Miriam Bentwich Comments

In their thought-provoking commentary, Cardenas-Comfort and Majumder (p. 1687) have argued for the merits entailed in state laws that are designed to increase the adherence to vaccination policy through transparent reporting of vaccination rates per school. The authors essentially claim that such laws are particularly valuable against the backdrop of an increasing parental exemption rate from vaccination, while being perfectly aligned with key principles of medical ethics such as autonomy and social justice.^1,2 However, it seems that although mandatory school reporting of vaccination rates may offer a good solution to this concern, such measures might also involve less desirable ramifications from an ethical perspective. I seek to illuminate these less desirable ramifications, namely, to stress that along the “good” entailed in these laws, they also may result in “bad” and even “ugly” ramifications.

THE DEONTOLOGICAL BAD

Cardenas-Comfort and Majumder acknowledge and supposedly address the potential infringement of privacy entailed in the proposed transparency reporting laws regarding the school vaccination rate. However, privacy is merely one facet of a larger principle of bioethics—autonomy. This larger principle is associated with the idea of voluntariness, including its support for people’s right of choosing not to share with others their health preferences for themselves or for their children. Autonomy is infringed, then, when coercion or manipulation are used,³ and it is often said to stem from a deontological moral perspective, emphasizing the need for adhering to certain principles or rules, regardless of their consequences.^4,5

Therefore, even if we assume that the privacy of parents and their unvaccinated children would be secured, the question still remains whether such parents will be able to make their own voluntary choices regarding vaccination, in view of the proposed transparency laws. Certainly, such laws would create clear incentives for schools not to admit unvaccinated children, or at the very least to refuse the admission of “newly” unvaccinated children once the cutoff threshold is reached. Consequently, parents whose personal philosophy or religious belief is against vaccination would not be able to exercise their free choice in this matter, whether because of outright coercion or more subtle manipulation on the part of the school’s authorities.

THE CONSEQUENTIALIST UGLY

The proposal for addressing vaccination hesitancy (or refusal) through obligating schools to report their rate of unvaccinated children is also problematic from a consequentialist moral standpoint. If there is something that can be learned from earlier antivaccination movements and previous legal attempts to curtail them forcefully, it involves their consequences insofar as public trust is concerned. Antivaccination movements are not only a contemporary phenomenon. Rather, such movements existed from the beginning of the first modern vaccination.⁶ At some point, these antivaccination public sentiments were met with legal measures, including fines and even imprisonment. The backlash, conveying deep public distrust in public health authorities, was soon to follow (e.g., the public protest in Leicester, England), leading eventually to the authorities’ recognition of conscious or religious exemption from vaccination.

However, in the past, at least the public distrust could be conveyed to a clear address—the state was accountable for the legal measures that were taken to prevent antivaccination and indeed it ultimately responded. By contrast, the current proposal may shift the attention to the schools’ authorities instead. One possible consequence of this shift would be the creation of a misguided public distrust against schools’ managements, teachers, and even other parents, none of whom could actually be held accountable and who certainly lack the authority to respond adequately to such distrust. Hence the potential “ugliness,” so to speak.