Should the immunisation of children be made compulsory?
Echo Issue Outline: copyright © Echo Education Services
First published in The Echo news digest and newspaper sources index.
Issue outline by J M McInerney
Please note:
The issue being treated here is not whether immunisation is beneficial or harmful.
The principal issue, as we have presented it, is whether compulsion is the most effective and most appropriate method of ensuring a high rate of immunisation.
On January 7, 1997, it was reported that a Queensland childcare centre had received a ruling from the Human Rights and Equal Opportunities Commission, allowing it to exclude two unimmunised children from the centre.
On January 29, 1997, the federal Education Minister, Dr Kemp, proposed making enrolment in primary school conditional upon a child having received the full range of available vaccinations. Dr Kemp's proposal will be discussed at a meeting of state education ministers in February.
These two attempts to compel parents to have their children immunised come at the same time as the federal Health Minister, Mr Wooldridge, has began to put in place a campaign to increase immunisation rates in Australia.
One of the means recommended by Dr Wooldridge's think tank for increasing immunisation rates is to have all states and territories legislate for vaccination certificates to be compulsory for children entering child-care centres, pre-schools and schools.
However, though Dr Wooldridge is not opposed to making vaccination a condition of school entry, he has said that he believes it will be possible to improve Australia's immunisation rate without compulsion.
There are others who are opposed to any element of compulsion in Australia's attempts to increase the number of children fully vaccinated.
Background
Currently, Australian children are readily able to be immunised against diphtheria, tetanus, whooping cough, polio, measles, mumps, rubella and Hib (haemophilus influenza type B).
However, immunisation rates for all of these illnesses are at a level that concerns health authorities.
Of those children currently aged between three months and six years 65% are thought to be fully immunised against diphtheria and tetanus, 53% against whooping cough, 82% against polio, 85% against measles, 84% against mumps, 78% against rubella and 50% against Hib.
The exact figures given for immunisation rates tend to vary as there is some dispute about the validity of Australia's records regarding child-immunisation.
Last year the federal government indicated that it would be attempting to address Australia's immunisation problem.
On December 27, 1996, federal Health Minister, Dr Wooldridge, announced that in 1997 the federal government would fund a campaign to increase immunisation rates in Australia.
$32 million was set aside in the last budget to fund the immunisation program in 1997 and 1998.
Trial immunisation booths in shopping centres and other small scale measures were to be in place by January, 1997. Immunisation guidelines were to be released to general practitioners in February and a media campaign is to begin in May. Details of the full strategy are to be announced in early February, 1997.
However, the release of information regarding the national strategy seems to have been overtaken by events, with three children dying of whooping in January, 1997.
Dr Wooldridge's early indications that his government was considering an incentive program have met with some criticism from those who object to parents being subsidised for caring for their children.
The incentive program may involve meal vouchers or cash bonuses, to encourage parents to have their children immunised against diseases such as whooping cough.
There has also been the suggestion that local councils and/or general practitioners might receive incentives based on their immunisation rates.
Though both state and federal health ministers appear to favour a program of education and encouragement to increase immunisation rates, there are others who are proposing some form of compulsion.
The most common form of compulsion considered is to have enrolment at school conditional upon the presentation of a complete vaccination certificate.
This would mean that children who had not been fully vaccinated would not be able to attend school.
It has been suggested that there would then be a school-based vaccination program to catch up or supplement the immunisation of those children whose program had not been completed by the time they were ready to start school.
It has also been suggested that crŠches, pre-schools and kindergartens should similarly be able to exclude children who had not been fully vaccinated.
Another suggestion is that parents who do not have their children fully immunised could be fined. An additional possibility is that parents who fail to have their children immunised could lose Family Allowance and Child Endowment payments.
Arguments against parents being required to have their children immunised
One of the key arguments against parents being forced to have their children immunised is that education is likely to be more effective than compulsion as a means of promoting immunisation.
According to this line of argument, a significant number of parents do not have their children immunised because they are afraid of the potential side-effects of immunisation.
The Australian, in its editorial of January 13, 1997, referred to a 1995 Bureau of Statistics survey which found that 25 per cent of those parents surveyed who had not had their children immunised were worried about side-effects.
Meryl Dovey, the president of the Australian Vaccination Network, an anti-immunisation organisation, has also claimed that studies show that the main reason parents choose not to vaccinate their children is fear of side-effects.
It has been argued that attempting to force such parents to have their children immunised will not work because they will not act in a way which they believe endangers their children.
The government now appears to acknowledge that compulsion will not be effective with those parents who are concerned that being vaccinated may harm their children.
The first reports of possible attempts to make school enrolment conditional on a complete vaccination certificate, suggested that only those with ethical or religious objections to immunisation would be exempt.
A later report stated that parents with fears about the safety of immunisation would also be exempt.
It has been suggested that this means that unless concerned parents can be convinced of the safety and effectiveness of immunisation they will either ignore attempts at compulsion or be exempted from them.
One parent, whose letter was published in The Australian, on January 24, had just decided to have a child immunised, but complained about how difficult is was to find information to support this decision.
A number of medical experts agree and argue that the best way to encourage immunisation is to present parents with the facts so that they can see that the advantages outweigh the possible dangers.
Dr Norman Swan, a well-known Australian health reporter, has claimed, `The worst thing you can do is deepen or denigrate the worries people have about their children's health because there are enough examples of people voicing real concerns and not being listened to.
`Not dealing with the issue because it is too hard makes people think there is something to fear.'
Many parents react with hostility to the suggestion that their failure to immunise their children is the result of indifference and are demanding information so that they can make an informed decision.
This position was put by Mr Brendan Falvey, writing to The Australian, in response to a letter from Dr Ian Griffith, who had suggested that parents who did not have their children immunised were `apathetic' or `complacent'.
Mr Falvey argues, `Parents are usually reasonable, caring people. They are not apathetic ... Rather than trying to belittle parents, proponents of vaccination should admit the sometimes-disastrous effects of vaccination ... Parents need balanced facts, not an arrogant "we know best" attitude.'
Another reason why it is claimed that education rather than compulsion is likely to be sufficient to have parents immunise their children, is that those parents who have not had their children immunised because they fear the dangers of vaccination, may have not had their children vaccinated because they are unaware of the dangers posed by many infectious diseases.
The historical success of Australia's mass vaccination program has meant that many parents have no first-hand experience of infectious diseases and so do not realise how hazardous they can be.
The director of health services at the Australian Medical Association, Harry Nespolon, has argued, `I think there is a general problem that this generation of parents has not seen kids with callipers from polio, has not seen people dying from tetanus or dying from whooping cough, although that is beginning to happen again,'
(The AMA, though supporting general education on immunisation, actually favours compulsory immunisation.)
A further argument against attempting to compel parents to have their children immunised is essentially an ethical one. It has been claimed that it should remain a question of freedom of choice whether a person receives a particular medical treatment or not.
Currently it is not possible for any person to be forced to take medical treatment of any kind against their wishes. It is argued that the same principle should apply in relation to immunisation, which is not even a treatment for a disease, but an attempt to prevent a person contracting one.
According to this line of argument, compulsory immunisation would undermine the personal autonomy of the individual concerned.
A further argument offered against any form of compulsory immunisation is that it could leave state and federal governments and any other agency, such as childcare centres, who were attempting to compel parents to vaccinate their children, liable to be sued should the child suffer any adverse side-effects as a result of the vaccination.
The importance of legal liability has been stressed by Gavin Putland, writing to The Australian, who has noted, `If the Federal Government wants to lift immunisation rates, all it has to do, is pass legislation to the effect that ... [it] accepts liability for all adverse consequences of immunisation ...'
Finally, it has been claimed, the responsibility for immunisation does not lie solely with parents. Some critics of compulsory immunisation have maintained that not all general practitioners or local councils have
either promoted vaccination sufficiently or made it readily enough available.
According to this line of argument it is not appropriate to compel parents to have their children vaccinated, when other non-coercive methods of lifting the vaccination rate have not been used sufficiently.
Kay McNiece, a spokesperson for the Department of Health, has stated, `We believe that the best way is to try to point out to parents their responsibility, but not only parents but doctors ... To be quite frank, doctors have been as apathetic as many parents. Many of the young doctors have not come across infectious diseases either.'
According to this point of view, rather than trying to compel parents to have their children immunised, doctors should be educated, or encouraged by other means, to take an active part in promoting immunisation to parents.
It has been claimed that doctors are particularly well placed to inform parents of the advantages of immunisation and to reassure them about possible side-effects.
The federal Health Minister, Dr Wooldridge, has also been critical of some local councils, claiming that some have decided to cease being involved in the immunisation program.
Arguments in favour of parents being required to have their children immunised
The central argument offered to justify parents being required to have their children immunised is the claim that immunisation rates for many diseases are now so low that Australia is endanger of epidemics occurring which could result in wide-spread death and disability.
The director of the TVW Telethon Institute for Child Health Research, Professor Fiona Stanley, has claimed, `Vaccine-preventable diseases are coming back in epidemic proportions because parents are not vaccinating their children.'
Professor Stanley has also claimed, `These are entirely preventable illnesses which are killing children. That's our biggest fear.'
Referring specifically to whooping cough, the federal Health Minister, Dr Wooldridge, has claimed that up to 150 Australian children could die of the disease this year given its fatality rate and the number of children unimmunised.
Dr Wooldridge has said, `... when you have 30 to 40 per cent unimmunised you do get epidemics. If there's a big population unimmunised, one kid gives it to ten, who give it to 100, who give it to 1000.'
Dr Wooldridge has also claimed that falling vaccination rates put children at risk of dying from measles.
Dr Wooldridge has cited 42 deaths attributable to measles or measles complications in the last two years.
Dr Wooldridge has further claimed, `In Australia over the next few years you can expect boys to become sterile because of measles, parents to have deformed babies because of German measles and kids to be dying of whooping cough.'
According to those who favour compulsion the situation is so serious that Australia does not have the time to see if education campaigns and incentives will induce the required number of parents to ensure that their children are fully immunised.
According to this line of argument, compulsory immunisation is an issue of greater significance than individual freedom of choice. The Queensland president of the Australian Medical Association, Dr Eileen Burkett, has claimed, `This is where you have to put the public health issue above the individual.'
Those who hold this view argue that it is not reasonable to allow parents to exercise a freedom of choice with regard to vaccination, if by so doing they put the lives of large numbers of other children at risk.
What concerns supporters of compulsory immunisation is that unimmunised children may develop diseases such as whooping cough and then pass them on to babies, too young to have been immunised, to whom the disease is likely to prove fatal.
This situation was outlined in an editorial published in The Australian on January 13, 1997.
`Two infants died of whooping cough in NSW last year - too young to be immunised, they were infected by older children who should have been.'
It is also claimed by some that in exercising their own freedom of choice, parents who do not have their children immunised are endangering those children, without having given them the opportunity to exercise any choice in the matter.
This position has been put by a columnist in The Australian, Barry Cohen, who has argued, `To the "freedom of choice" argument there are two obvious answers. Children do not have a choice. Nor do those who are placed at risk by the unimmunised.'
Further, there are those who argue that the vast majority of those parents who do not have their children immunised are not concerned by possible side-effects, but have simply not got around to ensure that their children completed the full immunisation program.
The director of health services at the Australian Medical Association, Harry Nespolon, has claimed, `About 97 per cent of parents actually agree that their children should be immunised and are not opposed to immunisation of their children ... It is really just complacency.'
This position has also been put by Dr Ian Griffith, Senior Lecturer, Pharmaceutical Microbiology, Victorian College of Pharmacy Monash University.
`It seems 90 per cent of Australians are in favour of immunisation. I bet a similar number are in favour of democracy yet, because of widespread apathy, voting has to be compulsory. And advertising campaigns to get people to vote don't work - ask the British.
`If Australians just don't care about the much more important issue of vaccination, shouldn't this, too, be mandatory?'
Finally, it is argued that any system aimed at requiring people to have their children vaccinated can afford to make allowance for those whose religious, ethical or medical concerns would make them refuse immunisation.
According to this line of argument, a community is relatively safe from preventable infectious disease so long as 90 to 95 per cent of its members are immunised.
It has been claimed that the five to ten per cent of the population whom this allows to remain unimmunised, should allow for those who have objections of conscience or other major concerns about immunisation to exercise their freedom of choice without endangering either their own children or the offspring of others.
According to this line of argument, coercive measures are aimed at the some 20 to 30 per cent of parents who have not had their children immunised because of apparent complacency.
Dr Wooldridge has claimed that some one to two per cent of parents do not have their children immunised on religious or medical grounds. He has also claimed that this level of non-compliance with the national immunisation program was not responsible for the recent whooping cough outbreak in NSW.
`As a country we can cope with two per cent being unimmunised because ... you don't get epidemics ...'
Further implications
It is all but certain that this issue will not go away.
The different state education ministers are about to discuss Dr Kemp's proposal that vaccination be a condition of starting school. It seems unlikely that this proposal will go ahead as a number of the state education ministers and other state spokespeople have indicated a lack of support for any bid to make immunisation compulsory.
Whatever the education ministers decide the issue will continue to excite interest.
Dr Wooldridge will announce details of his national immunisation strategy this month, while in May there will be a media campaign to promote immunisation.
If predictions are correct and Australia does witness further child deaths from diseases such as whooping cough, this will also serve to keep the immunisation debate alive.
Ultimately the success of any immunisation strategy appears likely to depend on the size of that small group of parents who, after careful thought, deliberately decide not to have their children immunised.
If this group is no more than the two to three per cent that some commentators suggest then their persistent refusal to immunise their children should not prove significant.
If, however, the group is larger than this and perhaps growing, then education as a means of persuading parents to immunise their children becomes more important.
The debate over whether education or compulsion is the best means to encourage parents to have their children immunised may well have been made less crucial by recent immunological developments.
Recent research at the New Children's Hospital in Sydney, has offered the possibility of a five-in-one vaccine which would reduce from fifteen to five the number of vaccinations needed to fully immunise a child.
An additional feature of the five-in-one vaccine is said to be far fewer side-effects. It has been claimed that there is almost no fever, soreness at the point of injection or irritability with the new form of immunisation.
Should this form of vaccination pass the trials which are being conducted over the next six months, its availability might do much to both increase the ease with which children can be immunised and reduce the fears of those parents are concerned about side-effects.
Sources
The Age
27/12/96 page 2 news item by Marion Downey, `Commonwealth campaign to tackle low immunisation rates'
10/1/97 page 5 news item by Louise Martin, `Infectious disease makes a dangerous comeback'
21/1/97 page 3 news item by Ben Mitchell, `Warning on whooping cough deaths'
22/1/97 page 14 a series of letters to the editor on immunisation
29/1/97 page 6 news item, `Five-in-one vaccine tests show promise'
29/1/97 page 6 news item by Stephen Cauchi, `Low immunisation rate leaves children exposed'
29/1/97 page 9 analysis by Bettina Arndt, `Suffer little children'
29/1/97 page 9 news item by Steve Dow, `Whooping cough far from beaten'
29/1/97 page 9 news item, `Vaccination - the real risks'
30/1/97 page 2 news item by Karen Middleton, `Warning: immunise or else'
31/1/97 page 1 news item, `Hospitals gear up for deadly epidemic'
31/1/97 page 4 news item by Diana Thorp and Justine Ferrari, `AMA backs school ban'
The Australian
7/1/97 page 5 news item by Megan Saunders, `Ruling backs childacre health bans'
10/1/97 page 7 news item by Justine Ferrari, `Incentives likely in child jab campaign'
13/1/97 page 8 editorial, `Parents not immune from blame'
20/1/97 page 3 news item by David Nason, `Killer disease starts as innocent cough'
21/1/97 page 3 news item by Georgina Windsor, `Whooping cough may kill 150: Minister'
21/1/97 page 11 analysis by Jennifer Foreshew, `What makes parents ignore the threat of potentially fatal diseases?'
21/1/97 page 13 comment by Barry Cohen, `Vaccination is the sane option'
24/1/97 page 12 a series of letters to the editor under the heading, `Parents deprived of an informed choice on jabs'
25/1/97 page 22 letter to the editor from Dr Ian Griffith, `Parents apathetic on vaccinations'
29/1/97 page 10 letter to the editor from Brendan Falvey, `Parents belittled'
30/1/97 page 3 news item by Carolyn Jones, `School ban plan forces parents to immunise'
The Herald Sun
3/11/96 page 23 news item by Gerard McManus, `New push to immunise'
26/1/97 page 3 news item by Anthony Black, `School push on jabs'
26/1/97 page 3 news item, `Penalty plan for parents'
26/1/97 page 20 news item by Graeme O'Neill, `Return of the death cough'
26/1/97 page 20 news item, `So simple to play it safe'
26/1/97 page 21 news item by Tanya Taylor, `Ignorance, lack of funds blamed'
28/1/97 page 11 news item, `Five-in-one jab for fewer tears'
31/1/97 page 5 news item by Ed Gannon, `Plea on child jabs'
What They Said ...
`Parents are usually reasonable, caring people. They are not apathetic ... Rather than trying to belittle parents, proponents of vaccination should admit the sometimes-disastrous effects of vaccination ... Parents need balanced facts, not an arrogant "we know best" attitude'
Mr Brendan Falvey, writing to The Australian
`It seems 90 per cent of Australians are in favour of immunisation. I bet a similar number are in favour of democracy yet, because of widespread apathy, voting has to be compulsory ... If Australians just don't care about the much more important issue of vaccination, shouldn't this, too, be mandatory?'
Dr Ian Griffith, Victorian College of Pharmacy Monash University.