form an opinion and accept or reject these values. Some began to doubt their judgment and system of values. Several turned towards members of their social network for approval of their decision. More particularly, social opinion was severely critical of individuals who elected not to have their children vaccinated. The decision process was far from individual, with many network members, even complete strangers, interfering in the debate, sometimes without invitation. The decisional process was made more complex by the multiplication of discussions and opinions.

Responsibility of others towards you: the plea for individual freedom

Another way to broach this popular concept was to analyse people's opinions of those who consciously and voluntarily refused vaccination in the name of personal freedom. The issue here does not concern our own responsibility towards others (e.g. children, grandparents, citizens), but the responsibility of other citizens, immediate family, inner circle and strangers towards you.

The results showed that participants first defended those who refused to cooperate in increased vaccination coverage rather than accuse them of being irresponsible. They raised the fact that vaccination is a personal choice and that as reasonable citizens, individuals fundamentally make logical choices based on “common sense.”

I think it is each individual's responsibility. We make the decision to get vaccinated or not. I would not bear a grudge against my neighbour if he did not get vaccinated. And I would not expect him to bear a grudge against me if I decided not to get vaccinated.” (translation).

Along the same lines, some participants felt that making those who refused vaccination feel guilty was unjustified. By placing the emphasis on citizen responsibility, public health would be infantilizing the population. Citizens are considered to be adults “spontaneously concerned by the people around them” and aware of their responsibilities and the consequences of their choices. They need not be dictated to about how to think and act in a pandemic situation. The argument stating that citizens are responsible for getting vaccinated to protect others was seen as a violation of the freedom to choose. But this did not prevent some participants from acknowledging that they had indeed benefited indirectly from the vaccination of others. “Why get vaccinated if all the others get vaccinated? And, if a free rider contracts the virus, he will only be able to spread it to other free riders” (translation).

On the other hand, some participants admitted having pressured members of their immediate circle who did not get vaccinated, indicating that these close parents or friends were not acting responsibly. However, whereas for the majority it seemed admissible to pressure immediate family members, the implicit use of the same argument by public health authorities was condemned and deemed unacceptable.

“One can recommend it, but not force it. It cannot be stated that those who don't go are taking advantage of the others. This is not an argument that the government should employ” (translation).

Indeed, several participants acknowledged that some refused vaccination out of conviction of the dangers of vaccines, the pointlessness of vaccination or simply by lack of concern, and not with the conscious will to ‘take advantage of a system.’ Thus, according to our participants, any attempt at stigmatizing non‐vaccinated individuals as ‘free riders’ would have serious consequences, heightening social tensions, marginality and the emergence of scapegoats. These are reflections of social justice implied by the reservations that citizens had towards blaming the naysayers.

Solidarity and civic duty

In addition to the notion of individual responsibility, participants provided their opinion of pleas for solidarity towards public health institutions to maximize vaccination coverage. The concept of civic duty raised serious debate among participants. Indirectly, the issue addressed solidarity and the interventions of public institutions mandated to protect the population against the risks of an epidemic.

First, it should be noted that generally speaking, participants in the focus groups had a negative perception of any individual responsibility towards institutions. On the contrary, the department of health and public health authorities were viewed as being responsible towards citizens and not vice‐versa. Yet, the majority of participants acknowledged that the institutions had properly accomplished their mandate of protecting the public, even at the cost of interventions sometimes deemed too invasive. But they rejected any summons for solidarity amongst society at large as a justification or argument to increase participation in the vaccination campaign. The concept of ‘civic duty’ was then viewed negatively: it gave individuals the impression that they were being controlled and restrained in their choice.

“Obliging everyone to get vaccinated using the excuse that vaccination is a civic duty is not the proper path to follow. We live in a free country and should have the choice of deciding whether we want to protect ourselves and our family or inner circle” (translation).

This argument also had political overtones; people felt that they were already being harassed by the state over a series of duties. The notion of civic duty had several connotations associated with political ‘constraints’ and ‘obligations.’ Responsibilities and duties to our inner circle should take precedence.

“This notion of responsibility would not change my point of view. I would always get vaccinated to protect my family. I will protect my family before I protect others. For me it is more of a family duty than a civic duty” (translation).

In short, participants remained reticent for the most part, even radically opposed, to any discourse aimed at ‘citizen’ responsibility. However, this did not preclude the existence of a divergent discourse in favour of recourse to the civic duty argument. Some viewed it more as an opportunity to heighten awareness of collective issues and the possible consequences of individual choices on society. Those not responsible for vulnerable family members did not necessarily feel concerned or influenced by the wellbeing of members of their inner circle. The argument of solidarity and duty might more easily sway these individuals. Thus, illustrating the plurality of values amongst the population, some participants considered that a vaccination campaign based on the concepts of duty and solidarity might, in some cases, provide an opportunity to raise awareness of others' needs and promote awareness of the limits of individualism.

Social justice

The population associated two components of the vaccination campaign with the value of social justice. The first was equal access to the vaccine and the act of vaccination; the second referred to criteria defining the subgroups given priority access to vaccines in the context of the progressive supply of vaccination sites.

The first dimension received only cursory attention from the discussion groups. In the context of Quebec's free health services, the cost‐free nature of the vaccine was viewed as a vested right. Yet, some participants indicated that “the fact that the vaccine is free for all confirms that this protection is not limited to the rich alone and that the principle of equality is properly applied in our health system” (translation). Some even specified that the cost‐free vaccine and the ‘privilege’ in terms of equal access reassured them regarding the campaign.

“I thought to myself that at least here [Quebec, Canada] the government has the means [to pay for the vaccines]. So how many people might not have been vaccinated had the service not been free? I thought to myself, at least we have that privilege. This reassures me; at least if anything happens, I have a government and something that will ensure that we will be cared for” (translation).

Although equality of access to vaccination is considered a vested right in the Canadian health system, the organization and operation of the vaccination campaign raised several questions. The aspect that fed feelings of ‘injustice’ was the definition of priority subgroups considered more vulnerable to both the virus and its transmission (e.g. pregnant women, young children, persons with respiratory problems, etc.). Some people felt slighted by the adjustments and breaches with the principle of equality and universal access to care in the name of the greater ‘risk’ faced by these subpopulations. The epidemiological data justifying this prioritization were not communicated to the public at large. Some criteria implicitly fell under the notion of ‘common sense’ (e.g. pregnant women, young children). Other criteria were even less clear to the average citizen (e.g. lack of priority of elderly citizens).

In fact it was the ‘hiccups’ perceived in the organization of the access process to vaccination that fuelled the debate on ‘injustices.’ Sick prisoners and well‐known actors having presumably (according to mass media) benefitted from unjustified priority access fed popular frustration. Cases of parents being vaccinated at the same time as their children were denounced (when, in principle, they should have waited for the adults' access (last group) to the vaccine). Many people raised the inconsistency of asking children to be present in the company of adults and then refusing vaccination to said parents. In conclusion, issues of unfairness were not raised by participants in regards to access to vaccination but in reaction to perceived failures in the vaccination procedures.

Pertinence of public consultation

What does the general population think of the pertinence of public consultation and the attention paid by ethics frameworks to the values of ‘democracy’ and ‘respect of the population's point of view’? Once again, the results of this study pointed to divergent opinions. The majority of participants felt that the population is insufficiently qualified to offer advice on the subject of a pandemic. The population lacks ‘expertise’ on the topic in order to be consulted. Likewise, “authorities are elected by the population and experts are specially trained for this type of situation” (translation). These participants appealed for greater trust in the authorities responsible for protection in the event of an epidemic.

“In my opinion, if the situation is serious, decisions to be made are within the competence of authorities in place and it is not the man on the street who should try to impose his view. More so, since when you ask the man on the street, you get 3500 different ideas. So I don't think that it would be acceptable to consult people in any way whatsoever” (translation).

Some participants mentioned that the authorities had already listened to the population, for example by receiving feedback from people from the vaccination centers, and by amending their strategy over time. Therefore, it was possible to trust the authorities and it should not be necessary to consult the population as well.

However, a significant portion of the participants were favorable to public consultation. In their opinion, it was the duty of the public health authorities to consult the people.

“I understand that you have decisions to make, but I would like to discuss the situation with you and have you and other people listen to what I have to say” (translation).

“I think that a responsible government will seek the opinion of its population one way or the other; this is the underpinning of democracy. Civic duty is not only casting a vote, it is also voicing one's opinion” (translation).

Discussion

Vaccination is not mandatory in Canada. Likewise, influenza pandemic ethics frameworks generally concede a large measure of importance to the freedom of individuals to accept or refuse vaccination. Scientific literature on the ethics of vaccination29, 30, 31 endeavors to define the limits of this freedom, rather than question civic responsibility and the defense of the common good in the name of solidarity. The position of the Nuffield Council on Bioethics reveals this ambiguity: “On the basis of the value of community and stewardship considerations, it is in principle ethically justified to encourage individuals to take part in vaccination programs when there is no, or only a small, personal benefit, but significant benefits for others. However, consent is essential, and there should be careful assessments of the benefits to be gained for the population and the possible harm that may result for the people who receive the vaccination.”32

The popular views analyzed through exchanges within the focus groups in our study confirmed the precedence of this value of freedom in their positions. Of course, our French‐speaking participants in Quebec recognized the merits of a massive vaccination campaign such as the one set up fight the A(H1N1) virus. Despite criticism expressed regarding the lack of information on the choice of priority groups to vaccinate or the operation of vaccination centers, participants acknowledged that the state had no choice but to intervene preventively. However, the primacy of the value of freedom of choice clearly emerged. Although participants acknowledged strong responsibility (and limits to freedom) when family members (children and elderly parents) were concerned, and that to the point of severely berating those who “put their loved ones in danger through their obstinacy,” only a minority among them acknowledged any responsibility towards others (distant members of their social network, neighbours, work colleagues). Indeed, as DeCoster shows in a debate about the role of emotions in rationing health care services, the perspective of saving identifiable lives (those with which we have a direct connection) stimulates vaccination more efficiently that saving statistical lives (a hypothetical at‐risk group).14

The vaccination campaign more or less implicitly raised the issue of free riders indirectly taking advantage of the benefits of vaccination coverage through the vaccination of other citizens. According to the Nuffield Council on Bioethics, “Where population immunity exists and provides protection for those who refuse vaccination, it could be suggested that individuals who are not vaccinated are free riders, as they do not share their fair burden while nevertheless benefiting from population immunity.”32 Given the ethical analyses made regarding this argument of free riding,20, 29, 33 we wanted to analyse this additional facet of the principle of justice. Our results showed that the population did not seem to begrudge free riders for their lack of civic responsibility and embraced a moral position based on the absence of value judgments. Irrespective of the reasons for refusing vaccination (convictions, lack of information, beliefs, laziness), our participants declined to judge people who rejected vaccination or consider them as free riders or irresponsible individuals. Thus, popular moralities are based on a backdrop of tolerance for those who affirm their freedom of choice.

Some theorists on prevention argue that the benefits of such interventions lie at the level of populations, whereas any risks of harm are borne by the individual participants who do not have the disease itself. This “prevention problem” has been rejected by Dawson.30 For him, preventive vaccination programs seek to create and maintain herd protection which, as a public good, is a benefit shared by all individuals in the relevant population. Our results showed that while not denying the impacts of vaccination on public wellbeing, a large portion of the focus group participants felt the need to ponder this contribution to the community through concern for the respect of autonomy, liberty and agency.

In the ethics frameworks proposed to manage pandemic situations, very little reference was made to the solidarity of individuals towards the community. When the issue was raised, it consisted of delegated solidarity: public health authorities are mandated in our name to guarantee everyone free access to vaccination at no cost. The solidarity at issue in these ethics frameworks requires no individual investment in the form of a gesture to make in the ‘name of solidarity.’ Despite the responsibility that Quebecers seems to acknowledge towards members of their inner circle (i.e. children, husband and close friends) and despite strong support for social policy guaranteeing universal cost‐free access to vaccination, the value of individual responsibility takes precedence over the value of ‘solidarity.’ The sometimes radical rejection of recourse by the state to arguments raising the spectre of ‘civic duty’ or ‘civic responsibility’ confirms the primacy in public morality of individual responsibility over solidarity towards the community. The (committed) solidarity of each individual towards others fades behind the (impersonal) solidarity of all toward each individual. For several, it is not solidarity viewed as an altruistic gesture (vaccination) made in the name of community solidarity.

Yet, the value of social justice is at the root of this public morality. The majority of participants acknowledged responsibility towards the more impoverished who might not be able to pay for vaccination in the absence of a Canadian and Quebec health system guaranteeing universal access through state financing. Here, solidarity was expressed in the form of strong concern for redistributive justice; it was desirable, even normal, that the economically deprived have free access to vaccination. The importance of this ‘sense of justice’ towards the impoverished was corroborated by a recent Canadian survey on pandemic flu preparations reporting that for 70% of the Canadians, ‘wealthy countries like Canada should provide international assistance to help poorer countries prepare for a pandemic, even if it reduces the resources available to Canadians.’34 This is in line with the conclusions of focus group deliberations about social distancing measures in the State of Michigan,9 where participants expressed concern for those experiencing unemployment and having to deal with low and fragile incomes. Our participants shared this view of the fair distribution of benefits and burdens associated with social distancing measures.

Note that most national and international ethics frameworks applied to pandemic situations make public participation and consultation an integral part of ethical public health. Likewise, a series of studies provide various overviews of methods and strategies to encourage consultation of the population and the development of committed citizens.19, 35, 36, 37 For Kotalik, “principles of transparency and accountability require that those who are going to be affected be informed. A concern that public discussion of a probable flu pandemic would cause alarm among the public is not sufficient justification for non‐communication.”38 In fact, regarding risk communication, there is a growing consensus about principles such as transparency, respect of the population's point of view and trustworthiness.39 Some even state that such consultation would be considered by the population not only as a right, but also a responsibility of the state.40 However, the results of the present study suggest reservations regarding the latter affirmation. Of course Quebecers are not opposed to such consultation. A minority amongst them are even of the opinion that it should be the duty of public health authorities, particularly after a vaccination campaign, to gather suggestions on how to improve procedures. However, this position is less black and white for the majority of participants. Some are strongly against it, stating that it is the responsibility of experts and/or political authorities to manage vaccination campaigns. For others, this contribution can only be marginal “considering the profound divergences in public opinions.”

Conclusion

Our approach using focus groups allowed us to update the components of public moral discourse on the conditions and ethical limitations of the vaccination campaign against the (A)H1N1 virus. Although our research focused on a specific linguistic group (French‐language Quebecers) in a country having a comprehensive health system, results presented here illustrate the difficulty for public health institutions to reconcile theoretical ethical principles and interpretations of popular morality. There is always some gap between theoretical considerations and their actual implementation in concrete interventions. Our results initially show that the public discussion around the ethical principles such as individual responsibility, solidarity, social justice and public consultation highlighted the plurality of public opinion on each of the themes. However, general trends did emerge. First, participants seemed to favour individual freedom of choice and a voluntary vaccination program. Even those favourable to vaccination and to a relatively invasive promotion campaign recognized the right of fellow citizens to freedom of choice. Great reticence was evinced regarding any state intervention in individual choices. This respect of others’ choices was also expressed through the lack of value judgments associated with free riders.

The promotion of a ‘collective’ version of solidarity and social justice (everyone standing together for the universality and cost‐free nature of the vaccination) and the rejection of ‘civic duty implying the commitment of each individual (through concrete action) towards all, appear to serve as the underpinning of a public health ethics basically built around the notion of respect of autonomy and freedom of choice, even if this freedom of choice is weighted by a strong feeling of a duty towards one's inner circle.

The challenge to promote solidarity appears huge for public health, but at the same time we suggest that working on the promotion of such committed solidarity should be carried out while taking care to avoid the pitfalls of a guilt‐oriented approach by stressing notions of ‘civic duty’ and ‘citizen responsibility.’ A very strong majority of participants deemed it important that access to vaccination be free for everyone and that vulnerable and more at‐risk group are prioritized in their access to the vaccine. Considering the importance granted by the population to this value of social justice, perhaps invoking such an ethical value would be more likely to positively influence the attitude of those who refuse vaccination rather than insisting on vaccination as a ‘civic duty’ and prevention as a duty to precaution.

Author's contribution

The review of literature and analysis of articles were carried out by Raymond Massé and Michel Désy. They both acted as facilitators and led the participants in discussions. Raymond Massé is principal investigator.

Ethical approval

Ethics approval for this study was obtained from the Laval University research ethics committee.

Sources of funding

This study was funded by the Canadian Institute of Health Research and The Institute of Population and Public Health (Canada) grant (H1N—104053).