Why is imposing vaccination / immunization so hard to achieve?

Question

This has been in my mind for a while, so I am breaking the ice on the politics site.

I am living in Romania (Eastern European country within the European Union), so this question might be too localized, although I have heard about similar problems in other European countries as well.

Recently, we had a tremendous debate about the vaccination / immunization. This was especially relevant after some vaccine target diseases made some victims. E.g. Measles outbreak makes victims

I am wondering why it is so hard to make vaccination mandatory by law? There are so many arguments for it, that I do not see any serious debate (except for political will)

1. Clinical studies - check here for reference - have shown high safety of the vaccines

2. Herd immunity - (definition) - the most tricky effect is that immunization must high enough at the population level to be effective. By not vaccinating your kid, you are actually exposing other children (or even adults in some cases).

3. Efficacy - has been proven by many studies and be confirmed directly by either asking grandparents about how many used to die in the old days or by checking how easy is to die from various infectious diseases in countries that cannot offer vaccination for the people

4. Possible denial of education - some institutions (especially private ones) do not allow non-vaccinated kids to attend classes. This however is against the right for an education

Ex-Health Minister (a technocrat) managed to impose participation at some short course about vaccination awareness to all parents, before being legally allowed to not vaccinate their children, but he was unable to go further.

Also, another issue is that, under the protection of expression right (free speech), anyone can virtually express him/herself against vaccination without any scientific proof. However, I see this as an abuse since the European Convention on Human Rights clearly states that:

Article 10 provides the right to freedom of expression, subject to certain restrictions that are "in accordance with law" and "necessary in a democratic society". This right includes the freedom to hold opinions, and to receive and impart information and ideas, but allows restrictions for:

territorial integrity or public safety

protection of health or morals

Answer 1

The chief reason is because patient autonomy is considered a key value in modern medical ethics, and that forcing people to get vaccinated violates this. Patient autonomy states that a patient should be able to make their own decisions relating to health care given to them (and, by extension, make decisions health care providers disagree with).

Patient autonomy is not an absolute rule. For example it is generally agreed upon that it's acceptable to violate patient autonomy in cases where the patient is not considered to be sound of mind and unfit to make rational decisions (think mental illnesses).

When exactly patient autonomy should be overruled and to which degree is a debate that has been going on for centuries, but it generally doesn't apply to cases where a person is of sound mind and makes a decision which violates the best available scientific evidence (or more crudely put, is being stupid).

---

A second reason is that modern government usually don't take a stance on "truth" unless there's a pressing need to. There are some philosophical reasons for this; how do we know who is right? In other words, what is truth? Can we know what is true? How do we know something is false?

These questions are not easy. There are real limits to what we can know, and some things can be considered unknowable. Specifically, I can't prove that vaccines don't cause autism. I can only show there is no credible evidence for that claim discovered thus far, but that's not the same as disproving the claim. This James Randi lecture explains the concept in some more depth.

Some might say that this distinction is somewhat philosophical, and that in practice we can prove that vaccines don't cause autism (this is what Randi argues), and this might be true for matters of science, but in this context it's not a scientific question, but rather a question on ethics and how to organize society.

The current prevalent attitude is that personal beliefs – no matter how irrational or contrary to evidence – are "sacred", and not something that the government (or society) should directly interfere with.

This is why we have free speech, freedom of religion, and all the rest of it. Much of this is just a rephrasing of "freedom to believe in your own reality". And "freedom to believe" is worth very little without the freedom to actually act on those beliefs. Which, in this case, means not vaccinating.

Arguments in favour of mandatory vaccinations

None of the above is absolute though – very little is – and there are some arguments in favour of mandatory vaccination programs, which I'll briefly outline below.

Other people may be disadvantaged by a patient's decision

The foundational rule of medical ethics is do no harm (Hippocratic oath). But do no harm to whom, exactly? A single person? Or a population? Vaccines are typically not especially beneficial to a single individual, but are to the entire population due to herd immunity.

Some people view vaccinations so beneficial to the population as a whole that it may override autonomy in some cases. There is some historical precedent for this. Opposition to vaccines is not new, and during the 18th and 19th centuries a number of countries made the smallpox vaccine mandatory. For example in 1902 the United States Supreme Court declared that a state has the right to order vaccinations to protect the people from a devastating disease, while also recognizing that individual liberty was important (Jacobson v. Massachusetts).

Since then a few things have changed though. Medical ethics standards have become more codified, and individualism has significantly gained influence in Western society, so autonomy is typically given much greater weight. In addition, the medical crisis of the 18th, and 19th century were considerably more acute. The measles outbreak you cite is terrible, but on the other hand it has killed "only" two children, whereas the smallpox outbreaks of the 18th and 19th century typically killed hundreds or more, and presumably would have killed many more if there had been no compulsory vaccination.

All of this is part of a larger discussion when exactly the general good will override the individual rights. There are no clear answers here, and there probably never will be. It's a personal value judgement, and if you ask 100 people you will likely get 100 subtly different answers.

However, we must consider that the effects of not vaccinating children are comparatively mild in "the grand scheme of things". The risk of actually getting ill is very small, and the total number of people who have gotten ill (or even died) is very small as well. Especially if we compare this to other preventable diseases such as smoking or obesity.

The affected are typically children

Relating to patient autonomy mentioned earlier is informed consent, which is exactly what the name suggests it is: a patient must be informed of the health care action, and she must give consent before the care giver can perform the health care action.

Children are usually considered to lack the decision making ability to give informed consent for medical procedures. It's acceptable for a care-giver to give an four-year old an injection even though it's screaming "I don't want to, it's going to hurt!" as the child cannot be informed and cannot give consent, so the child's parents (or legal guardians) have to give informed consent by proxy.

It's generally accepted that a third party (usually the government in some form) should intervene if the parent's decision or actions counter the child's best interests in such a way that the child is seriously harmed. But where do we draw the line? Intervening on every possible thing that might cause harm is impractical and undesirable (it would be a absolute dictatorship) while never intervening would lead to abject abuse (paedophilia, child labour, etc.)

This, like the previous section, is a personal value judgement. In general however, it is considered that not vaccinating a child doesn't harm the child enough to overrule this. As mentioned in the previous section, chances are that the unvaccinated will live their lives happily without getting measles or any other vaccine-preventable disease.

Besides, what's next? Will parents of obese children get in trouble? That's probably a lot more of a pressing problem than vaccinations.

Concluding remarks

Opposition to vaccination is not new, but it has seen a large surge in the last twenty years after Andrew Wakefield's (now retracted) 1998 paper published in The Lancet where he fraudulently claimed that vaccines cause autism. Even so, the practical effects have been fairly limited. Yes, there have been outbreaks, and yes, people have died, but the scope of it has been small and most children still get vacinated. So the pressure to actually do something has been fairly limited.

This may change in the future, though. As the effects of non-vaccinated people may become greater. And some countries (such as Slovenia) do have mandatory vaccination programs, while some other countries (like many U.S. states) have some limited mandatory vaccination program with various opt-out clauses. Some politicians have also offered their support for stricter mandatory vaccination programs, such as Hillary Clinton and Ben Carson during the Presidential campaign.

It's also possible that a new lethal disease will rear its ugly head in the future, like the Black Death did in the middle ages. Should such an epidemic arise, vaccines almost certainly will be made mandatory, but this is not what we're talking about here.

Caveats

This answer comes with some caveats:

1. There are a lot of subtleties and exception that are not covered. You can write a book in response to your question, so I've had to choose between brevity and, well, writing a book :-)
2. I've generalized a lot, which is why I used the words generally and typically so often. There are a lot of differences and subtleties in attitudes to this topic, but I think – hope – I've captured the essence of it.
3. This applies to Western culture. I have no idea what the prevalent attitudes are in China or India. You mentioned Romania in your question, I also don't know anything about the on-going debate there, but in general, these are the most important considerations in the debate.

Links

Some interesting links, some of which were used as a source for this answer.

• Autonomy, The Internet Encyclopedia of Philosophy
• historyofvaccines.org
• Towards a twenty-first-century Jacobson v. Massachusetts
• How The 'Pox' Epidemic Changed Vaccination Rules
• Truth, The Internet Encyclopedia of Philosophy

Answer 2

A key design principle of modern democracies is that all power must come with limitations to prevent its misuse, because government officials consistently demonstrate a propensity to abuse whatever power they have.

If the government has the power to dictate that someone be subject to medical treatments against their will, how could this power be abused? Well, how has it been abused in the past?

The Soviets abused psychiatry as a way to control dissidents. The United States allowed forced sterlization for eugenics purposes for many years. That case is particularly interesting, because it was based on a lie: the family lied about the girl's character in court, to cover up the fact she had been raped by a family member. Adrian Schoolcraft was involuntarily committed by police to attempt to thwart him from exposing their corruption. A similar thing happened to Gustl Mollath in Germany; his 'paranoid delusions' of a conspiracy of tax evasion turned out to be... a real conspiracy of tax evasion.

Also in the United States, things like this happened:

In 1956 Donaldson travelled to Florida to visit his elderly parents. While there, Donaldson reported that he believed one of his neighbors in Philadelphia might be poisoning his food. His father, worried that his son suffered from paranoid delusions, petitioned the court for a sanity hearing. Donaldson was evaluated, diagnosed with "paranoid schizophrenia," and civilly committed to the Florida State mental health system. At his commitment trial, Donaldson did not have legal counsel present to represent his case. Once he entered the Florida hospital, Donaldson was placed with dangerous criminals, even though he had never been proved to be dangerous to himself or others. His ward was understaffed, with only one doctor (who happened to be an obstetrician) for over 1,000 male patients. There were no psychiatrists or counsellors, and the only nurse on site worked in the infirmary.5

This is horrible. Imprisoning someone for twenty years because of a "trial" where they couldn't even effectively defend themselves (no lawyer), in facilities woefully inadequate to treat him if he actually suffered from what he was diagnosed with, is an outrage. One doctor cannot treat more than a thousand people. It simply cannot be done. That's eight hours per person per year assuming the doctor never sleeps and spends literally every moment of every day treating patients.

It's a sick mockery of treatment. It's prison by another name, keeping these individuals from causing trouble by locking them up. They got away with it for a long time because they slapped the word 'treatment' on it and had a doctor instead of a prison warden.

So. How can the ability to force people to get vaccinated be used against them? It might be used as a pretext to take their children away ("opposing vaccination by definition makes you guilty of the crime of endangering the safety of a child"). It would make a convenient pretext to round up the homeless. Just declare them a public health hazard and ordering their detention for "vaccination shots" (never mind that this particular person is vaccinated, the group as a whole is known not to vaccinate, so some collateral damage is the whole point. I mean, is unavoidable, your honor). If it's easy to force someone to get vaccinated, it could even mean that if you piss off the wrong bureaucrat, or don't vote the way you're supposed to, the paperwork proving you're vaccinated "gets lost", and that's all they would need to conveniently have a judge sign an order that same day directing the police to involuntarily check you into a hospital.

If any of that sounds far-fetched or crazy, check my citations. It isn't very far removed from the kinds of things mentioned there. To keep these fears hypothetical, the rules are structured in such a way that it is very difficult for the government to force someone to undergo medical treatment over their express objections. One of the consequences of this is unfortunately the ability of vaccine hoax believers to endanger the rest of us. This is the price that we have to pay, because we have seen what happens when the government's power is not constrained.

A similar line of reasoning establishes why the vaccine hoaxers are allowed to spread their ideas. It wouldn't be hard to stamp this out if we could simply arrest people and fine or imprison them for spreading these ideas. The harm done by allowing this silliness to spread is nothing compared to the harms done when the government tells people what they can and can't say.