The ethics of vaccination

In the last 12-18 months the discussion about sexually transmitted diseases and school-age vaccinations has heated up. With the introduction of Gardasil, the human papilloma virus vaccine, onto the market, the discussion has expanded to whether or not it should be made mandatory for young girls.

Naively, I thought this would largely be a non-issue. I mean, who in the world would like to see their sister, daughter, wife, niece, granddaughter, or friend be diagnosed with cervical cancer or geintal warts?

The vaccine protects against infection of HPV types 6, 11, 16, and 18. Together, these four types cause approximately 90% of all cases of genital warts. Type 16 causes about 50% of cases of cervical cancer, and Type 18 an additional 15-20%. In addition, though the evidence is not unequivocal as it is in cervical cancer, Types 16 and 18 are likely involved in the development of vaginal, vulvar, and anal cancers. The vaccine is nearly 100% effective against infection from these 4 types. So far it's only indicated for girls and women ages 9-26.

So how do you get HPV of any type? Sexual transmission. It is the most common sexually transmitted disease In fact, according to the MMWR nearly 80% of all sexually active adults will have contracted some type of HPV by age 50. This means that if you have sex when you are 12 and promiscuous, 18 and responsible, 25 and married or monogamous, homosexual, heterosexual, a boy, a girl, or forced to have sex against your will, or have sex with or without a condom (to be sure, condoms decrease the rate of transmission but are not 100% effective), you can still contract the infection. So, unless you are a celibate human being for your entire life, you are at risk.

So state governments are starting to debate whether or not to make the vaccine mandatory. Why make anything mandatory? Well, usually it has to do with how it is transmitted, like measles or pertussis for example. Not only does vaccinating your kid protect your kid, but vaccinating in groups can theoretically provide some protection to the community as a whole. When it becomes a public health issue we start making things mandatory.

I stumbled upon an editorial in the Charleston Daily Mail where the author suggests that it is medically unethical to require the HPV vaccine. He says: "Here we are talking about forcing a person to undergo mandatory drug therapy (vaccination), when they have no disease, under the presumption that they might get a disease based on future poor behavior."

Woah nelly. Hold up. Wait a minute. Say what?! Poor behavior?

I was a little afraid of this sentiment in the general public. Based on the information I presented above, is it not clear that anyone who is sexually active, behaving well or otherwise, is at risk for this? Obviously if you have multiple partners you are at higher risk. But even a young woman who never had sexual intercourse prior to marriage could still get HPV and therefore is at risk for cervical (and vulvar and vaginal and anal) cancer.

[So far we don't know if it also protects boys and men, who, are the carriers. If it does work, we might get the aforementioned herd immunity and perhaps then the demise of the virus altogether. We will also then have a powerful tool to reduce the incidence of genital warts and anal cancer in gay men.]

The whole issue is clearly at the intersection of moral values and medicine. My guess is we don't like to think of our children having sex, whether our children are kids or adults. But it happens. It happens at school, it happens after school, it happens when parents are home and not, it happens consensually and by force, it happens in marriages and in monogamous relationships, it happens for money, it happens for love and for hate. And sometimes when it happens, a virus goes with it and sometimes that virus causes cancer. And now we have a vaccine which, by all reports available, seems to have nearly 100% protection against it. Why not make it mandatory? Besides, in the end, nothing in this country is really mandatory. You can beg borrow and steal your way out of almost anything. This is no different. If you really don't want your kid to have the vaccine, they don't have to have it. But there will come a time when you have to search far and wide to find a specialist that knows how to treat cervical cancer because it is so rare.

At least I hope so.