Compulsory Childhood Vaccination in Malaysia: Public Health versus Parental Autonomy

Abstract

Background: Following the death of two unvaccinated siblings, eleven months and two years old of diphtheria in June 2016, the Ministry of Health Malaysia is now emphasizing the need to enforce compulsory childhood vaccination in Malaysia. Vaccination is the main health intervention to reduce child mortality. Despite the success of vaccination, there has been an increase in the number of vaccine hesitancy, especially among parents. Research has identified many factors associated with parental vaccine refusal and hesitancy toward childhood vaccination, which varies from religious, medical as well as personal belief factors. This complicates matters as childhood vaccination involves a balance between parents’ autonomy in deciding whether to vaccinate their children and the benefits to public health. Between parental autonomy in deciding to vaccinate their children and the benefits of vaccination to public health, which will prevail? Objective: This paper seeks to examine the ethical issues of enforcing compulsory vaccination for children in Malaysia. Results: if Malaysia were to come up with a legal framework of compulsory childhood vaccination, reference can be made to the legislated statutes in other countries, taking into account that some provisions such as exemptions to vaccination may be modified to suit it with Malaysian local circumstances and International Journal of Academic Research in Business and Social Sciences Vol. 8 , No. 12, Dec, 2018, E-ISSN: 22 22 -6990 © 2018 HRMARS 1542 inhabitants. Conclusion: In improving health communication, aside from two way communications between parents and health officers, many other communication tools are also available. They include mass electronic media, digital media, print media, social mobilization and mobile technology. Introduction Unvaccinated individuals pose a public health threat to the society at large. The World Health Organization estimates that vaccines for diphtheria, pertussis, tetanus, and measles save between two and three million lives every year. Despite being cited as the most successful achievement in public health, certain groups still challenge this success by refusing vaccination for a variety of reasons including religious, scientific and political. The uncertainty towards vaccines leads to an increase in the number of people questioning and seeking alternatives for vaccines. Vaccine hesitancy is an emerging term in vaccine decision-making. The SAGE Working Group on Vaccine Hesitancy defined vaccine hesitancy as a delay in acceptance or refusal of vaccination despite availability of vaccination services (Larson, et al, 2014). With the changes in modern times and technology, the attitude of parents started to change. Parents nowadays are better informed on the issue of vaccination, due to the fact that information on vaccines can be acquired easily online. The spread of anti-vaccine and vaccine-fear sentiments has become common through social networks, both online and in person also contributes to the exercise of parental autonomy in refusing to vaccinate their children. Most of the studies analyzing the reasons for vaccine hesitancy or refusal among parents focused on parents’ philosophical or ideological ideas. Vaccine hesitant parents often defend their position on the basis that what they believe is in the best interests of their children, or what they believe as good parenting‘. Their reasons vary, however, with some believing that vaccines cause more harm than good, while some prefer natural immunity over unnatural vaccination. Meanwhile, others subscribe to the practice of free riding, that they will enjoy herd immunity without subjecting their child to the risk associated with vaccination (Diekema, 2005). Some refusals are due to the reason that there is no need for vaccination for eliminated illnesses seems justifiable, while some are quite absurd, for example the conspiracy theory that a government entity could be conducting intelligence gathering operations under the pretext of a vaccination program (Hendrix, et al, 2016). Other reasons for not vaccinating children include medical contraindications, insufficient communication with the medical staff, lack of knowledge or incorrect information among parents about vaccine-preventable diseases, low availability of and access to medical services, and low trust in medical authorities. In a 2012 study in Malaysia, among the factors influencing compliance to vaccination depends on the parents, health officers as well as the environmental factors. The parents factor include lack of knowledge or inaccurate perception about the importance of vaccines and the seriousness of the diseases prevented by the vaccines, socioeconomic status, high birth order and big family size, single parent and families who live in temporary housing or who migrate between jobs. Meanwhile, the health officers factor include waiting time, motivation of health officers, suitability of the timing of immunization sessions, attitude of health officers, reaction to side effects and charges for the services. The environmental factors included logistic barriers, limited accessibility to health care due to poor roads or inadequate public transportation, preparedness of community for immunization sessions and information dissemination among the community (Azhar, et al, 2012). It can be International Journal of Academic Research in Business and Social Sciences Vol. 8 , No. 12, Dec, 2018, E-ISSN: 22 22 -6990 © 2018 HRMARS 1543 concluded from the studies that parents demand the autonomous right to make decisions regarding their child's vaccinations, they perceive their refusal as characteristic of good parenting, and they are critical of and distrust the medical establishment. Other factors that affects vaccine acceptance/refusal include the gender of the baby, the mother's age, the mother's occupation, the mode of payment for the vaccine, the number of previous visits to the clinic by the parents, the number of counseling sessions given to the parents and the pre-counseling awareness or knowledge of rotavirus disease and rotavirus vaccine (Kannan, et al, 2010). As part of the overall package of maternal and child health services in Malaysia, all children are provided with free immunization. It is available in all government health facilities where child health services are provided, both in rural and urban areas. Private sector, through private clinics and hospitals supplement the services. The Malaysia Ministry of Health provides childhood vaccination schedule which serves as a guideline for parents, however as of date there are no law making vaccine compulsory in Malaysia. The Parliament enacted the Prevention and Control of Infectious Diseases Act 1988 (PCIDA), a statute that relates to the spread of diseases which relates more to the prevention of importation of infectious disease and control of the spread of infectious disease in Malaysia. Results PARENTAL AUTONOMY VERSUS PUBLIC HEALTH The parents approach to vaccination by making a decision based on parental autonomy places strong emphasis on the freedom, privacy and informed consent of parents in vaccine decision making. Current social conditions have encouraged greater patient autonomy in dealing with medical issues. In the case of childhood vaccination, patient autonomy comes in the form of parental autonomy as parents are the one who can make decisions with regard to their children medical needs, even if that decision is a refusal to accept medical treatment i.e. vaccination. Will (2011) described the parents‘refusal towards vaccination as their need of freedom to say "no" to the medical recommendation after considering the advantages and disadvantages as they analyzed the issue of vaccination. The choices they make seem rational to them, given the information they have. Beck and Giddens (1994) described this decision-making process as a reflexive thinking where in modern life, people make their own decisions by independent thinking, regardless of what the government says. According to Aharon et al. (2017), most of the interviewed parents mentioned their demand for autonomy in making their own decisions about their body and health including vaccination administration. In their opinion, everyone should have the freedom to decide in this matter, and it is the parents‘obligation and right to do as they see fit for their children. This includes choosing an alternative vaccination program, asking questions, and investigating the issue of vaccination. Another contrasting concept in medical services, paternalism refers to the idea that sometimes action needs to be taken by the authorities to protect the health and welfare of the public, even though the action may be against their will. The action is by way of public health interventions, for example compulsory vaccination to prevent infectious disease which often infringe on the rights of individuals (parents). International Journal of Academic Research in Business and Social Sciences Vol. 8 , No. 12, Dec, 2018, E-ISSN: 22 22 -6990 © 2018 HRMARS 1544 Health officers (doctors) are taught the principle of paternalism, which means actions done for the benefit of others. Thus when doctors impose on parents to vaccinate their children, their acts are carried out with the justification of doing good, i.e., protecting the welfare of the child and the public at large. This argument is often used to justify what would have been an intrusive public health intervention such as compulsory vaccination against particular contagious diseases, due to its overall benefits to society (Phua, 2013). Hence, we have programs such as compulsory vaccination schedules for children, with non-compliance being punished by exclusion of unvaccinated kids from public schools. Discussion HOW FAR PARENTAL AUTONOMY OUTWEIGHS IMPORTANCE FOR PUBLIC HEALTH? In the United States Supreme Court case of Jacobson v Massachusetts in 2005, the US court upheld the