The results of the study Benchmarking Regional Health Management II suggest that compulsory measles immunisation is a good practice in public health management. Yet, the potential achievement of the desired health outcome alone is not a sufficient reason to make the immunisation obligatory. Rather, compulsory measles immunisation is a morally challenging measure. In this article, compulsory measles immunisation is critically evaluated from a public health ethics point of view. For this evaluation, a set of ethical criteria is proposed: respect for autonomy, health maximisation, efficiency, proportionality and social justice. The authors suggest it should not be taken for granted that compulsory measles immunisation should be championed, rather, health policy makers in the European Union should try to raise immunisation rates with non-compulsory means.
Key words: measles, immunisation, compulsion, ethics, European Union
The Benchmarking Regional Health Management II study (Ben II, EU project 2003106) compared the public health management systems of 19 European regions with regard to their structures, processes, policies and health outcomes. The analysis was conducted along three tracers: measles immunisation, breast cancer screening and care and diabetes (type ?) care. Among the examples of good practice for measles immunisation, the Ben ? study identified two regions that fulfil the criteria for good practice. These regions are Moravia-Silesia (Czech Republic) and Szabolcs-Szatmár-Bereg (Hungary). They achieved very high rates of uptake for the first and second doses of measles immunisation, in 2005 close to or above 95%. The study found that these regions have compulsory measles immunisation policies. Despite this finding, compulsory measles immunisation is neither necessary [e.g. Madeira (Portugal) reaches also 95% for the second measles immunisation dose without compulsory measles immunisation], nor necessarily sufficient for high immunisation rates (Western Greece also has compulsory measles immunisation but immunisation rates are not that high) (1). The authors of the BEN II study found compulsory measles immunisation to be a public health measure that requires ethical discussions.
Thus, in this paper the authors examine if, or under what conditions, a compulsory measles immunisation would be ethically justified. Firstly an ethical framework to present plausible criteria for discussion is presented. In other words, moral benchmarks for ethically justified good conduct of public health measures are offered. The paper goes on to show how these criteria may be used to support a robust argument in this regard.
AN ETHICAL FRAMEWORK
Principles are useful tools for medical and public health ethics (2). To find guidance for ethical evaluation, one can use a concise set of broad ethical principles. A framework for public health ethics has to be different from that one of medical ethics due to the different perspectives and duties public health and medicine have. Generally, in medical ethics one uses the principles: respect for autonomy, beneficence, non-maleficence and justice (3); such principles focus on bringing good to patients or research subjects without harming them or making them means to someone else's ends.
Public health ethical principles can consist of the following generalised norms that reflect the public health enterprise to maintain and promote population health - whilst still acknowledging "side constraints" (4) that remind practitioners that populations consist of valuable individuals. These principles are: health maximisation, respect for human dignity, social justice, efficiency and proportionality (Table 1) (5). These principles can be considered an "ethical toolbox" for public health practitioners and scientists and benchmarks for ethically good and right public health research and practice. It is the role of public health practitioners and researchers to balance these principles in their daily work and/or specify them to more concrete moral rules and judgments within particular contexts. …