Addressing Vaccine Hesitancy Requires an Ethically Consistent Health Strategy

"...there are underexamined ethical issues regarding how the concerns of hesitant parents are addressed across clinical and public policy contexts – these have ramifications for trust."

This commentary starts from the understanding that vaccine hesitancy is complex but linked inextricably to a lack of trust - in vaccines, expertise, and traditional sources of authority. In the case of childhood vaccination, efforts to cultivate trust in vaccination primarily draw on the concept of parent-centred care (PCC). Public health strategies that can override parental concerns and values with coercive measures are parallel but competing to PCC-oriented efforts. In what follows, Laura Williamson and Hannah Glaab begin by outlining concerns that competing vaccination strategies ethically conflict, before examining: the variable experience of PCC; the increasing use of mandatory vaccination; and proposals for a "presumptive" approach in vaccination consultations. They argue that if trust in vaccination is to be built and sustained in the longer term, it is essential to formulate an integrated, consistent ethical approach to vaccination policy and practice.

On the one hand, promoting trust through PCC involves healthcare professionals (HCPs) and service users working together to help ensure that health decisions are based on the best available evidence and the values of those seeking health services. In the context of vaccination, parents have reported they want HCPs to listen to their vaccination concerns and answer questions they have. Such a two-way exchange can not only cultivate trust but also support informed consent, an important requirement in clinical contexts.

On the PCC approach, parents are led to believe that their views are ethically and practically important. However, they can then experience their wishes and concerns being overridden by use of coercion (e.g., mandatory vaccination for school entry) to promote vaccination. According to Williamson and Glaab, this situation risks being counterproductive for efforts to build trust in vaccination. Although public health strategies can be ethically justified in limiting freedoms, they say, a parent-centred approach seldom acknowledges how it is impacted by contemporaneous coercive measures. In addition, the clinical encounter is not well suited to helping parents consider the public dimensions of vaccination, despite these being important for trust formation and informed decision-making.

This kind of tension can be seen in debates on "presumptive" consultations, which involve HCPs trying to secure vaccination uptake by making a statement such as, "Today, we are going to do some shots", rather than asking parents about their preferred course of action. Confidence in vaccination systems is also potentially impacted by media articles relating to the publication of the study on presumptive vaccination by Opel et al. that included headlines such as: "To get parents to vaccinate their kids, don't ask. Just tell." Williamson and Glaab write, "In the volatile context of declining vaccination this message could, internationally, promote doubts in the minds of parents about whether vaccination will be imposed if they attend for a consultation, and so impede their engagement with health services. That such concerns threaten to undermine trust and exacerbate vaccine hesitancy is unfortunate."

Williamson and Glaab suggest that efforts to address vaccine hesitancy require more consistent engagement of parental and citizen views. For example, work on PCC highlights the need to address parents (or patients) within their wider social contexts, and this may mean moderating the prominence of parental choice by highlighting that informed decisions are formed relationally. Parents have been found to show little interest in herd immunity and tend to focus solely on their private interests relating to their child, yet the HCP could emphasise that informed, autonomous decisions are made, not in isolation, but with the support of others. In other words, "embedding relational autonomy at the heart of immunization debates could also help to create an ethical climate in which non-vaccinating behaviours like 'free-riding' are less acceptable."

Vaccine hesitancy is also impacted by issues requiring wider public debate, such as lack of trust in government or pharmaceutical companies. Although Williamson and Glaab acknowledge that it is not logistically feasible for all these issues to be addressed in clinical vaccination consultations, they argue that "civic deliberation could be usefully employed as part of an improved response to vaccine hesitancy." This could take the form of deliberative events that engage parents to examine tensions between the private and public dimensions of vaccination. Such "deliberation offers a way for vaccine hesitant parents to subject strategies with which they do not agree - perhaps the routine overriding of parental permission by vaccine mandates - to critical scrutiny. This could help avoid the perceived need for coercive strategies to get people to vaccinate or win public approval for such approaches, or measures like incentivization." Along with evidence-based information, Williamson and Glaab suggest, these types of debates need to be informed by ethical support that equips parents and professionals to respond to the private and public dimensions of vaccination in a more even-handed, transparent manner.

In conclusion, "Efforts to address vaccine hesitancy need to avoid simple reliance on either parental values or coercive public policies. To do this effectively requires increasing citizen engagement on vaccination to help inform a parent-centered approach and legitimize public policy measures. In addition, cultivating a more ethically consistent strategy means moving beyond the current silos of health ethics - clinical and public health ethics - ...to develop a more integrated approach for addressing vaccine hesitancy."