Vaccine bioethics and public health | Vacunas (English Edition)

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Varo Baena" "autores" => array:1 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Varo Baena" "email" => array:1 [ 0 => "antonio.varo.baena@juntadeandalucia.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección de Epidemiología de la Delegación Territorial de Salud y Familias, Junta de Andalucía, Córdoba, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad de Córdoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bioética de vacunaciones y salud pública" ] ] "textoCompleto" => "“Ethics, in so far as it springs from the desire to say something about the ultimate meaning of life, the absolute good, the absolute valuable, can be no science. What it says does not add to our knowledge in any sense. But it is a document of a tendency in the human mind…”<a class="elsevierStyleCrossRef" href="#bib0175">1</a> Ludwig Wittgenstein.IntroductionThe meaning of bioethicsThe interrelationship between the sciences and humanities disappeared from the entire history of medicine during the 19th century. To some extent bioethics has re-established this link, albeit disparately and possibly opportunistically, as science and philosophy are conditioned by the preconceived or unconscious approach and idea of the researcher. The actual term bioethics refers to 2 different aspects: scientific culture and (humanistic) philosophy. The former involves knowledge and the latter the morally correct application of that knowledge through reflection and dialogue. In philological terms the Greeks gave life 2 terms, zoe and bios, each with a different meaning. Zoe referred to life in general without further characterisation and lived without limits, it would be something akin to the eternal living principle, the time of being, it is the principle which opposes death.<a class="elsevierStyleCrossRef" href="#bib0180">2</a>Bios is individual life, the future time of each being admitted into the zoe. Thus in its strict sense “biology” should be called “zoology”. In the word bioethics, the Greek bios is transformed into a zoe which was the original sense given to it by the father of bioethics Van Rensselaer Potter, introducing this term for the first time in his article “Bioethics: The science of survival”.<a class="elsevierStyleCrossRef" href="#bib0185">3</a> The concept and the scope of application was subsequently extended by André Hellegers to that of biomedical sciences.<a class="elsevierStyleCrossRef" href="#bib0190">4</a> This generalisation was also deduced from the definition Potter gave of bioethics as the systematic study of human action in both health and human sciences, but in keeping with moral standards.<a class="elsevierStyleCrossRef" href="#bib0190">4</a> In other words, for Potter the term bioethics had a global meaning, representing the moral problems of the relationship between the development of technology and the ecological and human future of the planet.Later, in 1978, as a consequence of the biotechnological challenges, the research and development of new treatments and the role of the patient in decision-making, and also as a reaction against the scandals of experiments carried out on human beings, the concept of medicine and specifically clinical medicine and research involving patients was curtailed in the famous Belmont report.<a class="elsevierStyleCrossRef" href="#bib0195">5</a> Thus, the International Association of Bioethics defines bioethics as the study of ethical, legal, philosophical and other related issues emerging from healthcare and biological sciences.<a class="elsevierStyleCrossRef" href="#bib0190">4</a> The term “biological sciences” was added undoubtedly in consideration of the unstoppable development of biomedicine where ethical problems are often wildly beyond any previously imagined and it is the epitome of what in bioethics is called the slippery slope. And this was without even knowing about the CRISPER technique and the social and ethical revolution which this technique could unleash – by far the most important bioethical challenge of this century to date.Regarding ethics in the strictest sense of the word, it is the Kantian imperative regarding what I should do or can do that impels it, in contrast to the ethics of responsibility of Weber and Hans Jonas which is based on the consequences of behaviour rather than on any previous standard of duty. However, from a holistic truism there is nothing which impedes an ethics of responsibility being complementary to and not exclusive of a Kantian ethic. In reality the principle underlying universal civic ethics is human dignity, understood as a life in keeping with one's own free conscience and in favour of a moral virtue.There are some who think that bioethics is reduced to ethics commissions, even that their power is above their pretensions. Although this is an exaggerated statement, it does hit the nail on the head regarding the excessive bureaucracy of a discipline like bioethics which is precisely the opposite: all reflection on bioethical health-based problems is the antithesis of routine, of protocolised reports, of meetings with a rapidly dispatched order of the day, and in any event, its scope should not be reduced to clinical medicine. But we should not be so pessimistic. For Peter Singer, bioethics lecturer at the University of Princeton, the practical part of philosophy (for us of bioethics as an applied philosophy) ought to help towards the creation of a fairer world.<a class="elsevierStyleCrossRef" href="#bib0200">6</a>We can start from the basis used by Adela Cortina that bioethics, with all of its shortcomings, is the type of applied ethics upon which the greatest international level of consensus exists: the 4 principles and the Helsinki Rules are already indisputable guidelines in the application of medical practice.<a class="elsevierStyleCrossRef" href="#bib0205">7</a> In this sense Habermas writes: “only those norms can claim to be valid that meet (or could meet) with the approval of all possible affected persons in their capacity as participants in practical discourse”.<a class="elsevierStyleCrossRef" href="#bib0210">8</a> Michael J. Sandel also affirms: “We have to find a way of reasoning together on difficult moral issues”.<a class="elsevierStyleCrossRef" href="#bib0215">9</a> According to Habermas it is thought that ethics is an exercise of communication and dialogue and the formation of public opinion and bioethics of public health is a tool or should be, but not a crutch for managerial or institutional infrastructure (as clinical bioethics has already become).Public health bioethicsEthics – the duty to do or not to do something – is always applied, practical ethics. Bioethics, like applied ethics, has traditionally been reduced to clinical bioethics and clinical bioethics would be closer to the Socratic question where ethics begins, of “how should one live?” rather than the Kantian question of “what is our duty?” This is closer to public health bioethics because any type of decision which affects public health implicitly involves a bioethical stance even if this is not explicitly specified. For this reason there are insufficient models based on classical ethics. It was not until the 1990s that talk began regarding public health bioethics which adopted several names (organisational ethics, institutional ethics, public health ethics), but the complete term of bioethics was relegated to clinical medicine. We use the term bioethics referring to the bioethics of public health because we understand that it fits in better with the original concept of bioethics and that it is in some way an appropriate backlash to this specific bioethics that was developed in the United States as a second stage of clinical bioethics. It has become an integration or an improvement on clinical bioethics, on a higher level, although the bioethics in public health presents as many or more ethical problems than clinical bioethics.The essential difference is that if clinical bioethics affects patients’ decisions and individual care, the Gordian knot of public health bioethics is its collective liability for public health decision-making, which includes vaccinations. For José María Martín Moreno public health can be identified with the combination of society's organised efforts towards an essential mission: to prevent diseases and promote health.<a class="elsevierStyleCrossRef" href="#bib0220">10</a> This implies that it moves from an individual vision and application to a collective and holistic one that drives both the health system and collective decisions. This is what the bioethicist Ezekiel J. Emanuel believed, for whom medical ethics had to stop being aimed at clinical cases and move on to institutional ones, we had to stop addressing problems from a philosophical bent and adopt the viewpoint of political science.<a class="elsevierStyleCrossRef" href="#bib0225">11</a>Public health bioethics would be based on what Adela Cortina calls mesobioethics, an intermediate level of approximation and which refers to the ethics of the healthcare organisations and civic bioethics, with macrobioethics being biopolitics and ecoethics and microbioethics being clinical bioethics and biomedicine.<a class="elsevierStyleCrossRef" href="#bib0230">12</a> For the philosopher it was necessary to move from the logic of individual action to collective action, i.e. to moralise the institutions and organisations, in such a way that the consequences would be beneficial.<a class="elsevierStyleCrossRef" href="#bib0205">7</a> Public health bioethics is thus linked to organisational ethics or institutional if preferred, which complement instead of oppose professional ethics: i.e. the ethics of the individual are not incompatible with the ethics of the societies, among other things because they share a morality and several common values. It is significant that Diego Gracia entitled an article “Professional ethics and institutional ethics: convergence or conflict?”.<a class="elsevierStyleCrossRef" href="#bib0235">13</a>A qualitative and bioethical study of public healthQualitative studyA descriptive qualitative study published in the book Public Healthbioethics14 aimed to determine from the responses of professionals of the Andalusia Health System which values had to be taken into consideration when taking decisions in public health. Methodology was as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•The target population was the personnel who formed part of the Public Health System of Andalusia (including the healthcare administration).</li><li class="elsevierStyleListItem" id="lsti0010">•The type of sampling was convenience and intentional.</li><li class="elsevierStyleListItem" id="lsti0015">•Thirty eight respondents were used, 3 of whom did not respond and 3 of whom did not correctly complete the questionnaire.</li><li class="elsevierStyleListItem" id="lsti0020">•An anonymous self-completion questionnaire with an ad hoc design was used, with the most frequent aspects on prioritisation found in the literature and this was dispatched by electronic mail.</li><li class="elsevierStyleListItem" id="lsti0025">•One open-ended question was responded to: Rank from 1 to 10 the priority of the different aspects on which public health decisions should be based, according to your point of view of the importance you attach to each one of them (1: maximum priority; 10: minimum priority).</li><li class="elsevierStyleListItem" id="lsti0030">•Numerical prioritisation techniques were used to rank relevance, adapted from the Rand scale.</li></ul>Results were as follows:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035">•Professional profile: 20 doctors, 6 nurses, 6 others (3 civil servants, 2 pharmacists and one biologist). The job in the Andalusian Public Healthcare System was: public health: 16 (50%), care workers: 12 (37.5%) and managerial staff: 4 (12.5%).</li><li class="elsevierStyleListItem" id="lsti0040">•The priority values in public health for taking decisions were the severity and incidence/magnitude of them.</li><li class="elsevierStyleListItem" id="lsti0045">•The least relevant, were political directives and public opinion.</li></ul>As a conclusion it may be deduced that several collective differentiated values exist in public healthdecision making which would involve specific bioethics to which a fifth principle would be added to the classical bioethical principles, namely Opportunity. By opportunity we understand the possibility of applying values when taking a public health decision which makes this decision a clear benefit tor society with no appreciable prejudices against other individual principles and rights. In this respect one should take into account what the moral philosopher Bernard Williams said about appealing to peoples’ real interests generally being used as a reason to persuade them against their apparent interests (i.e. just as they perceive them) and in fact, if one course of action is in keeping with someone's real interests, the fact that they did not perceive it as such does not mean that, assuming they cannot be persuaded, it would be necessary to coerce them if they wished to defend their real interests.<a class="elsevierStyleCrossRef" href="#bib0245">15</a> Thus, if the ethics of healthcare organisations is the discernment of values to guide management decisions to take patient care one step further, public health bioethics would be (and we dare to define it) the discipline which reflects on collective values inherent in a democratic society, their application in the decisions which in public health are determined in a community and on the ethical conflicts which these decisions carry though a deliberative method.<a class="elsevierStyleCrossRef" href="#bib0240">14</a> There are three issues to consider here:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">•Dialogue rather than confrontation between the individual and the collective, as an ethical-social safeguard, with the criteria of justice and opportunity.</li><li class="elsevierStyleListItem" id="lsti0055">•Insufficiency of models based on classical bioethics, with a variety of focal points.</li><li class="elsevierStyleListItem" id="lsti0060">•Aimed more at decision-taking and prioritisation than at behaviours, bearing in mind the cost/opportunity of the measure, its transparency and the appropriate information.</li></ul>The bioethics of public health and vaccinology: characterisation of a bioethic in vaccinationsIssues to considerWith the application of bioethics we are referring to the means, but not the end. The end is the social benefit of disease prevention. Some years ago, the Ministry of Health created a guide for assessing the implementation of vaccines in which these types of question were posed<a class="elsevierStyleCrossRef" href="#bib0250">16</a>: is the disease a public health problem? Is the available vaccine safe and efficacious? What impact will adding a new vaccine to the current immunisation schedule have? What will the cost/effect of the vaccine be? What the Ministry was in fact doing was to apply the bioethical principles of beneficence, non maleficence and equality. Obviously, it was not defined in this way, nor were all the aspects of this issue completed. One of them is transparency, i.e. appropriate public information since management of information also implies ethical aspects: detailed epidemiological information may be used for perverse purposes (a government official could recommend not travelling to certain areas of another country, and this would have a consequential economic impact). However, in contrast, limited information leads to a lack of awareness by professionals and citizens on the risk they may be facing.<a class="elsevierStyleCrossRef" href="#bib0255">17</a> Also, is best practice the same as a bioethic on vaccinations? No, but that bioethic does include best practice with information, informed consent, accurate application and prescription of vaccines, confidentiality, registering, availability, accessibility, security and training.Applications of the main public health bioethics principles in vaccinologyBeneficenceIt seems an obvious fact that beneficence on both an individual and group level is the ruling principle of vaccination bioethics. If there has been one healthcare measure which has had the most effect in public health, coupled with comprehensive sanitation and drinking water treatment, it has without a doubt been vaccinations. Not even the use of antibiotics may be compared when we consider the consequent regression and mortality which resistance to antibiotics has led to throughout the world and particularly in the Western world. Reiterating the data does not make them any less eloquent here: the disappearance of smallpox; the eradication of poliomyelitis in most parts of the world; the reduction of mortality from measles (despite the upsurge throughout the world in cases of measles due to the anti-vaccination campaigns, although levels have never reached those prior to vaccination); the reduction in cases of rabies, tetanus, meningitis, invasive pneumococcal disease, cervical cancer, etc.Non-maleficenceNon- maleficence is one of the Hippocratic principles and consists in not causing intentional pain. This intentionality is what confers it with a moral component. It is obvious that all healthcare intervention carries with it the risk of producing unintentional harm. This is the main argument of the anti-vaccination groups: children are given vaccines to prevent illnesses they have not had, in exchange for the possibility of harming a healthy person. It is, however, striking, just as a single example, that there are no anti-antibiotic associations, when it is a well known fact that they cause thousands of deaths due to their resistance throughout the world and from their actual side effects. The undertaking of programmes for the reduction of harm is feasible, as advocated by Javier Tuells<a class="elsevierStyleCrossRef" href="#bib0260">18</a> and it concerns biorights, i.e. the legal consequences of decisions regarding vaccines. Since 1988 in the United States a federal programme has existed for compensation from the adverse effects of vaccines<a class="elsevierStyleCrossRef" href="#bib0265">19</a> and in this sense Javier Tuells demands a compensatory programme for harm from vaccines, especially if they are obligatory and fall within what we could call social vaccinology, i.e. the psychological, social and political factors affecting public assurance regarding vaccines.JusticeThis consists in non discrimination, reducing situations of inequality or treating each person (the principle of universal justice) according to his or her needs. In bioethics the principle of justice is actually closer to the principle of equality, a different principle, and of non discrimination, than that of justice if we understand by this the Aristotelian concept of giving each according to his merits, although not in the utilitarian sense that justice means the greatest good for the highest number of people, which would be more in accord with the ethics of vaccination and equality in justice. The inclusion of vaccines in the immunisation schedule works in this direction thanks to the accessibility of vaccinations, with consideration of the differences between social strata, countries and communities. One example of injustice would be not making vaccination against pneumococcal available to the whole population. Also the Ministry decision in 2013 to block the chickenpox vaccine in pharmacies affects justice, since there are people who may be able to obtain the vaccine abroad and others who may not. It has also been studied that being of foreign origin is a factor which impacts not completing the vaccination guidelines against human papilloma in teenagers,<a class="elsevierStyleCrossRef" href="#bib0270">20</a> and that socioeconomic differences<a class="elsevierStyleCrossRef" href="#bib0275">21</a> impact different vaccination coverage.AutonomyThis is the most controversial and most difficult-to-apply principle in vaccinology because it presupposes the necessary conditions to act autonomously, which is almost never possible, either due to the age of the person receiving the vaccine or to available and comprehensive information given to their families The before-mentioned transparency and participation are related to autonomy, but it is difficult to implement even through the Bioethics Commissions or the Vaccine Commissions in the autonomous communities. For the oncologist and essayist Andrzej Szczeklik it is not autonomy but the person who represents an absolute value: a person's dignity cannot be reduced to their freedom, since freedom may emanate both from dignified and undignified human behaviour.<a class="elsevierStyleCrossRef" href="#bib0280">22</a> This is so much the case that since 2018 in Holland young people of 16 years and over may get the vaccines their parents did not want for them, particularly in Calvinist religious communities, with guarantee of their privacy and appropriate information.OpportunityThis refers to the decision to carry out a healthcare action in public health whilst respecting the moral values and the beneficial impact of this action. In reality it is the application of the ethics of Weberian responsibility. This principle is as important as the others. Vaccination is administered at a certain time and the question is raised as to whether there is a moral responsibility to undertake it at a certain time and under certain collective and social conditions. Its delay could also harm many of those who are to be vaccinated. This affects all the ethical principles. What consequences could a delayed decision have? Sometimes it is difficult if not impossible to answer this question if we are not basing it on the truism that when there is a benefit that benefit could always have been introduced earlier. But knowledge and science are unavoidable duties, no less than ethical principles. This principle which concerns the bioethics of public health is closely linked with efficiency (social efficiency saves resources) and justice, the central pillars of public intervention in any area of collective activity.<a class="elsevierStyleCrossRef" href="#bib0285">23</a> Regarding efficiency, several studies address the financial value of vaccines, considering immunisation to be a cost-effective intervention.<a class="elsevierStyleCrossRef" href="#bib0290">24</a> One example of opportunity is the implementation of vaccination against malaria which began in 2019 in Malawi, Ghana and Kenya, as a highly specific vaccine with regards to its efficacy and impact on public healthPublic health bioethical problems in vaccinationsIf ethics are social we cannot forget that their application is individual (the moral) and in this area there may well be more bioethical questions regarding vaccinations than possibly suspected, when considering two of their aspects already mentioned: clinical and health-based. Some of them may be the following (specifying the most relevant bioethical criterion or criteria but do not excluding the others and paying particular attention to health-based bioethics):<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065">-Is vaccine research preferentially made for diseases occurring in the developed world? Most relevant criteria: justice and opportunity.</li><li class="elsevierStyleListItem" id="lsti0070">-Is clinical safety guaranteed? Accepting there can never be zero risk. Most relevant criterion: Non maleficence.</li><li class="elsevierStyleListItem" id="lsti0075">-Is it viable to vaccinate only a small part of the population against meningococcal B? Most relevant criterion: Justice.</li><li class="elsevierStyleListItem" id="lsti0080">-Should young adults be vaccinated against the papilloma virus to prevent one disease – cervical cancer – which they do not have but which they may transmit? Most relevant criterion: Beneficence.</li><li class="elsevierStyleListItem" id="lsti0085">-Should differences in vaccination coverage due to socioeconomic differences and different vaccine accessibility exist? Most relevant criteria. Justice and autonomy.</li><li class="elsevierStyleListItem" id="lsti0090">-Does being foreign have an impact on being less vaccinated against the human papilloma virus, as suggested by some studies? Most relevant criteria. Justice and beneficence.</li><li class="elsevierStyleListItem" id="lsti0095">-Is the market conditioned by the introduction of vaccines? Most relevant criteria: Justice and opportunity.</li><li class="elsevierStyleListItem" id="lsti0100">-Is uncertainty appropriately managed? Most relevant criterion: Non maleficence.</li><li class="elsevierStyleListItem" id="lsti0105">-Is it ethical to incentivise vaccines chrematistically? Most relevant criteria: Justice and opportunity.</li><li class="elsevierStyleListItem" id="lsti0110">-Is a ministerial decision to block vaccine in pharmacies just? Most relevant criteria: Justice and opportunity.</li><li class="elsevierStyleListItem" id="lsti0115">-Is it ethical to intentionally not vaccinate a control group of children? (Some studies have tried to resolve this problem with a random assignation to the groups and offering the standard locally available treatment<a class="elsevierStyleCrossRef" href="#bib0295">25</a> although we doubt that the procedure totally rules out the ethical dilemma). Most relevant criteria: Justice, opportunity and beneficence.</li><li class="elsevierStyleListItem" id="lsti0120">-Is it ethical to oblige children to be vaccinated when their parents reject it? Is it an ethical measure to make vaccination obligatory in order to be admitted to a school? Most relevant criterion: Autonomy.</li><li class="elsevierStyleListItem" id="lsti0125">-Are patients informed about the immune status of the professional caring for them? (particularly regarding vaccination against influenza. Have they been vaccinated against it or not?) Most relevant criteria: Autonomy and non maleficence.</li><li class="elsevierStyleListItem" id="lsti0130">-Should any effective vaccine (regardless of its efficacy and/or efficiency) be made universal to the susceptible population? Most relevant criterion: Opportunity.</li><li class="elsevierStyleListItem" id="lsti0135">-Is it better to vaccinate a few people rather than no one? Most relevant criteria: Opportunity and Justice.</li><li class="elsevierStyleListItem" id="lsti0140">-Gender expression, is it ethically acceptable to be able to receive a vaccination? Most relevant criteria: Justice and autonomy.</li><li class="elsevierStyleListItem" id="lsti0145">-Should healthcare professionals operate independently from pharmaceutical companies and consequently impact their opportunities to research and train? Most relevant criterion: Opportunity.</li></ul>This is by no mean an exhaustive list of all the bioethical questions and conflicts because, among other issues, we could also direct our attention to the bioethics of anti-vaccination: children who do not receive vaccinations are 35 times more likely to contract measles than those children whose parents did not reject the vaccines.<a class="elsevierStyleCrossRef" href="#bib0300">26</a> Furthermore, the request that anti-vaccination parents be recorded in the medical record proposed by some paediatricians is also a bioethical conflict which affects not only the criteria already referred to but others such as confidentiality and privacy. Spinoza's criteria and guide to reason would have to be applied here, where someone would choose the better of 2 good things and the lesser of two evils.<a class="elsevierStyleCrossRef" href="#bib0305">27</a>Enforceability of vaccines in the populationOne of the most contentious issues already mentioned is that of obligatory vaccination for the general population and healthcare workers because of the implications this vaccination has. Ramiro Avilés y Lobo has a very timely opinion in this respect when he talks about the correlation between ethical principle and economic concept being useful here because efficiency also demands, at least in some cases, not just state financing with obligatory contributions but also the enforceability of consumption of the public good. Immunisation through vaccines is a public good and is therefore financed by the state. But it would not be efficient if vaccinations were financed through taxes and were not enforceable. If a person rejects a vaccine they are benefitting from the general immunisation achieved by those who do receive the vaccine and if a sufficiently large group of people refuse vaccination this may impede the breaking of the infectious chain and frustrate the aim of the vaccination campaign.<a class="elsevierStyleCrossRef" href="#bib0310">28</a> In other words opportunity and social efficiency are prioritised by the enforceability of vaccination. However, the attitude in countries like Spain where vaccination coverage rates are very high, could lead to situations of rejection by affecting its citizen's’ autonomy. Notwithstanding, under certain circumstances this obligation takes precedence for public health, as occurred in Granada in 2009 during an outbreak of measles in a school when the judge decreed that vaccination was to be enforced. Such a procedure would not appear to be ideal, however.Bioethics in vaccination of healthcare personnelProfessionals should be exemplary. Should we here be discussing the flu vaccine? The Barcelona College of Doctors has even addressed this issue by suggesting the suspension of practice of physicians who criticise vaccines. Should the medical professionals show exemplariness in vaccinations (particularly the influenza vaccination)? Nobody questions the need for surgeons to wash their hands before operating, is vaccinating the same?Final observationMax Weber warned against the proliferation of ethics in our society of opposing values. When we mention a vaccination bioethic it is not our wish to add to what Fernando Savater calls an “inflation of ethics”.<a class="elsevierStyleCrossRef" href="#bib0315">29</a> But bioethics cannot merely remain a rhetorical exercise. The vaccination bioethic is linked to the decision-making procedures to improve human development and vaccination activity itself but without becoming just another bureaucratic authority. It is a syncretism between Kantian moral based on the universality of principles, individual dignity and autonomy and the utilitarian moral which aims to produce the greatest good for the greatest number of people – what we would call the common good, i.e. a cross between purpose-based teleological ethics and duty-based deontological ethics. The latter is without a doubt the prevailing moral in healthcare: it is no coincidence that the Hippocratic medical oath is called the Deontological Code.The weakness of public health bioethics and everything derived from it in the bioethics of vaccinations is possibly, aside from its bureaucratization, its politicisation, because the collective decisions are made by political and governmental bodies. This has been demonstrated in former decisions such as the vaccination for meningococcal in a certain community over 20 years ago which led to the famous meningitis crisis. At the same time decisions in public health fall within the area of administration and good government with a collective vision of resources and distribution. The ethical criterion in politics and in government dealings responds to a philosophy, to a way of resolving conflicts and offering results with fairness and justice to satisfy the plurality of interests contributing to the social good, without losing sight of its goal to serve its citizens.<a class="elsevierStyleCrossRef" href="#bib0320">30</a>The demand for justice and quality is necessary when ethical criteria are applied in order to distribute resources. And among these ethical criteria one must include transparency, impartiality, professionalism, efficiency, commitment or veracity, likely to be defined as universal, attaining general recognition.<a class="elsevierStyleCrossRef" href="#bib0325">31</a> A general presumption exists regarding justice. Peter Singer writes that to take a decision “In place of my own interests I now have to take into account the interests of all those affected by my decision. This requires me to weigh up all these interests and adopt the course of action most likely to maximise the interests of those affected”.<a class="elsevierStyleCrossRef" href="#bib0330">32</a> As Albert Camus states, we have to bear in mind that demanding justice can result in injustice if it is not first founded on an ethical justification of justice.<a class="elsevierStyleCrossRef" href="#bib0335">33</a> Here Marta Nussbaum proposes something essential in the bioethics of vaccinations which is that human development has to look more at the creation of the conditions to overcome poverty and inequality, rather than simply being limited to the quantitative study of economic data.<a class="elsevierStyleCrossRef" href="#bib0340">34</a> Is this a contradiction from that discussed before on the distribution of resources? On the contrary, it is a necessary link to the criterion of opportunity. By this we understand that with regards to vaccinations our responsibility is both health-based and social. Ethical considerations should be integrated into public health decision-making, along with political and scientific ones and bioethics in vaccinations may be the paradigm of a dialogic ethic, legitimised by consensus and dialogue, despite agreements being difficult to achieve due to the imbalance of information. Of course, we have no ethical answers for some of the questions that may be raised, nor can we always invoke legal options. This is a different characteristic of bioethics and a process of deliberation and reflection, the purpose of which is to determine what moral goods are at stake and what actions should be taken so as not to harm the essential good of the person: their dignity.Conflict of interestThe author has no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1510438" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1370093" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1510439" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1370092" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "The meaning of bioethics" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Public health bioethics" ] ] ] 5 => array:3 [ "identificador" => "sec0020" "titulo" => "A qualitative and bioethical study of public health" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Qualitative study" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "The bioethics of public health and vaccinology: characterisation of a bioethic in vaccinations" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Issues to consider" ] 1 => array:3 [ "identificador" => "sec0040" "titulo" => "Applications of the main public health bioethics principles in vaccinology" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Beneficence" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Non-maleficence" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Justice" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Autonomy" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Opportunity" ] ] ] ] ] 7 => array:3 [ "identificador" => "sec0070" "titulo" => "Public health bioethical problems in vaccinations" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0075" "titulo" => "Enforceability of vaccines in the population" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Bioethics in vaccination of healthcare personnel" ] ] ] ] ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Final observation" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-29" "fechaAceptado" => "2019-07-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1370093" "palabras" => array:3 [ 0 => "Bioethics" 1 => "Vaccine" 2 => "Public health" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1370092" "palabras" => array:3 [ 0 => "Bioética" 1 => "Vacunas" 2 => "Salud pública" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Bioethics goes beyond the ethical problems that arise in clinical practice concerning vaccination. It is conditioned both by teleological (aristotelian) ethics that has a good purpose orientation and by the ethical ethics (kantian) in which moral goodness is determined by the awareness of duty as a human being. According to the principle of opportunity we study what are the possibilities available that are more suitable to reach a purpose since the values and principles of Bioethics should be a useful tool for public health and, being that vaccinations are a part of it, in the decision-making." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En vacunaciones la bioética va más allá de los problemas éticos que se plantean en la práctica clínica aun siendo partícipe de ella. Viene condicionada tanto por la ética teleológica (aristotélica) que se orienta por un fin bueno y por la ética deontológica (kantiana) en la que la bondad moral viene determinada por la conciencia del deber como ser humano. 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Vaccine bioethics and public health

Bioética de vacunaciones y salud pública

A. Varo Baenaa,b

a Sección de Epidemiología de la Delegación Territorial de Salud y Familias, Junta de Andalucía, Córdoba, Spain

b Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad de Córdoba, Spain

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        "titulo" => "Bio&#233;tica de vacunaciones y salud p&#250;blica"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#8220;Ethics&#44; in so far as it springs from the desire to say something about the ultimate meaning of life&#44; the absolute good&#44; the absolute valuable&#44; can be no science&#46; What it says does not add to our knowledge in any sense&#46; But it is a document of a tendency in the human mind&#8230;&#8221;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Ludwig Wittgenstein&#46;</p></span></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">The meaning of bioethics</span><p id="par0010" class="elsevierStylePara elsevierViewall">The interrelationship between the sciences and humanities disappeared from the entire history of medicine during the 19th century&#46; To some extent bioethics has re-established this link&#44; albeit disparately and possibly opportunistically&#44; as science and philosophy are conditioned by the preconceived or unconscious approach and idea of the researcher&#46; The actual term bioethics refers to 2 different aspects&#58; scientific culture and &#40;humanistic&#41; philosophy&#46; The former involves knowledge and the latter the morally correct application of that knowledge through reflection and dialogue&#46; In philological terms the Greeks gave life 2 terms&#44; <span class="elsevierStyleItalic">zoe</span> and <span class="elsevierStyleItalic">bios&#44;</span> each with a different meaning&#46; Zoe referred to life in general without further characterisation and lived without limits&#44; it would be something akin to the eternal living principle&#44; the time of being&#44; it is the principle which opposes death&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleItalic">Bios</span> is individual life&#44; the future time of each being admitted into the zoe&#46; Thus in its strict sense &#8220;biology&#8221; should be called &#8220;zoology&#8221;&#46; In the word bioethics&#44; the Greek <span class="elsevierStyleItalic">bios</span> is transformed into a <span class="elsevierStyleItalic">zoe</span> which was the original sense given to it by the father of bioethics Van Rensselaer Potter&#44; introducing this term for the first time in his article &#8220;<span class="elsevierStyleItalic">Bioethics&#58; The science of survival&#8221;&#46;</span><a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">3</span></a> The concept and the scope of application was subsequently extended by Andr&#233; Hellegers to that of biomedical sciences&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a> This generalisation was also deduced from the definition Potter gave of bioethics as the systematic study of human action in both health and human sciences&#44; but in keeping with moral standards&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a> In other words&#44; for Potter the term bioethics had a global meaning&#44; representing the moral problems of the relationship between the development of technology and the ecological and human future of the planet&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Later&#44; in 1978&#44; as a consequence of the biotechnological challenges&#44; the research and development of new treatments and the role of the patient in decision-making&#44; and also as a reaction against the scandals of experiments carried out on human beings&#44; the concept of medicine and specifically clinical medicine and research involving patients was curtailed in the famous Belmont report&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> Thus&#44; the International Association of Bioethics defines bioethics as the study of ethical&#44; legal&#44; philosophical and other related issues emerging from healthcare and biological sciences&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a> The term &#8220;biological sciences&#8221; was added undoubtedly in consideration of the unstoppable development of biomedicine where ethical problems are often wildly beyond any previously imagined and it is the epitome of what in bioethics is called the slippery slope&#46; And this was without even knowing about the CRISPER technique and the social and ethical revolution which this technique could unleash &#8211; by far the most important bioethical challenge of this century to date&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Regarding ethics in the strictest sense of the word&#44; it is the Kantian imperative regarding what I should do or can do that impels it&#44; in contrast to the ethics of responsibility of Weber and Hans Jonas which is based on the consequences of behaviour rather than on any previous standard of duty&#46; However&#44; from a holistic truism there is nothing which impedes an ethics of responsibility being complementary to and not exclusive of a Kantian ethic&#46; In reality the principle underlying universal civic ethics is human dignity&#44; understood as a life in keeping with one&#39;s own free conscience and in favour of a moral virtue&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are some who think that bioethics is reduced to ethics commissions&#44; even that their power is above their pretensions&#46; Although this is an exaggerated statement&#44; it does hit the nail on the head regarding the excessive bureaucracy of a discipline like bioethics which is precisely the opposite&#58; all reflection on bioethical health-based problems is the antithesis of routine&#44; of protocolised reports&#44; of meetings with a rapidly dispatched order of the day&#44; and in any event&#44; its scope should not be reduced to clinical medicine&#46; But we should not be so pessimistic&#46; For Peter Singer&#44; bioethics lecturer at the University of Princeton&#44; the practical part of philosophy &#40;for us of bioethics as an applied philosophy&#41; ought to help towards the creation of a fairer world&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We can start from the basis used by Adela Cortina that bioethics&#44; with all of its shortcomings&#44; is the type of applied ethics upon which the greatest international level of consensus exists&#58; the 4 principles and the Helsinki Rules are already indisputable guidelines in the application of medical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> In this sense Habermas writes&#58; &#8220;only those norms can claim to be valid that meet &#40;or could meet&#41; with the approval of all possible affected persons in their capacity as participants in practical discourse&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> Michael J&#46; Sandel also affirms&#58; &#8220;We have to find a way of reasoning together on difficult moral issues&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> According to Habermas it is thought that ethics is an exercise of communication and dialogue and the formation of public opinion and bioethics of public health is a tool or should be&#44; but not a crutch for managerial or institutional infrastructure &#40;as clinical bioethics has already become&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Public health bioethics</span><p id="par0040" class="elsevierStylePara elsevierViewall">Ethics &#8211; the duty to do or not to do something &#8211; is always applied&#44; practical ethics&#46; Bioethics&#44; like applied ethics&#44; has traditionally been reduced to clinical bioethics and clinical bioethics would be closer to the Socratic question where ethics begins&#44; of &#8220;how should one live&#63;&#8221; rather than the Kantian question of &#8220;what is our duty&#63;&#8221; This is closer to public health bioethics because any type of decision which affects public health implicitly involves a bioethical stance even if this is not explicitly specified&#46; For this reason there are insufficient models based on classical ethics&#46; It was not until the 1990s that talk began regarding public health bioethics which adopted several names &#40;organisational ethics&#44; institutional ethics&#44; public health ethics&#41;&#44; but the complete term of <span class="elsevierStyleItalic">bioethics</span> was relegated to clinical medicine&#46; We use the term <span class="elsevierStyleItalic">bioethics</span> referring to the <span class="elsevierStyleItalic">bioethics of public health</span> because we understand that it fits in better with the original concept of bioethics and that it is in some way an appropriate backlash to this specific bioethics that was developed in the United States as a second stage of clinical bioethics&#46; It has become an integration or an improvement on clinical bioethics&#44; on a higher level&#44; although the bioethics in public health presents as many or more ethical problems than clinical bioethics&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The essential difference is that if clinical bioethics affects patients&#8217; decisions and individual care&#44; the Gordian knot of public health bioethics is its collective liability for public health decision-making&#44; which includes vaccinations&#46; For Jos&#233; Mar&#237;a Mart&#237;n Moreno public health can be identified with the combination of society&#39;s organised efforts towards an essential mission&#58; to prevent diseases and promote health&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">10</span></a> This implies that it moves from an individual vision and application to a collective and holistic one that drives both the health system and collective decisions&#46; This is what the bioethicist Ezekiel J&#46; Emanuel believed&#44; for whom medical ethics had to stop being aimed at clinical cases and move on to institutional ones&#44; we had to stop addressing problems from a philosophical bent and adopt the viewpoint of political science&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Public health bioethics would be based on what Adela Cortina calls <span class="elsevierStyleItalic">mesobioethics</span>&#44; an intermediate level of approximation and which refers to the ethics of the healthcare organisations and civic bioethics&#44; with <span class="elsevierStyleItalic">macrobioethics</span> being biopolitics and ecoethics and <span class="elsevierStyleItalic">microbioethics</span> being clinical bioethics and biomedicine&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">12</span></a> For the philosopher it was necessary to move from the logic of individual action to collective action&#44; i&#46;e&#46; to <span class="elsevierStyleItalic">moralise</span> the institutions and organisations&#44; in such a way that the consequences would be beneficial&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">7</span></a> Public health bioethics is thus linked to organisational ethics or institutional if preferred&#44; which complement instead of oppose professional ethics&#58; i&#46;e&#46; the ethics of the individual are not incompatible with the ethics of the societies&#44; among other things because they share a morality and several common values&#46; It is significant that Diego Gracia entitled an article &#8220;<span class="elsevierStyleItalic">Professional ethics and institutional ethics&#58; convergence or conflict&#63;&#8221;&#46;</span><a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">13</span></a></p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">A qualitative and bioethical study of public health</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Qualitative study</span><p id="par0055" class="elsevierStylePara elsevierViewall">A descriptive qualitative study published in the book <span class="elsevierStyleItalic">Public Health</span><span class="elsevierStyleItalic">bioethics</span>14 aimed to determine from the responses of professionals of the Andalusia Health System which values had to be taken into consideration when taking decisions in public health&#46; <span class="elsevierStyleItalic">Methodology</span> was as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">target population</span> was the personnel who formed part of the Public Health System of Andalusia &#40;including the healthcare administration&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The type of <span class="elsevierStyleItalic">sampling was convenience and intentional</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Thirty eight <span class="elsevierStyleItalic">respondents</span> were used&#44; 3 of whom did not respond and 3 of whom did not correctly complete the questionnaire&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">An <span class="elsevierStyleItalic">anonymous self-completion questionnaire</span> with an ad hoc design was used&#44; with the most frequent aspects on prioritisation found in the literature and this was dispatched by electronic mail&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">One open-ended question was responded to&#58; Rank from 1 to 10 the priority of the different aspects on which public health decisions should be based&#44; according to your point of view of the importance you attach to each one of them &#40;1&#58; maximum priority&#59; 10&#58; minimum priority&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Numerical prioritisation techniques were used to rank relevance&#44; adapted from the <span class="elsevierStyleItalic">Rand scale</span>&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Results</span> were as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Professional profile&#58;</span> 20 doctors&#44; 6 nurses&#44; 6 others &#40;3 civil servants&#44; 2 pharmacists and one biologist&#41;&#46; The <span class="elsevierStyleItalic">job</span> in the Andalusian Public Healthcare System was&#58; public health&#58; 16 &#40;50&#37;&#41;&#44; care workers&#58; 12 &#40;37&#46;5&#37;&#41; and managerial staff&#58; 4 &#40;12&#46;5&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">priority values</span> in public health for taking decisions were the severity and incidence&#47;magnitude of them&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">least relevant&#44; were political directives and public opinion</span>&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">As a <span class="elsevierStyleItalic">conclusion</span> it may be deduced that several collective differentiated values exist in public healthdecision making which would involve specific bioethics to which a <span class="elsevierStyleItalic">fifth principle</span> would be added to the classical bioethical principles&#44; namely <span class="elsevierStyleItalic">Opportunity&#46;</span> By opportunity we understand the possibility of applying values when taking a public health decision which makes this decision a clear benefit tor society with no appreciable prejudices against other individual principles and rights&#46; In this respect one should take into account what the moral philosopher Bernard Williams said about appealing to peoples&#8217; real interests generally being used as a reason to persuade them against their apparent interests &#40;i&#46;e&#46; just as they perceive them&#41; and in fact&#44; if one course of action is in keeping with someone&#39;s real interests&#44; the fact that they did not perceive it as such does not mean that&#44; assuming they cannot be persuaded&#44; it would be necessary to coerce them if they wished to defend their real interests&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">15</span></a> Thus&#44; if the ethics of healthcare organisations is the discernment of values to guide management decisions to take patient care one step further&#44; <span class="elsevierStyleItalic">public health bioethics</span> would be &#40;and we dare to define it&#41; the discipline which reflects on collective values inherent in a democratic society&#44; their application in the decisions which in public health are determined in a community and on the ethical conflicts which these decisions carry though a deliberative method&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a> There are three issues to consider here&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dialogue</span> rather than confrontation between <span class="elsevierStyleItalic">the individual and the collective&#44;</span> as an ethical-social safeguard&#44; with the criteria of justice and opportunity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Insufficiency</span> of models based on <span class="elsevierStyleItalic">classical bioethics&#44; with a variety of focal points</span>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Aimed more at <span class="elsevierStyleItalic">decision-taking</span> and prioritisation than at behaviours&#44; bearing in mind the cost&#47;opportunity of the measure&#44; its transparency and the appropriate information&#46;</p></li></ul></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The bioethics of public health and vaccinology&#58; characterisation of a bioethic in vaccinations</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Issues to consider</span><p id="par0130" class="elsevierStylePara elsevierViewall">With the application of bioethics we are referring to the means&#44; but not the end&#46; The end is the social benefit of disease prevention&#46; Some years ago&#44; the Ministry of Health created a guide for assessing the implementation of vaccines in which these types of question were posed<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">16</span></a>&#58; is the disease a public health problem&#63; Is the available vaccine safe and efficacious&#63; What impact will adding a new vaccine to the current immunisation schedule have&#63; What will the cost&#47;effect of the vaccine be&#63; What the Ministry was in fact doing was to apply the bioethical principles of beneficence&#44; non maleficence and equality&#46; Obviously&#44; it was not defined in this way&#44; nor were all the aspects of this issue completed&#46; One of them is transparency&#44; i&#46;e&#46; appropriate public information since management of information also implies ethical aspects&#58; detailed epidemiological information may be used for perverse purposes &#40;a government official could recommend not travelling to certain areas of another country&#44; and this would have a consequential economic impact&#41;&#46; However&#44; in contrast&#44; limited information leads to a lack of awareness by professionals and citizens on the risk they may be facing&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a> Also&#44; is best practice the same as a bioethic on vaccinations&#63; No&#44; but that bioethic does include best practice with information&#44; informed consent&#44; accurate application and prescription of vaccines&#44; confidentiality&#44; registering&#44; availability&#44; accessibility&#44; security and training&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Applications of the main public health bioethics principles in vaccinology</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Beneficence</span><p id="par0135" class="elsevierStylePara elsevierViewall">It seems an obvious fact that beneficence on both an individual and group level is the ruling principle of vaccination bioethics&#46; If there has been one healthcare measure which has had the most effect in public health&#44; coupled with comprehensive sanitation and drinking water treatment&#44; it has without a doubt been vaccinations&#46; Not even the use of antibiotics may be compared when we consider the consequent regression and mortality which resistance to antibiotics has led to throughout the world and particularly in the Western world&#46; Reiterating the data does not make them any less eloquent here&#58; the disappearance of smallpox&#59; the eradication of poliomyelitis in most parts of the world&#59; the reduction of mortality from measles &#40;despite the upsurge throughout the world in cases of measles due to the anti-vaccination campaigns&#44; although levels have never reached those prior to vaccination&#41;&#59; the reduction in cases of rabies&#44; tetanus&#44; meningitis&#44; invasive pneumococcal disease&#44; cervical cancer&#44; etc&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Non-maleficence</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Non- maleficence</span> is one of the Hippocratic principles and consists in not causing intentional pain&#46; This intentionality is what confers it with a moral component&#46; It is obvious that all healthcare intervention carries with it the risk of producing unintentional harm&#46; This is the main argument of the anti-vaccination groups&#58; children are given vaccines to prevent illnesses they have not had&#44; in exchange for the possibility of harming a healthy person&#46; It is&#44; however&#44; striking&#44; just as a single example&#44; that there are no anti-antibiotic associations&#44; when it is a well known fact that they cause thousands of deaths due to their resistance throughout the world and from their actual side effects&#46; The undertaking of programmes for the reduction of harm is feasible&#44; as advocated by Javier Tuells<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">18</span></a> and it concerns biorights&#44; i&#46;e&#46; the legal consequences of decisions regarding vaccines&#46; Since 1988 in the United States a federal programme has existed for compensation from the adverse effects of vaccines<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> and in this sense Javier Tuells demands a compensatory programme for harm from vaccines&#44; especially if they are obligatory and fall within what we could call social vaccinology&#44; i&#46;e&#46; the psychological&#44; social and political factors affecting public assurance regarding vaccines&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Justice</span><p id="par0145" class="elsevierStylePara elsevierViewall">This consists in non discrimination&#44; reducing situations of inequality or treating each person &#40;the principle of universal justice&#41; according to his or her needs&#46; In bioethics the principle of justice is actually closer to the principle of equality&#44; a different principle&#44; and of non discrimination&#44; than that of justice if we understand by this the Aristotelian concept of giving each according to his merits&#44; although not in the utilitarian sense that justice means the greatest good for the highest number of people&#44; which would be more in accord with the ethics of vaccination and equality in justice&#46; The inclusion of vaccines in the immunisation schedule works in this direction thanks to the accessibility of vaccinations&#44; with consideration of the differences between social strata&#44; countries and communities&#46; One example of injustice would be not making vaccination against pneumococcal available to the whole population&#46; Also the Ministry decision in 2013 to block the chickenpox vaccine in pharmacies affects justice&#44; since there are people who may be able to obtain the vaccine abroad and others who may not&#46; It has also been studied that being of foreign origin is a factor which impacts not completing the vaccination guidelines against human papilloma in teenagers&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> and that socioeconomic differences<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> impact different vaccination coverage&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Autonomy</span><p id="par0150" class="elsevierStylePara elsevierViewall">This is the most controversial and most difficult-to-apply principle in vaccinology because it presupposes the necessary conditions to act autonomously&#44; which is almost never possible&#44; either due to the age of the person receiving the vaccine or to available and comprehensive information given to their families The before-mentioned transparency and participation are related to autonomy&#44; but it is difficult to implement even through the Bioethics Commissions or the Vaccine Commissions in the autonomous communities&#46; For the oncologist and essayist Andrzej Szczeklik it is not autonomy but the person who represents an absolute value&#58; a person&#39;s dignity cannot be reduced to their freedom&#44; since freedom may emanate both from dignified and undignified human behaviour&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">22</span></a> This is so much the case that since 2018 in Holland young people of 16 years and over may get the vaccines their parents did not want for them&#44; particularly in Calvinist religious communities&#44; with guarantee of their privacy and appropriate information&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Opportunity</span><p id="par0155" class="elsevierStylePara elsevierViewall">This refers to the decision to carry out a healthcare action in public health whilst respecting the moral values and the beneficial impact of this action&#46; In reality it is the application of the ethics of Weberian responsibility&#46; This principle is as important as the others&#46; Vaccination is administered at a certain time and the question is raised as to whether there is a moral responsibility to undertake it at a certain time and under certain collective and social conditions&#46; Its delay could also harm many of those who are to be vaccinated&#46; This affects all the ethical principles&#46; What consequences could a delayed decision have&#63; Sometimes it is difficult if not impossible to answer this question if we are not basing it on the truism that when there is a benefit that benefit could always have been introduced earlier&#46; But knowledge and science are unavoidable duties&#44; no less than ethical principles&#46; This principle which concerns the bioethics of public health is closely linked with efficiency &#40;social efficiency saves resources&#41; and justice&#44; the central pillars of public intervention in any area of collective activity&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a> Regarding efficiency&#44; several studies address the financial value of vaccines&#44; considering immunisation to be a cost-effective intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a> One example of opportunity is the implementation of vaccination against malaria which began in 2019 in Malawi&#44; Ghana and Kenya&#44; as a highly specific vaccine with regards to its efficacy and impact on public health</p></span></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Public health bioethical problems in vaccinations</span><p id="par0160" class="elsevierStylePara elsevierViewall">If ethics are social we cannot forget that their application is individual &#40;the moral&#41; and in this area there may well be more bioethical questions regarding vaccinations than possibly suspected&#44; when considering two of their aspects already mentioned&#58; clinical and health-based&#46; Some of them may be the following &#40;specifying the most relevant bioethical criterion or criteria but do not excluding the others and paying particular attention to health-based bioethics&#41;&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Is vaccine research preferentially made for diseases occurring in the developed world&#63; Most relevant criteria&#58; justice and opportunity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Is clinical safety guaranteed&#63; Accepting there can never be zero risk&#46; Most relevant criterion&#58; Non maleficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Is it viable to vaccinate only a small part of the population against meningococcal B&#63; Most relevant criterion&#58; Justice&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Should young adults be vaccinated against the papilloma virus to prevent one disease &#8211; cervical cancer &#8211; which they do not have but which they may transmit&#63; Most relevant criterion&#58; Beneficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">Should differences in vaccination coverage due to socioeconomic differences and different vaccine accessibility exist&#63; Most relevant criteria&#46; Justice and autonomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">Does being foreign have an impact on being less vaccinated against the human papilloma virus&#44; as suggested by some studies&#63; Most relevant criteria&#46; Justice and beneficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Is the market conditioned by the introduction of vaccines&#63; Most relevant criteria&#58; Justice and opportunity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Is uncertainty appropriately managed&#63; Most relevant criterion&#58; Non maleficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Is it ethical to incentivise vaccines chrematistically&#63; Most relevant criteria&#58; Justice and opportunity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Is a ministerial decision to block vaccine in pharmacies just&#63; Most relevant criteria&#58; Justice and opportunity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Is it ethical to intentionally not vaccinate a control group of children&#63; &#40;Some studies have tried to resolve this problem with a random assignation to the groups and offering the standard locally available treatment<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">25</span></a> although we doubt that the procedure totally rules out the ethical dilemma&#41;&#46; Most relevant criteria&#58; Justice&#44; opportunity and beneficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Is it ethical to oblige children to be vaccinated when their parents reject it&#63; Is it an ethical measure to make vaccination obligatory in order to be admitted to a school&#63; Most relevant criterion&#58; Autonomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Are patients informed about the immune status of the professional caring for them&#63; &#40;particularly regarding vaccination against influenza&#46; Have they been vaccinated against it or not&#63;&#41; Most relevant criteria&#58; Autonomy and non maleficence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">Should any effective vaccine &#40;regardless of its efficacy and&#47;or efficiency&#41; be made universal to the susceptible population&#63; Most relevant criterion&#58; Opportunity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0235" class="elsevierStylePara elsevierViewall">Is it better to vaccinate a few people rather than no one&#63; Most relevant criteria&#58; Opportunity and Justice&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Gender expression&#44; is it ethically acceptable to be able to receive a vaccination&#63; Most relevant criteria&#58; Justice and autonomy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">Should healthcare professionals operate independently from pharmaceutical companies and consequently impact their opportunities to research and train&#63; Most relevant criterion&#58; Opportunity&#46;</p></li></ul></p><p id="par0250" class="elsevierStylePara elsevierViewall">This is by no mean an exhaustive list of all the bioethical questions and conflicts because&#44; among other issues&#44; we could also direct our attention to the bioethics of anti-vaccination&#58; children who do not receive vaccinations are 35 times more likely to contract measles than those children whose parents did not reject the vaccines&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a> Furthermore&#44; the request that anti-vaccination parents be recorded in the medical record proposed by some paediatricians is also a bioethical conflict which affects not only the criteria already referred to but others such as confidentiality and privacy&#46; Spinoza&#39;s criteria and guide to reason would have to be applied here&#44; where someone would choose the better of 2 good things and the lesser of two evils&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a></p><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Enforceability of vaccines in the population</span><p id="par0255" class="elsevierStylePara elsevierViewall">One of the most contentious issues already mentioned is that of obligatory vaccination for the general population and healthcare workers because of the implications this vaccination has&#46; Ramiro Avil&#233;s y Lobo has a very timely opinion in this respect when he talks about the correlation between ethical principle and economic concept being useful here because efficiency also demands&#44; at least in some cases&#44; not just state financing with obligatory contributions but also the enforceability of consumption of the public good&#46; Immunisation through vaccines is a public good and is therefore financed by the state&#46; But it would not be efficient if vaccinations were financed through taxes and were not enforceable&#46; If a person rejects a vaccine they are benefitting from the general immunisation achieved by those who do receive the vaccine and if a sufficiently large group of people refuse vaccination this may impede the breaking of the infectious chain and frustrate the aim of the vaccination campaign&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> In other words opportunity and social efficiency are prioritised by the enforceability of vaccination&#46; However&#44; the attitude in countries like Spain where vaccination coverage rates are very high&#44; could lead to situations of rejection by affecting its citizen&#39;s&#8217; autonomy&#46; Notwithstanding&#44; under certain circumstances this obligation takes precedence for public health&#44; as occurred in Granada in 2009 during an outbreak of measles in a school when the judge decreed that vaccination was to be enforced&#46; Such a procedure would not appear to be ideal&#44; however&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Bioethics in vaccination of healthcare personnel</span><p id="par0265" class="elsevierStylePara elsevierViewall">Professionals should be exemplary&#46; Should we here be discussing the flu vaccine&#63; The Barcelona College of Doctors has even addressed this issue by suggesting the suspension of practice of physicians who criticise vaccines&#46; Should the medical professionals show exemplariness in vaccinations &#40;particularly the influenza vaccination&#41;&#63; Nobody questions the need for surgeons to wash their hands before operating&#44; is vaccinating the same&#63;</p></span></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Final observation</span><p id="par0270" class="elsevierStylePara elsevierViewall">Max Weber warned against the proliferation of ethics in our society of opposing values&#46; When we mention a vaccination bioethic it is not our wish to add to what Fernando Savater calls an &#8220;inflation of ethics&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">29</span></a> But bioethics cannot merely remain a rhetorical exercise&#46; The vaccination bioethic is linked to the decision-making procedures to improve human development and vaccination activity itself but without becoming just another bureaucratic authority&#46; It is a syncretism between Kantian moral based on the universality of principles&#44; individual dignity and autonomy and the utilitarian moral which aims to produce the greatest good for the greatest number of people &#8211; what we would call the common good&#44; i&#46;e&#46; a cross between purpose-based teleological ethics and duty-based deontological ethics&#46; The latter is without a doubt the prevailing moral in healthcare&#58; it is no coincidence that the Hippocratic medical oath is called the Deontological Code&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">The weakness of public health bioethics and everything derived from it in the bioethics of vaccinations is possibly&#44; aside from its bureaucratization&#44; its politicisation&#44; because the collective decisions are made by political and governmental bodies&#46; This has been demonstrated in former decisions such as the vaccination for meningococcal in a certain community over 20 years ago which led to the famous meningitis crisis&#46; At the same time decisions in public health fall within the area of administration and good government with a collective vision of resources and distribution&#46; The ethical criterion in politics and in government dealings responds to a philosophy&#44; to a way of resolving conflicts and offering results with fairness and justice to satisfy the plurality of interests contributing to the social good&#44; without losing sight of its goal to serve its citizens&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">30</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">The demand for justice and quality is necessary when ethical criteria are applied in order to distribute resources&#46; And among these ethical criteria one must include transparency&#44; impartiality&#44; professionalism&#44; efficiency&#44; commitment or veracity&#44; likely to be defined as universal&#44; attaining general recognition&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">31</span></a> A general presumption exists regarding justice&#46; Peter Singer writes that to take a decision &#8220;In place of my own interests I now have to take into account the interests of all those affected by my decision&#46; This requires me to weigh up all these interests and adopt the course of action most likely to maximise the interests of those affected&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> As Albert Camus states&#44; we have to bear in mind that demanding justice can result in injustice if it is not first founded on an ethical justification of justice&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">33</span></a> Here Marta Nussbaum proposes something essential in the bioethics of vaccinations which is that human development has to look more at the creation of the conditions to overcome poverty and inequality&#44; rather than simply being limited to the quantitative study of economic data&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a> Is this a contradiction from that discussed before on the distribution of resources&#63; On the contrary&#44; it is a necessary link to the criterion of opportunity&#46; By this we understand that with regards to vaccinations our responsibility is both health-based and social&#46; Ethical considerations should be integrated into public health decision-making&#44; along with political and scientific ones and bioethics in vaccinations may be the paradigm of a dialogic ethic&#44; legitimised by consensus and dialogue&#44; despite agreements being difficult to achieve due to the imbalance of information&#46; Of course&#44; we have no ethical answers for some of the questions that may be raised&#44; nor can we always invoke legal options&#46; This is a different characteristic of bioethics and a process of deliberation and reflection&#44; the purpose of which is to determine what moral goods are at stake and what actions should be taken so as not to harm the essential good of the person&#58; their dignity&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0290" class="elsevierStylePara elsevierViewall">The author has no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bioethics goes beyond the ethical problems that arise in clinical practice concerning vaccination&#46; It is conditioned both by teleological &#40;aristotelian&#41; ethics that has a good purpose orientation and by the ethical ethics &#40;kantian&#41; in which moral goodness is determined by the awareness of duty as a human being&#46; According to the principle of opportunity we study what are the possibilities available that are more suitable to reach a purpose since the values and principles of Bioethics should be a useful tool for public health and&#44; being that vaccinations are a part of it&#44; in the decision-making&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En vacunaciones la bio&#233;tica va m&#225;s all&#225; de los problemas &#233;ticos que se plantean en la pr&#225;ctica cl&#237;nica aun siendo part&#237;cipe de ella&#46; Viene condicionada tanto por la &#233;tica teleol&#243;gica &#40;aristot&#233;lica&#41; que se orienta por un fin bueno y por la &#233;tica deontol&#243;gica &#40;kantiana&#41; en la que la bondad moral viene determinada por la conciencia del deber como ser humano&#46; Con el principio de oportunidad estudiamos cu&#225;les son entre las posibilidades que se plantean aquellas m&#225;s id&#243;neas para alcanzar un fin ya que los valores y principios de la bio&#233;tica deben ser un instrumento &#250;til para la salud p&#250;blica y como parte de ella para las vacunaciones&#44; en la toma de decisiones&#46;</p></span>"
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Article information

ISSN: 24451460
Original language: English

DOI:10.1016/j.vacune.2019.07.001

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