This chapter examines the twenty-first-century public health concept of hesitancy by placing it in a wider historical context. Hesitancy as an analytical category was developed by social scientists and adopted by the World Health Organization and other nations to explain the numerous vaccine crises that had occurred worldwide over previous decades. In Britain between 1998 and 2004 a significant drop in measles-mumps-rubella vaccine (MMR) take-up followed a series of media stories that it might cause autism. Initially, the government sought to refute this through a typical education campaign but was forced to adopt new strategies of risk communication. The internet had become an important tool for vaccine sceptics to spread doubt and for uncertain parents to seek information. Although the vaccination rate eventually recovered, many of the criticisms of the government and the vaccine during this period reflected deeper anxieties on the part of the public regarding the motives and competence of medical and political authorities in the 1990s and early 2000s. The MMR crisis was a product of a particular historical moment, and the construction of hesitancy that followed is coloured by this.
Part II begins with an examination of what the pertussis (whooping cough) vaccine crisis of the 1970s tells us about risk. The management of risk was an integral part of post-war public health and, indeed, of modern nation-states. The risks associated with infectious disease for both the state and individuals had to be weighed against the risks associated with specific vaccines. In the 1970s, reports that the pertussis vaccine might cause brain damage in some children resulted in a significant drop in take-up. A campaign for social security payments for children suffering from vaccine injury was successful, showing how the vaccination programme was tied to wider political concerns within the welfare state during a period of financial retrenchment. These debates are contrasted with those over the provision of rubella vaccine to girls and young women, where voluntary organisations demanded that the government should provide many more resources to the programme.
This chapter focuses on the example of the inactivated poliomyelitis vaccine (IPV) programme in the 1950s and early 1960s to show how the public expressed demand for vaccination services. On the one hand, the government struggled to raise the registration rate for the vaccine to target levels. On the other hand, parents and the media became increasingly frustrated over a series of supply crises. Some of these were caused by an inability or unwillingness to import American vaccine to cover shortfalls in production by British pharmaceutical companies. Others were caused by surges in demand, such as the rush by young adults to get the vaccine following the death of professional footballer Jeff Hall. Thus, demand was a major problem for the British government. Demanding parents could force policy responses (such as a commitment to import more vaccine). Surges in demand could stress the system to breaking point. But a lack of demand also threatened the Ministry of Health’s wider public health goals. The supply issues were only fully resolved after the introduction of the oral polio vaccine (OPV) in 1962.
In this chapter the decline of the routine smallpox vaccination programme is used to examine the theme of nation. While smallpox had been eliminated from Britain in the 1930s, occasional importations by air and sea showed the vulnerability of the nation to external public health threats. Moreover, since the disease often came from postcolonial Commonwealth nations – notably India and Pakistan – racialised views of threats to public health became more common during periods of anxiety about immigration and Britain’s place within the international community. The government attempted to combat declining vaccination rates through publicity campaigns, but struggled to convince the public to comply with its guidance. The public was not anti-vaccination, as shown by the demand for vaccination as a form of epidemic control when outbreaks occurred. However, by showing little enthusiasm for vaccination, coupled with the declining statistical and emotional threat of the disease during the 1960s, the British public helped to create the conditions for the removal of routine childhood smallpox vaccination in 1971 – years before the disease’s official eradication and before other European nations followed suit.
Vaccinating Britain investigates the relationship between the British public and vaccination policy since 1945. It is the first book to examine British vaccination policy across the post-war period and covers a range of vaccines, providing valuable context and insight for those interested in historical or present-day public health policy debates. Drawing on government documents, newspapers, internet archives and medical texts it shows how the modern vaccination system became established and how the public played a key role in its formation. British parents came to accept vaccination as a safe, effective and cost-efficient preventative measure. But occasional crises showed that faith in the system was tied to contemporary concerns about the medical profession, the power of the state and attitudes to individual vaccines. Thus, at times the British public demanded more comprehensive vaccination coverage from the welfare state; at others they eschewed specific vaccines that they thought were dangerous or unnecessary. Moreover, they did not always act uniformly, with “the public” capable of expressing contradictory demands that were often at odds with official policy. This case study of Britain’s vaccination system provides insight into the relationship between the British public and the welfare state, as well as contributing to the historiography of public health and medicine.
This chapter focuses on two key areas which require further clarity and elaboration in the context of research with children, namely, the requirements for research which does not offer the child the prospect of a direct benefit and the provisions around child assent and parental consent. The chapter examines legal and ethical guidance regarding these issues, setting out areas of uncertainty and ambiguity between the various governing instruments. It argues that the lack of clarity in these areas needs to be addressed in order to provide a robust system of protection for children, parents and those involved in clinical research with children. It makes proposals for reform drawing on the legal, ethical and academic guidance in the area and best practice in other countries.
This chapter argues that debates about conscientious objection in health care would benefit from distinguishing clearly between two distinct sets of issues 1) who qualifies for conscientious objection and 2) how conscientious objection ought to be limited in order to prevent harm to others. It argues that institutions (e.g. hospitals) and indirect participants (e.g. pregnancy counselors) ought not qualify for conscientious objection but for different reasons. Institutions ought not qualify because they do not have the kind of critical moral consciousness which is necessary to ground a right to conscientious objection. Indirect participants ought not qualify for two reasons: first, denying someone pre or post abortion care is harmful in discriminating against receivers of lawful abortion care and is more than is necessary for the protection of objectors’ moral integrity and secondly, information about pregnancy and abortion care will not necessarily lead to an abortion and after care cannot prevent abortion. In this way the chapter proposes that Irish debates about conscientious objection in a healthcare context need to move beyond a consideration of the powers of religiously run hospitals and towards a rights based method of assessing conscientious objection in light of the need to recognise moral integrity and prevent harm.
The Irish health system is confronted by a range of challenges, both emerging and recurring. In order to address these, it is essential that spaces are created for conversations around complex ethical and legal issues. This collection aims to provide a basis for ongoing engagement with selected issues in contemporary Irish health contexts. It includes contributions from scholars and practitioners across a range of disciplines, most particularly, ethics, law and medicine. The focus of the collection is interdisciplinary and the essays are situated at the intersection between ethics, law and medicine. Important issues addressed include admission to care homes; assisted suicide; adolescent decision-making; allocation of finite resources; conscientious objection; data protection; decision-making at the end of life; mental health; the rights of older people; patient responsibilities; stem cell research; the role of carers; and reproductive rights. From these discussion, the collection draws out the following interlinking themes, addressing difference; context and care; oversight and decision-making; and, regulating research. The essays are theoretically informed and are grounded in the realities of the Irish health system, by drawing on contributors’ contextual knowledge. This book makes an informed and balanced contribution to academic and broader public discourse.
Perspectives from the Neary and Halappanavar cases
This chapter considers two high profile Irish inquiries: the Lourdes Hospital Inquiry on the Neary case and the Health Information and Quality Authority (HIQA) Report on University Hospital Galway and the care of Savita Halappanavar from an organisational ethics perspective. The chapter outlines the significance of systemic factors in both cases and draws on literature from organisational clinical ethics and business ethics to provide a framework for thinking about the wider ethical responsibilities of healthcare organisations. It outlines how organisational structures are directly implicated in the facilitation of ethical actions by members of the organisation.
This chapter considers how inconsistencies can be resolved in the context of refusal of medical treatment by young people over sixteen by looking at the roles consent plays in medicine. In some cases the question of whether that refusal should be respected is purely academic – for practical reasons the treatment cannot be given. But where treatment could be provided in the light of such a refusal it is unclear whether it is permissible to do so. This is because it seems inconsistent both to say that a patient can consent to treatment but not refuse it, and to say that we ought to seek consent even where a refusal to provide it may be overridden. The chapter argues that there is a relatively straightforward argument to support the idea that young people can consent to, but not effectively refuse, medical treatment. What will turn out to require further explanation, at least on standard ways of approaching medical ethics, is the idea that it is always morally wrong to give an adult treatment that she refuses.