27 Oct “The ethical principle of autonomy is among the most fundamental in ethics, and it is particularly salient for those in public health, who must constantly balance the desire to improve health outcomes by changing behavior with respect for individual freedom

“The ethical principle of autonomy is among the most fundamental in ethics, and it is particularly salient for those in public health, who must constantly balance the desire to improve health outcomes by changing behavior with respect for individual freedom.” (Zimmerman, 2014)

 

 

 

For the case study examining the topic of autonomy in relation to the ethical dilemma below. There are other ethical tensions present, but the focus should be on how autonomy was violated. 

 

Important things to consider for the case study below is that Canada does not have a defined age of consent for vaccines. See more about this here: https://www.healthlinkbc.ca/healthlinkbc-files/infants-act-mature-minor-consent-and-immunization

 

 

 

Pay attention to the place this case study takes place, and the systems mentioned in order to accurately respond with stakeholder beliefs and values. 

 

Introduction:

 

On the eve of a provincial election in September 2007, the Ontario government introduced a federally funded, school-based Human Papillomavirus (HPV) vaccination program aimed at children aged 9-13. The vaccine confers immunity against four (6, 11, 16, 18) of the 100+ strains of HPV. Despite the publicly funded program, only one-half of potential recipients in Ontario participated in the vaccination program the first year. 

 

HPV is a sexually transmitted infection (STI) that is associated with the development of cervical cancer in women, and genital warts, anal cancer and some throat cancers in both men and women. Strains 16 & 18 are responsible for 70% of all cervical cancer cases and vaccination against these strains is most effective before onset of sexual activity.(1) In Canada, cervical cancer is responsible for 1.1% of female cancer deaths (< 450/year).(2) HPV is transmitted easily through non-penetrative sexual contact, and most infections clear spontaneously: within one year of exposure to HPV, about 70% of infected women clear the infection on their own; within two years, 90% clear it.(3)

 

The HPV vaccine is one of the most expensive vaccines on the market at over 100$ per dose. Luckily a pharmaceutical company offered it to the Ontario government it at cost, and assisted with risk communication to the public. Following the pharmaceutical company’s lead,(4) the Ontario program frames the product as a cervical cancer vaccine, not an STI vaccine. The framing of the product as a “cancer vaccine” also makes vaccination more palatable to parents who may be uncomfortable with vaccinating their children against STIs. But this conflates HPV infection with cervical cancer to create the perception of a public health crisis.(5-8)

 

The National Advisory Committee on Immunization recommends a policy of mass vaccination for all children aged 9 to 13 through their school. They provide suggestions for how to accomplish this, but leave implementation up to the school boards. 

 

We know that the HPV vaccine is effective in providing immunologic protection.(10)(7) As is the case for most risks for chronic disease, risks for cervical cancer in Canada are not distributed evenly across the population. The introduction of universal Pap screening in Canada resulted in declines in cervical cancer incidence and mortality among all income groups, with the biggest reductions seen in low-income women.(11) Despite this, a socioeconomic gradient in cervical cancer persists(11-12) and the prevalence of cervical cancer among marginalized groups, such as Aboriginal women, is higher than in the general population.(6) This has been attributed to poor reproductive and primary health care, low socioeconomic status and poor nutrition. If school vaccination is universally accepted, increasing access to HPV vaccination in schools may have a levelling impact and decrease differences in risk for cervical cancer from HPV strains 16 and 18. 

 

Case:

 

You are evaluating the vaccination program rollout in elementary and middle schools across the province. Because this vaccination program was announced as a last minute campaign promise, it has been challenging to know how schools are implementing this program. Your local medical officer of health (MOH) agrees, and asks you to conduct onsite visits at various schools across the province to ensure they are following the legal requirements for mature minor consent, hosting information sessions that all parents can attend, respecting privacy, and minimizing interruptions to classroom learning. 

 

You observe the following:

 

Information packets are sent home (in English/French) along with forms with a request for parental signature to every eligible students family. Each school also offers a Q&A session with the school nurse on a Friday during school hours (9:00am-3:00pm) before starting the program on a Monday. 

 

Once the vaccination program starts, classes with eligible students will take turns visiting the school clinic during recess. Before walking to the school clinic, the teacher does attendance and separates them into two groups based on the forms they received. The students who have parental consent, or are able/willing to offer their own consent, go wait in line at the school clinic. Students who do not have parental consent or are not able to offer their own consent, are sent to the gym for free time until the line at the clinic is done. 

 

You observe that older students able to give their own consent, seem to decide which group they stand in based on what the peers before them choose. While you make a note of it, you also know that peer pressure is hard at that age and can understand wanting to fit in. 

 

This system of taking attendance, separating the groups in class, and going to either the clinic or recess will be repeated for each dose throughout the school year, until all children of eligible age with consent for vaccination, have been fully vaccinated. 

 

You are impressed with how efficient this system is and how it minimizes school interruptions by using free time. You make note of it for your report. 

 

You also note how schools in areas with high rates of newcomers to Canada, almost no students end up in the gym for free time, so the vaccination program in those schools take much longer due to high participation. While touring these schools you notice posters focusing on immigrating to Canada and the types of forms the school needs for enrollment (including a filled out HPV vaccine form) along with free night classes to improve parental literacy. In order to be efficient with such a high volume of vaccinations in these schools, the school nurse tells you that they just confirm the child has a signed form (by themselves or a parent) and that their name is spelt correctly on the charting system. The school nurse also shares their surprise at the high number of consent forms turned in after the low attendance rate during the Q&A forum. 

 

You record this as an overall success, because a large goal of this program is to reduce the risk of cervical cancer in marginalized communities. 

 

When you return home, you send the program evaluation report the MOH, making sure to highlight the efficiency of using free time to minimize class disruptions and the high participation rates in marginalized communities.  Almost immediately after sending your report in, there is a province wide announcement that the HPV vaccination program has been suspended until further notice due to ethical concerns. 

 

 

 

Question to guide your thinking:

 

Is it ethical to knowingly amplify the perception of risk in order to increase compliance with a public health measure? If so, is this the case for a school-based vaccination program aimed at children? Does it make a difference if it is done with the aim of increasing access for disadvantaged groups? Did it increase access for these groups? Why or why not?

 

 

Issue statement:

 

 

 

Stakeholders Values and their beliefs:

 

 

 

Public Health Department:

 

 

 

Families involved in the studies:

 

 

 

Assumption:

 

 

 

 

 

Extra information:

 

 

 

Best Public Health course of action:

 

 

 

 

 

 

 

Reference:

 

Zimmerman FJ. Public Health Autonomy: A Critical Reappraisal. Hastings Center Report. 2017;47(6):38-45. doi:10.1002/hast.784