Medical Autonomy and Vaccines: A Kantian Imperative

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In The Fundamental Principles of the Metaphysic of Morals, Kant seeks to establish a concept of duty based solely on reason. He believed that one must not just act in “accordance with duty”…but also for “duty’s sake.” (1) He argues that reason provides the foundation upon which duty rests; the rightness of an action derives from its conformity to a moral rule that any person must follow in order to act rationally. This rule, according to Kant, is called the “categorical imperative;” this imperative requires that a person must never perform a particular act unless they can consistently intend that maxim (or principle) that motivates a particular action to become a universal law.  From this categorical imperative, Kant derives a second formulation that establishes his idea of a moral autonomy. The second formulation that Kant creates, based off his categorical imperative, states that someone must act so as to treat people as ends in themselves, never as a mere means. This notion looks at actions from the perspective of the one acted upon rather than the ends of the agent themselves. (1)

The idea of autonomy, in a modified sense, permeates through much of modern medical ethics. Autonomy in a medical system involves an individual’s choice of self-governance when it comes to medical decisions. (2, 3) This notion of self-governance has overarching implications when it comes to an individual in society as a whole. For example, if an individual elects to not immunize themselves or their children, legislation is available for the involuntary immunization of individuals; many states do, however, allow exemptions for involuntary immunizations based on medical, religious, or philosophical/personal beliefs. (4) This idea of exemptions, with respect to religious and philosophical reasons, has serious repercussions that can be seen in epidemiological surveys:

…In the U.S. vaccination rates of children entering kindergarten exceed 90% for most recommended vaccines. A closer look, however, reveals substantial local variation. In Washington State’s San Juan County, for example, 72% of kindergartners and 89% of sixth graders are either noncompliant with or exempt from vaccination requirements for school entry. Only 52.5% of kindergartners and 4% of sixth graders were adequately immunized against pertussis for the 2010–2011 school year…the county also has one of the state’s highest incidence rates of pertussis. (5)

The statistics clearly outline the dangers that communities can face when there are higher rates of noncompliance with vaccinations.

The ability for individuals to not receive vaccines, but remain healthy, rests upon the notion of herd immunity. “When a portion of a community is immunized, most are protected against that disease because there is little opportunity for an outbreak.  Even those who are not eligible for certain vaccines—such as infants, pregnant women, or immuno-compromised individuals—get some protection because the spread of contagious disease is contained.” (6) Herd immunity therefore creates a situation that allows those who opt out of particular vaccinations to use the community members around them as a pseudo-vaccine. In essence, people who elect not to receive these critical immunizations (unless done so for specific medical reasons) are using others as mere means; this idea of using others as a mere means is critical to what Kant advocated against.

Juxtaposing the idea of herd immunity to Kant’s categorical imperative reveals an underlying universal duty when it comes to vaccines. For an individual to opt out of receiving particular vaccines for religious or philosophical beliefs, they use the members of their community around them as a pseudo-vaccine via herd immunity. Herd immunity is provided without the consent of both parties and therefore impinges on the universal maxim that states: people should always be treated as ends in themselves and free autonomous agents. Individuals protected by the immunization of others are able to live healthy and productive lives and exercise the freedom of autonomy at the expense of others’ complete autonomy. Some may argue by labeling the categorical imperative as a universal moral ideal, I am also using others as a mere means to an end: by imposing my vaccine and disease eradication doctrine. This argument derives from the notion of cultural ethical relativism – the idea that people should determine the moral worth of actions and that other people cannot impose their ideals because they do not understand the other enough to make such distinctions.

Cultural ethical relativists claim “… there can be no nonethnocentric standards by which to judge actions,” meaning there is no neutral way to approach morality of particular actions because of the diversity in societies throughout the world. (1) We all have different rules that we apply to judging actions; morality evolves like fashion in clothes, etc. Ideals in a society are particular to that society; an outsider cannot ordain things as unacceptable for one society because it is not so in their own society. The concept of cultural ethical relativism, however, is a flawed position because of two main objections: the majority/minority issue and the issue with heterogeneous nations. The minority can never be right in moral matters; to be right it must become the majority.  The main concern with the majority rules for determining morality in a society is the benchmark for reaching the “majority.” Where should the benchmark be set in order to determine the majority? If it were set at 51% then a particular moral issue would potentially alternate between right and wrong fairly often, which would make ethical relativism very impractical showing how easy it is for moral matters to flip-flop. The second criticism of cultural ethical relativism is in the case of heterogeneous nations like the United States. When an individual is in a country like the United States where many different cultures and mini-societies overlap, they can receive conflicting moral standards making it difficult to decide what is right. (1)

Since the idea of cultural ethical relativism is flawed, the presence of universal moral principles therefore exists. When we involve ourselves in discussions about morality to strive to reach universal moral principles there exists a standard that needs to be met. William H. Shaw, a philosophy professor at San Jose State University, reaches the same conclusion with respect to moral issues:

…appeals to other sorts of considerations – for example, the rights of persons involved, fairness, or happiness produced – are perfectly appropriate and often suffice to establish at least the prima facie rightness or wrongness of the action. In other words, within moral discourse there are certain standard moves and relevant considerations – acknowledged by the vast majority of those who engage in it – just as there is an accepted framework of legal principles, policies, rules, and precedents on which a lawyer can and must draw in making his case… (1)

It becomes clear that when people engage in discussing a particular moral issue, there are standards that must be applied in determining the rightness or wrongness of an action. The standard here is Kant’s categorical imperative. Through treating others as autonomous individuals you establish them as ends in themselves and not as mere means to an end.

The attempts to eradicate the Polio virus demonstrates the applicability of the categorical imperative on the scale of global disease eradication. Polio virus is one of the most infectious viruses still present in the world; more than ninety percent of people are asymptomatic and therefore the virus can spread throughout communities and the world without people even realizing it. The mission to eradicate this particular disease represents one of the greatest challenges in modern times. (7, 8)

In 2003 several northern Nigerian states banned federally sponsored polio-vaccination campaigns. The stoppage was justified by “evidence” that the polio vaccine was contaminated with anti-fertility drugs intended to sterilize young Muslim girls. “The suspension in Northern Nigeria led to a global outbreak of polio; the disease spread into twenty countries across Africa, the Middle East, and Southeast Asia…” (9) contributing to a large percentage of the world’s cases of paralytic poliomyelitis. This example again demonstrates the power that a misinformed decision can have on communities throughout the entire world when it comes to vaccines. Communicable diseases are a global networking system and this example highlights the issues surrounding decisions people make that use others as mere means to an end. In this case, the boycott of a vaccine based on a misinformed decision ultimately led to the deaths and infections of many people who had no say in the governmental decision to boycott.

The aim of this essay involves predicating the notion that universal moral principles exist and that we must abide by them as rational and ethical persons in the world. When the idea of cultural ethical relativism is used to predicate ideologies opposed to particular preventative medical measures, in this case vaccinations, these individuals use other persons as mere means to an end. This idea of autonomy was first established by Kant and has implications that have permeated not only political systems, but also medicine. Once we accept the idea of the universal moral principle of autonomy, the notion of opting out of protective medical treatments, at the expense of other individual’s health and well being, becomes morally wrong. This then leads us to the task of not only educating individuals and governments about the need of these preventative measures, but the ramifications of their neglect.

 

References:

  1. Arthur J. Morality And Moral Controversies. Upper Saddle River, NJ: Prentice Hall; 2009.
  2. Coggon J, Miola J. Autonomy, Liberty, And Medical Decision-Making. L.J. The Cambridge Law Journal 2011;70(03):523–547.
  3. Varelius J. The value of autonomy in medical ethics. Medicine, Health Care and Philosophy Med Health Care Philos 2006;9(3):377–388.
  4. State Vaccine Requirements – National Vaccine Information Center. National Vaccine Information Center (NVIC). Available at: http://www.nvic.org/vaccine-laws/state-vaccine-requirements.aspx. Accessed March 13, 2016.
  5. Diekema DS. Improving Childhood Vaccination Rates. New England Journal of Medicine N Engl J Med 2012;366(5):391–393.
  6. National Institute of Allergy and Infectious Disease. Community Immunity (“Herd” Immunity). National Institutes of Health. 2010.
  7. Garon JR, Cochi SL, Orenstein WA. The Challenge of Global Poliomyelitis Eradication. Infect Dis Clin North Am 2015;29(4):651-65.
  8. Ghosh T. “Eradication and Control Programs: A Look at Polio.” Global Health Education Consortium. 2009.
  9. Kaufmann J, Feldbaum H. “Diplomacy And The Polio Immunization Boycott In Northern Nigeria.” Health Affairs 2009;28.4:1091-1101.

 


 

Justin Le Blanc was born and raised in Warwick, Rhode Island. He graduated from the University of Rhode Island in 2013 with a dual degree in Biological Sciences (B.S.) and Philosophy (B.A.) and was inducted as a member of Phi Beta Kappa. He is currently in his third year of medical school at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia. He will be applying for general surgery residencies this upcoming year.