Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values

Daniel A Salmon, Saad B Omer

Modern public health strives for maximizing benefits for the highest number of people while protecting individual rights. Restrictions on individual rights are justified for two reasons--for the benefit of the individual or the benefit of the community. In extreme situations there may be a need to protect the health of an individual and particularly a child; even by overriding individual/parental autonomy. However, The American Academy of Pediatrics recently concluded that "Continued (vaccine) refusal after adequate discussion should be respected unless the child is put at significant risk of serious harm (as, for example, might be the case during an epidemic). Only then should state agencies be involved to override parental discretion on the basis of medical neglect". Many countries have compulsory immunization requirements. These laws curtail individual autonomy in order to protect the community from infectious diseases because unvaccinated individuals pose risk to the community--including vaccinated individuals (since vaccines are not 100% efficacious), children too young to be vaccinated, and persons who have medical vaccine contraindications. There are situations where there can be a real or perceived divergence between individual and community benefits of vaccination. This divergence may occasionally be based upon current scientific evidence and may exemplify the need for overriding individual autonomy. A divergence between individual and community benefits may also exist when there are ideological beliefs incongruent with vaccination or individuals are unaware of or do not accept available scientific evidence. When the state curtails individual freedoms for the collective good, it should address several issues including the magnitude of the individual and community risk, the strength of the individual's conviction, wider and long-term consequences of restricting individual autonomy, effective risk communication, best available scientific evidence, and transparency of the decision making process.