Revision

Thank you everyone who gave me feedback on this project. I appreciate all of your recommendations and hope that, if you are re-reading this, I including your revision. Although I found it hard to change my writing I took what you all said to heart and did my best. The most I revised was structure, both in paragraphs and sentences, because that is what people told me to fix the most. Again, I thank you all and hope you enjoyed reading this essay –  Felipe Toso.

 

TETANUS IMMUNIZATION: REVISION

 

In our contemporary generation, we find ourselves living in a realm of contradictions. On one side, our world is expanding rapidly and we are graced with technological and medical advances that make our lives easier and should help us feel protected. At the same time, we also face a myriad of “public health issues” day to day, which may challenge our health and safety. For the sake of specificity, I will focus in on Tetanus immunization as a public health care topic in the United States.

Tetanus vaccinations (and vaccinations in general) spark great controversy and re-introduce the persistent theme of conflict. This theme of conflict is a central debate between the clashing interests of two essential powers: the first resides with the individual and his liberty to make his own decisions regarding vaccinations, a right which is naturally granted to him by the Constitution and disagreement ensues with the introduction of the second force, government, due to government’s right to intervene– even at a cost of infringing on individual autonomies—with the “interest” to protect the community.

Underlying this theme lay plenty of ammunition supporting or opposing mandating the Tetanus vaccine. This demands careful analysis before presenting the best possible approach to maximize benefits. What I will argue in this paper is that although the Tetanus vaccination is a public and collective good, since it provides immunization against a disease, it is not a public health issue. There a numerous reasons argued for this, but the main reason for this is that Tetanus is not contagious, so an individual’s choice to deny vaccination does not impinge on herd immunity and does not pose harm on anyone but himself. I stand against mandating the Tetanus vaccine. This is based on weighing the costs of legal obligation on the individual as well as the benefits of receiving the vaccination. The only exception, however, is that Tetanus should be mandatory in military service. This is due to the fact that if the individual got infected, it would have greater costs on the community and more importantly the rest of the military force.

Before delving into my reasoning, it is important to know that Tetanus is a non-contagious disease caused by the transmission of bacteria. Areas of contamination include saliva or through burns. However, the most common areas of contamination are deep wounds.[1] It is easily transferable through moist soil, making it more prevalent in countries near the equator because there is a surplus of soil in that fertile area. This implies that Tetanus is not as prevalent in the United States as in other countries, especially those close to the equator. In fact, Tetanus is among the least prevalent in the United Statestoday.This may be due to the fact that it is not contagious, so it does not spread to others in the community.

According to the Center of Disease Control, even if an individual does get infected, there is an incubation period up to three weeks. This is the time between the first exposure and the first set of symptoms, which are usually stiffness in the neck and difficulty swallowing[2]. The symptoms are clearly not detrimental at this stage, which allows time for vaccination, if desired. The Center of Disease Control provides global incidence rates of about 30%, and mortality rates of about 10-20%, which many claim are overestimates. As Geoffrey Rose explains in Sick Individuals and Sick Populations, “the determinants of incidence are not necessarily the same as the causes of cases” (Rose, 36). These incidence rates may not necessarily imply the prevalence of Tetanus at all, or even contribute to the mortality percentage; there may be other causes for death when cuts are exposed to moist soil or rusty nails. Interestingly enough, Tetanus came to the scene in the United States when the first case was tracked around the 1940’s; but as of 2000, there were only 41 reported cases of Tetanus in the United States[3]. Clearly, because of the constant advance in medicine and medical science since then, the numbers by now must be at a minimal level compared to the numbers in the past. Regardless, the nature of Tetanus itself is important in deciding whether mandating the vaccine would have more of a cost or benefit for the public.

So, who is the “public”? Who is affected by public health? The word “public” refers to the immediate population, and when introducing the word “health”, the definition extends to those that can be affected by the infectious disease or benefited by vaccination. In this sense, public health goods may be anything advantageous that is accessible, benefits, and provides pleasure to, the public. Collective health goods also fall into the broad category of “public health goods” but differ in that these “goods” require a collective effort to produce. For the most part, doctors or public health officials provide collective health goods to the community in creating Tetanus vaccinations against diseases. Therefore, Tetanus immunizations serve as both a public and collective health good. I recognize that as a public and collective good, the Tetanus vaccination does provide protection if an individual were to be exposed to certain high-risk conditions. Nevertheless, even if not getting immunized poses a potential risk, and receiving the vaccination would deter this chance, it must also be considered whether or not Tetanus is a public health issue. The benefit of protection does not imply that a lack of protection would be a risk. Compared to the emergence of other more life-threatening and contagious diseases such as HIV, Tetanus is not a very prominent health concern anymore in the United States. The reality that the peak of the Tetanus outbreak declined decades ago around the 1960’s, combined with the fact that Tetanus is not contagious, signifies that it does not pose a public or collective health problem.In fact, the harm is isolated to the individual, so the decision to refuse immunization does not jeopardize any hope for “herd immunity” against Tetanus.

The current government policy requires Tetanus immunization, especially to enter schools, but I believe it deserves a re-consideration. In comparison to the tentative risks of infection, the major cost in hindering autonomy would be greater. Mandating vaccines give the government permission to limit the liberties of those who oppose immunization, and deny them a right to make decisions. Ideally, the role of the government is to serve in the best interest of the people. When implementing public health policies, it is important to make decisions adhering to a best possible outcome for majority by reducing costs and maximizes benefits. Especially in matters regarding personal health, I believe that the government role should be controlled. Thus, intervention should only be warranted under certain circumstances. In his book, On Liberty, John Stuart Mill argues, “there is a limit to the legitimate interference of collective opinion with individual independence; and to find that limit, and maintain it against encroachment is as indispensable to a good condition of human affairs as protection against political despotism” (Mills, 5). I completely agree with Mills in that he highlights the importance of individual independence as separate from political decisions. His belief is crucial to maintain such autonomy. As such, I believe that the government should only exercise three essential duties regarding involvement in personal affairs. Beyond those boundaries, I support the power of the individual to decide on all areas of their private lives, as long as it does not harm others. The first role is that of a protector; in the case of contagiousoutbreaks or epidemics, where community is at risk, the government “power can rightfully [be] exercised over any member of a civilized community, against his will… to prevent harm to others” (Mills, 9). I also agree with Mills on this mention of the “harm principle” (Beauchamp, 46) as a justified intervention of government in personal affairs to protect everyone else. In such circumstances, the benefits of mandating immediate immunization in protecting others and halting the spread of the disease would outweigh the costs of temporarily freezing rights. But, unlike other “vaccine-preventable diseases”, herd immunity will not protect others from Tetanus[4]. In addition, immunity is not imperative because the disease does not spread, and denying vaccination does not jeopardize the health of others. Therefore, the choice to get the Tetanus vaccination should be a personal decision.

A second role of the government is that of an educator. The government has a moral and societal duty to educate citizens on pertinent matters. Especially with health, the government and government-funded services are required to create, monitor, regulate, and reform public goods—such as the Tetanus vaccination. This being so, it is the government’s responsibility to provide objective and candid health information to the public. This includes critical information on how it can be contracted, what the symptoms are, how to get vaccinated and the potential consequences in not getting vaccinated. After learning this crucial information people themselves should be held accountable and decide where or not to get the Tetanus vaccine. This leads into the third job as that of a facilitator.

The government should also provide the Tetanus vaccination for everyone equally (either through public or private health care measures). This includes economically and socially disadvantaged individuals, as well as the mentally impaired members of society who cannot afford, or do not have the means to receive, vaccinations. Under a duty and an ideal to do what is best for the people, the government must attend to all in the same regard and no one should have to live in fear of contracting Tetanus just because they cannot afford to be protected from it. Under these functions, the Tetanus vaccine should be highly recommended and readily available. On the other hand, the government should not coerce individuals to consent to it if they are opposed. This way, both sides are satisfied; the government can appeal to the public equally and reduce costs. In mandating too many policies on vaccinations, the government – as a protector, educator and facilitator– would run the risk of crossing into private territory with no justification. It is important, therefore, for the government to “pick and choose” its battles especially in private health affairs.

Although I stand firm that the Tetanus vaccine should only be strongly recommended, I do believe that mandating immunization should be required in military service because the probability of injury and the costs for treatment are too high. This actually presents an interesting argument because mandating vaccination for soldiers is not technically an exception because it does not directly infringe on their autonomy. The reason for this is that Americans are fortunate enough in that enlisting in the military is a voluntary service. Attached to this commitment, there are many specific guidelines, including a mandatory Tetanus vaccination. Because individuals choose to enlist, hence they still exercise their right of liberty, they agree to comply with the rules of the game and accept vaccination. This policy is rational because traveling to third world countries expose the soldiers to all diseases and significantly increase their risks of contracting Tetanus. As a protector, the government is justified in mandating vaccinations for soldiers for two reasons. One is to ensure that the mortality rates of soldiers run low, in the case that they do contract Tetanus and do not receive treatment. The other is to protect the citizens from expenses in taxes in the case that soldiers do contract a disease, and require medical attention. Therefore, soldiers’ refusal to get vaccinated, especially under the conditions where they travel, would not only increase their own risk, but would also have an immense cost (literally) on the government who funds the military. This effect would trickle down to the taxpayers and they would also be penalized. Preventing an economic liability, vaccinating soldiers is more beneficial than not. But even from a practical perspective, soldiers enlisting in the military knowing the risk of death are probably not the individuals who would oppose extra protection anyway.

As goes for most public health concerns, there will always be cases supporting mandatory Tetanus vaccinations. Those who support mandatory vaccination, and even government intervention in public health, believe that health always has some affects on the community. Under this belief, it is in the best interest of the people that it be regulated on a government level. Dan Beauchamp in Community, elaborates on this point and claims that “public health and safety are community or group interests… that can transcend and take priority over private interests if the legislature chooses”(Beauchamp, 46). I disagree with Beauchamp’s opinion on this matter. The basic unit of our individualistic culture is the individual; this is exemplified through general independence as human beings, the goals we set for ourselves, and our freedom to decide how to live our lives. This is especially true in the United States, which values diversity of opinion and self-sufficiency to high regards and ideals. As compared to collectivist cultures, individuals in the United States live for themselves, which is why it is contradictory in nature for the American government to impose so much on private affairs. Beauchamp’s perception that public health is a collective duty is sound only in the case that a disease may directly place the community in harm. Tetanus, however, does not do this. Therefore, because it is not a public health issue that involves or affects the rest, government should not “take priority over private interests” under no means. Beauchamp elaborates his points of view and states; “creating, extending, or strengthening the practices of public health—and the collective goods principle that underlies it—ought to be the primary justification for our health and safety policy” (Beauchamp, 53). On this note I will also have to strongly disagree with Beauchamp. As I have mentioned previously, just because immunization against Tetanus provides a collective good, it does not imply that it is at all a public issue. Here, Beauchamp generalizes a vague principle to a controversial issue in the realm of public health. The “collective goods” argument in this case is certainly not enough justification to intervene on autonomy– especially if refusing vaccination does not impose any direct issue on the public.

I recognize the several benefits of immunization. The benefits of immunization are that it protects and prevents possible death, it is relatively cheap to administer, has few fatal side effects, eliminates school liability issues, and reduces the taxpayer duty to pay off hospital debts of unvaccinated individuals. I will first touch on the main worry that if an individual gets infected with the Tetanus bacteria, they may die unless they are treated. I believe that this is an extreme level of apprehension because it assumes that everyone who gets a cut and happens to be in a high- risk environment will get Tetanus. Although exposure to such infested environments (if unvaccinated) may increase one’s risk, it does not instantaneously lead to infection. The “cost” of death if one does not get the Tetanus immunization is not one that poses an imminent threat anymore.

This lack of immediate danger to the individual and the community is not enough to allow the government to require Tetanus immunization for everyone. On the other hand, because the vaccine is relatively low in cost, simple to administer, and does not have too many negative side effects, receiving the vaccine is also relatively safe for those who do desire immunization. But, the simple benefit that the Tetanus vaccine is inexpensive is just a perk; if anything, it only serves to make the vaccine more available and affordable for those who do choose to get it. This is not, however, in any way sufficient enough as a benefit to require immunization. The common side effects of soreness, headaches, and rare seizures, are also so minimal. This would only be another enticement, and is still not enough to convince me.

Another area where proponents for mandatory Tetanus vaccination could find my argument controversial is when dealing with children. For contracting the disease itself, the targets of concern are children who are “at higher risk” because of their carelessness on the playground. This is ironic because, according to the Center of Disease Control, more adults have actually been reported to die from Tetanus[5]. Furthermore, the irony extents to the fact that many adults do not even continue with booster immunizations, and still there has not been an increase in mortality rates! More debate in the area of children is centered on a minor’s inability to consent, and the “liability” it poses on schools if an un-vaccinated child contracts Tetanus. As a school entrance requirement–public or private—I do not believe that these institutions have a right to mandate the vaccine. But one may ask, how about the minor who does not have a right to consent and is not aware of the risks if he is not immunized? Legally, parents or guardians have the right to decide on their child’s key life decisions; as minors, they are dependent beings—financially, socially, and emotionally.

The decisions parents make regarding their child on where they are educated, how they are raised, and what approaches to take (or not take) in their child’s health, are all personal matters. The government should not have a position to instruct parents on what constitutes as being in the child’s best interest, unless they are in imminent danger– which is not the case with Tetanus. As Mill explains, the government should allow people to live their own lives (Mills, 61), and should have no right to assume what is good for a child, or generalize their subjective well-being in an objective manner that applies to all children. Mandating immunization, the government may interfere on parents’ decisions to deny the Tetanus vaccination to their children. This would undermine their rights as parents. So, I ask, who should assume the role as parents: the government or parents themselves?

Well, how about liability; what if parents sue a school in the case that their child contracts Tetanus on the playground? First of all, in private schools, this would be an insurance issue and not directly a government issue. In all private institutions, insurance is strictly a private matter, and is therefore a concern between the school and the insurance company that the school chooses for protection. Private schools should be able to determine whether or not they require Tetanus vaccinations, as part of enrollment and the government should respect the decision of the school authorities. There is a reason why private schools are called “private”—the government is kept separate from its matters. If the school decides upon mandatory Tetanus vaccination, then the parents of children should comply, but if parents refuse, attendance should not be denied. In this incidence, the school should require a consent form. This would outline and explain the risks if the child is not vaccinated for Tetanus, as well as an section where the adult agrees to the terms and conditions and sign off on personal responsibility of costs if their child gets infected and needs treatment. This would target the issue of liability and the parent’s choice to refuse vaccination for their child would not be the school’s “problem” anymore. The circumstance is different for public schools because the government has control. Therefore, if the government recommends vaccination, this regulation would apply to all public schools.

One may argue this on the principle that if a non-vaccinated child gets infected and needs medical attention, this may harm the taxpayers of the community who would pay. A likely solution would be that similar to private schools where the government should requires consent forms as well. Signing this allows parents to assume responsibility of paying medical costs if anything happens to their child. This provides mutual benefit; schools would not worry about liability and individual rights are still prevailing. If parents value their legal right to make their own decisions so much, then they should be held accountable for all outcomes, or costs—literally and figuratively.

On this note, another major reason for mandatory vaccination is that if an individual does not get immunized from Tetanus and contracted it, treatment would have a negative external cost for taxpayers who would have to pay for the medical care. If people value their autonomy enough, they must really hold weight to an idea of personal accountability for their decisions. If their mindsets are that they are the “rulers of their own life”, then they should also accept a liability in the case of infection. But the fact is simple; Tetanus has an isolated and direct harm on only the individual. Fearing this potential cost that does not harm others does not, and should not, be enough of a justification for the United States government to mandate immunization.

It is true that non-immunization combined with dirt exposed to an open wound, may increase a risk. But, it does not guarantee infection. Mandating the Tetanus immunization is too much of an imposing measure taken to lessen a possibility. These steps are usually followed too much out of a worry for the future events. It is true that all benefits to vaccination are important, but those for Tetanus would probably hold more weight if Tetanus was more prevalent. In relation, I do not believe that those stated benefits are grand enough to outweigh the immediate cost of limiting autonomy, especially for those who oppose vaccination. Recommending Tetanus immunization is more ideal because it does not coerce individuals who either oppose it, or do not consider the infection risky enough. But, it still presents the option for those who want to take the extra step to vaccinate themselves and their children. So, why not benefit both sides by maximizing liberties?

I am not trying to undermine the fatality of Tetanus, or immunizations in general. I am simply arguing that government intervention should be careful when entering private lives. Especially in decisions, government needs to weigh the interests of opposing sides equally. Mandating a vaccine that does not pose harm on the rest would not be serving in the “best interest” of those who do not want immunization. I will conclude my discussion by questioning government intervention from an ethical perspective. As Beauchamp states, “public health belongs to the realm of the political and the ethical” (Beauchamp, 52). Having touched on the political aspect, I do not think interfering on autonomy is ethical. Is it fair that currently mandatory Tetanus vaccination is exempted under religious grounds, but not for choices on personal lifestyle? Both the rights of liberty and to exercise religion are granted to every United States citizen by the Constitution. As Mills argues, “each is the proper guardian of his own heath, whether bodily or mental and spiritual. Mankind are greater gainers by suffering each other to live as seems good to themselves than by compelling each to live as seems god to the rest” (Mills, 12). I also believe that the individual himself, and not any external force, is the only one who knows what is best for him.

In allowing certain exceptions, the government does not equally respect the value of these rights. Because government generally avoids religious topics, it should also keep a distance with personal freedoms. Religion is indeed a choice of lifestyle, but isn’t health a lifestyle too? Perhaps discussions about controlling religion is not “socially acceptable”, but considerations in controlling freedoms should not be accepted either. If government does hinder anyone from practicing their religion, it should not deny anyone the freedom to make decisions that concern their private lives. Recommending the Tetanus vaccine would respect the rights of those who desire vaccination, and those who oppose it, equally. This being said, after weighing the costs of limiting autonomy and benefits of receiving the vaccine, I reiterate that Tetanus is not threatening enough to implement mandatory immunization.

Bibliography

 

“Tetanus (Lockjaw) Vaccination.” Center of Disease Control and Prevention. Department of Heath and Human Services. USA.gov. Department of Heath and Human Services. 29 September 2010. <http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm&gt;.

“Immunizations and Vaccines and Not Vaccinating.” PKIDs Online. 1996. Parents of Kids with Infectious Diseases. Parents of Kids with Infectious Diseases. 1 October 2010. <http://pkids.org/isearch/index.php&gt;.

 

[1] “Tetanus (Lockjaw) Vaccination”. Center for Disease Control and Prevention.

[2] “Tetanus (Lockjaw) Vaccination”. Center for Disease Control and Prevention.

[3] “Immunizations and Vaccines and Not Vaccinating.” PKIDs Online.

[4] “Immunizations and Vaccines and Not Vaccinating.” PKIDs Online.

[5] “Tetanus (Lockjaw) Vaccination.” Center of Disease Control and Prevention.

 

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