Editorial
The right to vaccination and the individual duty in collective health during a pandemic
Juliana Bertoldi Francoa,b,
, Pilar Lecussan Gutierrezb, Fábio Roberto Cabarb,c, Chin An Linb,d
Corresponding author
a Departamento de Odontologia, Instituto Central e Hospital Auxiliar de Suzano, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
b Comitê de Bioética, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
c Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
d Medicina Interna Geral, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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These principles must be defended by health institutions and professionals.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a></p><p id="para0002" class="elsevierStylePara elsevierViewall">Since it has started, the unprecedented public health crisis represented by the COVID-19 pandemic, the principles, and values of Bioethics has become increasingly important in the discussion of issues related to health care, such as resource allocation, end-of-life care, televisits, treatments not based on evidence, vaccine refusal, among others, are issues discussed so far.<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a></p><p id="para0003" class="elsevierStylePara elsevierViewall">Vaccination is considered one of the greatest achievements in public health. Immunization programs have contributed to the decline in mortality and morbidity from infectious diseases and are responsible for the worldwide eradication of smallpox and polio. In order to achieve this success, high population adherence is necessary for the direct protection of vaccinated individuals, as well as high vaccination coverage rates, induce indirect protection, the so-called herd immunity.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0004" class="elsevierStylePara elsevierViewall">The anti-vaccine movements are seen in several countries around the world, especially regarding the application of vaccines in children, in which parents are responsible for this decision, with countless factors being used to justify the refusal of vaccination. In high-income countries with successful immunization programs and effective disease control, the fear of adverse reactions that the vaccine can cause is the major justification for the denial.<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a></p><p id="para0005" class="elsevierStylePara elsevierViewall">The lack of parental trust in vaccines, for example, in the United States and the United Kingdom, is also linked to the many controversies and myths that have been brought to the population by the media and are currently maintained by anti-vaccine activists,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> such as the association of hepatitis B vaccines with multiple sclerosis, mumps, measles and rubella vaccine with autism, or even whooping cough vaccine leading to severe brain damage, seizures and mental disability. In adults, there is a supposed relationship between the tetanus vaccine and female sterilization. These associations, also called a conspiracy theory, caused a reduction in vaccination rates and later reflected in a significant increase in the number of cases and deaths worldwide.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0006" class="elsevierStylePara elsevierViewall">At the beginning of the COVID-19 pandemic, we had health professionals acting courageously inpatient care, developing health policy issues, and scientists working hard to develop vaccines to prevent COVID-19. Once vaccines proved to be safe and effective, their availability introduced a new ethical issue regarding the choice of people who would be immunized first. After the initial hysteria, the world faced cases of vaccine leftovers in developed countries due to population denials for vaccination, putting at risk the benefits that mass immunization provides and, consequently, pandemic control around the world.<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">As harder this chaotic moment may be, vaccines developed for COVID-19 have the denial a part of the population against the existence of the disease, the forms of prevention, and the benefits of the vaccine. These justifications are related to government policy, unfounded beliefs about diseases and the benefits of vaccines, the power of social media, the spread of “fake news”, doubts about the insufficient time for doing research for safe vaccines omission bias, and coincidence bias.<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">Jara et al.<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> studied the effectiveness of the Coronavac vaccine in Chile in a population of about 10 million people. They found its effectiveness in preventing the disease in 65.9%, 87.5% in preventing hospitalization, 90.3% in preventing admission to the Intensive Care Unit, and preventable death in 86.3%. This study not only proves that vaccination is effective in protecting the individual but also shows that it can prevent serious forms of disease and death, which presents vaccination as the correct public health policy for the control of infectious and contagious diseases. Nonetheless, this result was only achieved because more than 79% of the adult population in Chile was vaccinated with two doses. Thus, the importance of massively vaccinating the population is highlighted.</p><p id="para0009" class="elsevierStylePara elsevierViewall">Bioethics defends autonomy in a limited way, especially considering the autonomy of the individual versus the autonomy of the collective, causing harm to the vast majority. Nevertheless, it is important to guide the discussion that autonomy ends when an individual attitude brings potential harm to the community, mainly related to the sanitary control of diseases and devastating implications for humanity.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">The individual decision not to be vaccinated is a situation that fits in this context. Jara et al.<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> showed that one of the most effective measures of pandemic control is mass vaccination. When people decide not to be vaccinated based on personal convictions, one of the pillars of the pandemic control measures is broken, which can bring irreparable health damage to them and everyone around them (family, friends, and colleagues from work, for example).</p><p id="para0011" class="elsevierStylePara elsevierViewall">In Brazil, despite the Supreme Court (STF), in 2020, deciding that the vaccine is mandatory, not compulsory,<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> it reported that restrictive (political, administrative, and sanitary) and educational measures could be adopted for people who insist on refusing to be vaccinated in order to protect the community.<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a></p><p id="para0012" class="elsevierStylePara elsevierViewall">From a bioethical point of view, non-maleficence in many situations is more costly than beneficence. The latter denotes a proactive attitude toward doing good, while non-maleficence brings, in essence, a reflective attitude and limiting beneficence by reminding us that we cannot and must not cause harm, even if the intention is good.<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a></p><p id="para0013" class="elsevierStylePara elsevierViewall">Hence, when the authors think about returning to daily activities, in a practical way, people not vaccinated by personal conviction (philosophical, religious, political, among others) should not be admitted to a hospital environment (as patient companion or visit, not to mention health care professionals), mainly in the wards. The population admitted to the hospital is fragile and vulnerable, making these individuals more susceptible to infection by agents such as SARS-CoV-2, causing damage to their clinical condition. The infection of these patients can be either direct, in the case of the person with the companion or visit, or indirectly, in cases of patients who are in the same hospital environment, such as in shared rooms.<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0014" class="elsevierStylePara elsevierViewall">The denial of access to this group of people is a protective attitude both for them and for hospitalized patients since an unvaccinated person, once entering the hospital environment, can be infected by the virus circulating in that environment, as well as it can infect hospitalized patients. In this way, the principles of beneficence and non-maleficence are contemplated.</p><p id="para0015" class="elsevierStylePara elsevierViewall">Broadening the scope of the discussion, still thinking about Health Institutions, Emanuel and Skorton<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> discuss the vaccination of health workers and highlight three aspects:<ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">1</span><p id="para0016" class="elsevierStylePara elsevierViewall">Health professionals have an ethical duty and professional responsibility to protect others. The goals of healthcare workers are to promote the health and well-being of patients, families, inpatients, and the wider community. Getting vaccinated is one way to achieve this goal and protect the 'patients' health.</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">2</span><p id="para0017" class="elsevierStylePara elsevierViewall">It is the duty and responsibility that health workers, so not only those on the front line, but also administrative workers and those who work to maintain the hospital's technical functionality and facilities, should be vaccinated to avoid compromising the health of everyone around.</p></li><li class="elsevierStyleListItem" id="celistitem0003"><span class="elsevierStyleLabel">3</span><p id="para0018" class="elsevierStylePara elsevierViewall">Requiring healthcare employees to be vaccinated against COVID-19 is nothing new, it is an extension of well-established policies and practices around the world. Many healthcare facilities already required their employees to be vaccinated against hepatitis B, influenza, and other infectious diseases. As a result, health workers have historically been models of good behavior, especially in vaccination campaigns. In doing so, health workers provide good examples for the general population and show the importance of vaccination against COVID-19, and, ultimately, all vaccines.</p></li></ul></p><p id="para0019" class="elsevierStylePara elsevierViewall">Emanuel and Skorton<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a> even propose administrative measures against those who refuse to receive the vaccine (such as dismissal or suspension from office or removal from activities without remuneration), given the importance of the matter and its social impact on the control of pandemics.</p><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Conclusion</span><p id="para0020" class="elsevierStylePara elsevierViewall">Although the anti-vaccine movement is growing, there is no evidence base since we know that big epidemics were and are still controlled with the use of vaccines. As much as fear and apprehension are relevant to the individual, common sense and clarity regarding the few adverse effects resulting from vaccination are negligible when compared with the harm caused by the disease in question.</p><p id="para0021" class="elsevierStylePara elsevierViewall">Not authorizing the presence of unvaccinated people by conviction constitutes a bioethical practice, as it protects hospitalized patients, employees, and unvaccinated people. Vaccination is a right that must be assumed as a duty by everyone for the effective and collective control of the pandemic by COVID-19.</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Authors' contributions</span><p id="para0022" class="elsevierStylePara elsevierViewall">Juliana Bertoldi Franco wrote the manuscript. Pilar Lecussan Gutierrez and Fábio Roberto Cabar reviewed the manuscript. Chin An Lin reviewed the manuscript and contributed to improving the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0001" "titulo" => "Conclusion" ] 1 => array:2 [ "identificador" => "sec0002" "titulo" => "Authors' contributions" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-02-17" "fechaAceptado" => "2022-04-11" "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec1" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0001" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bioethical principles and values during pandemics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "CA Lin" 1 => "H Grunspun" 2 => "JC Nazareth" 3 => "RA. 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Accessed on 20th August, 2021." ] ] ] 9 => array:3 [ "identificador" => "bib0010" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mandating COVID-19 Vaccination for Health Care Workers" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "EJ Emanuel" 1 => "DJ Skorton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "fecha" => "2021" "paginaInicial" => "1308" "paginaFinal" => "1310" "editorial" => "Ann Inter Med" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/18075932/000000770000000C/v3_202308251443/S180759322200031X/v3_202308251443/en/main.assets" "Apartado" => array:4 [ "identificador" => "94922" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorials" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/18075932/000000770000000C/v3_202308251443/S180759322200031X/v3_202308251443/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S180759322200031X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 43 | 33 | 76 |
| 2024 September | 51 | 25 | 76 |
| 2024 August | 31 | 21 | 52 |
| 2024 July | 40 | 28 | 68 |
| 2024 June | 31 | 27 | 58 |
| 2024 May | 39 | 40 | 79 |
| 2024 April | 43 | 49 | 92 |
| 2024 March | 50 | 32 | 82 |
| 2024 February | 35 | 26 | 61 |
| 2024 January | 53 | 22 | 75 |
| 2023 December | 18 | 19 | 37 |
| 2023 November | 53 | 43 | 96 |
| 2023 October | 41 | 36 | 77 |
| 2023 September | 35 | 30 | 65 |
| 2023 August | 40 | 15 | 55 |
| 2023 July | 25 | 28 | 53 |
| 2023 June | 32 | 33 | 65 |
| 2023 May | 21 | 11 | 32 |
| 2023 April | 14 | 2 | 16 |
| 2023 March | 5 | 2 | 7 |
| 2023 February | 13 | 4 | 17 |
| 2023 January | 14 | 6 | 20 |
| 2022 December | 15 | 3 | 18 |
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