Preventing Polka-Dot Problems: Should Measles Vaccination be Compulsory?

Jim Todd reports about his measles experience at BBC News. A number of years back such a report about how a case of adult measles feels would have been absurd, since so many had suffered it. A few years back it would have been absurd because measles was rare thanks to vaccination. But now, due to a reduction in vaccinations, the risk of measles is rising. Health chiefs in London are stepping up the vaccination program to try to stave off the rising number of cases. The key problem is that in many areas of London only 62% of toddlers
have been immunised, compared to the 95% that is needed to achieve herd immunity.
Vaccinated people act as firebreaks: if enough people are immune to a
disease long chains of infection become improbable, and epidemics do
not occur. Given this, should measles vaccination be compulsory?

In many ways vaccination has been a victim of its own success: people
underestimate the danger of the illness since they have not seen its
effects.

The main reason for the UK decline in vaccination has been claims that the MMR vaccine increases the risk of autism. The real causes for the rise in autism diagnosis is likely a change in diagnosis criteria. Reports of autism increase as reports of mental retardation and learning disabilities decrease. This is a sign of diagnostic substitution where educators apply the autism label to children who previously would
   have been diagnosed differently.

But even if there had been a real link between the vaccine and autism it seems that vaccination would be rational. About 15 persons per 10,000 who gets measles develop acute demyelinating encephalitis, which has 10-15% mortality rate and causes permanent brain damage in 25% of children. Overall measles mortality is around 10-5 people in 10,000 infected (in the West; in underdeveloped nations it is 1 in 10). The incidence of autism is around 4.5 per 10,000 people. Autistic people can have lives worth living (even if they have a higher chance of problems than "neurotypicals") while a measles infection can cut a life short. Thus if a vaccine doubled the rate of autism it would still increase the chances of living a good life.

Vaccination is a public good: if widely used it confers a benefit to everyone and it is not possible to exclude someone from this benefit even if he does not contribute. Public goods are often said to lead to market failures where people refrain from paying for them. The cost of vaccination is relatively low and mostly consist of the hassle for the parents and temporary annoyance in the child. Vaccinated people are also assured of a slightly better health than the non-vaccinated people who have to hope they do not encounter any infected person – the vaccinated form a privileged group. Hence there has not been much free-riders. However, the risk of not vaccinating is commonly underestimated due to lack of examples of the consequences and the normal human inability to grasp low probabilities intuitively, and the risks of vaccination are played up by various anti-vaccination pseudo-science groups (claiming it is natural, or that alternative medicine or nutrition provides better treatment – something often in their own interest to claim, but not supported by evidence).

Since the cost is not primarily paid through money but as time, it is hard to redistribute (precluding assurance contracts, coasian solutions, subsidies or buying out the free riders). Social norms can keep down free riders, but if being non-vaccinated is invisible public opprobrium has little effect. That seems to leave two options: either reward vaccinated kids (or parents) in some way, or make vaccination obligatory.

There is an interesting analogy here with Robert Nozick’s argument in Anarchy, State, and Utopia about how rational, self-interested people who do not wish to coerce each other would anyway form a minimal state for mutual protection. It seems that protecting us from pathogens is not in principle different from protecting us from criminals or enemy attack. Vaccination is akin to setting up an internal police force.  Furthermore, in Nozick’s theory the state would also extend its protection to independents that did not wish this since it would make its own clients safer. By compensating them (largely by the benefits they gain from protection) it can outweigh the wrong done by impugning on their freedom. So even from a libertarian standpoint vaccination may be a legitimate tax-funded activity and there are reasons to have obligatory vaccination.

One can object to the above analogy that while the state may be right in limiting the freedom of independents in the case of rights violations since it only limits the ability to commit crimes and the right to form one’s own protection organisation, in the case of vaccination the state now intrudes much further and violates our right to control our bodies. This is a valid objection. While the intrusion is slight (and often committed for our own sake in childhood while we are still not fully responsible for ourselves) rejecting it could have a strong symbolic meaning, similar to how Jehovah’s Witnesses refuse blood products. Refusing a potentially lifesaving treatment may be an expression of one’s autonomy. But if refusing a treatment puts others at risk tolerance of this refusal will be narrower.  In the case of epidemic disease the risk grows the more people refuse vaccination: if herd immunity exists there is little reason to force vaccinations onto unwilling people, but when few are vaccinated compulsive vaccination may be moral.

If compensation for participating in vaccination is provided, it seems that more people would be willing to do it; the people who would absolutely refuse are likely a small minority. How large should the compensation be?  From the perspective of the health care system and insurance companies vaccination is a cost-effective way of reducing future costs. Assuming we knew the price elasticity of people somewhat unwilling to vaccinate it would be relatively easy to calculate the right price. Lottery tickets or increased future allocation of other healthcare might also be possible. More likely even symbolic rewards for participating like a gold star on the patient record or bumper stickers may have a positive effect. It seems that the low costs, slight privilege effects of being vaccinated and generally recognized benefits do not require an enormous incitement to make people behave rationally; they just need being reminded about them. Some people might object that rewarding compliance makes the motivation external rather than internal, and that will reduce virtue. But while some may vaccinate themselves or their children out of virtue or altruism, pure self-interest or concern for the child is enough to motivate it.

All in all, vaccination is one of the most cost-effective public health measures around. Even in a minarchist nightwatch state they are legitimate uses of tax money. There appears to be a case for making vaccination compulsory as long as herd immunity has not been reached (and the illness is sufficiently severe, which measles probably is). In any case, adding compensation to the process might be appropriate.

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