Quite a few of my recent posts – all tagged I think ‘Reclaim the
State’ – have been based around the idea of personal choice and self-ownership
and the degree to which these ideas should be pre-eminent. Some claim I know –
and not just individualist anarchists - that individual rights do indeed trump
all others. Where conflict arises between individuals this argument seems to me
to rely on the principle that defence of those rights by all means necessary is
legitimate – ultimately therefore on armed force. I’ll perhaps come back to
that another time.
Most however, me included, accept that some limitations on
individual actions are essential, while continuing to disagree on what those
limitations might be and their extent. For example, if someone has a highly
contagious and potentially fatal disease like smallpox, most would think it a
very severe view of liberty not to accept that the infected person should be
isolated from society to prevent that disease spreading. The loss of liberty
for this person is surely essential for the avoidance of a much greater evil,
namely the spread of that disease to many others and does them no lasting harm.
Even so, this is still a complex issue. While isolation is a
fairly neutral term, it still means imprisonment; moreover imprisonment for
reasons beyond the control of the infected person. While there is precedent, this must always
be a difficult decision. It raises serious questions about the balance between
the collective rights of people in society against those of individuals. In the
case of Mary Mallon –
otherwise known as ‘Typhoid Mary’, she knowingly placed others at risk, even
though she had been repeatedly been told of the threat she posed to others. She
was kept in a hospital away from society for three years until she promised not
to work with food. She broke that promise and was confined again, this time
until her death. It is known that she was responsible for the deaths of at
least 3 people, possibly as many as 50.
In Mary’s case, transmission of the disease did not occur except
through poor hygiene in the handling of food. It is possible to imagine however
much more virulent diseases where an asymptomatic carrier is at large. As a
thought experiment imagine a highly virulent, perhaps genetically engineered
disease which somehow turns 1% of those infected into symptom less carriers.
These people show no symptoms but if allowed to wander around would infect the
rest of the population and spread the disease further. Assuming some test is
available to identify them, should they be confined? Perhaps more to the point
how do we administer the tests required? Blood tests for example are invasive
and in themselves require consent. Is it legitimate therefore to require
everyone to submit to a blood test in order to identify the 1% who are
carriers?
What happens if the percentage is not 1% but 10%, 20%, 30% or 40%?
Is there a threshold point at which the risk to society at large, perhaps to
humanity itself makes such an intrusion acceptable? What happens if these
people choose not to be tested or confined? Can the state use deadly force to
protect others? Some of the implications of this are dealt with in a science
fiction context in Greg Bear’s book ‘Darwin’s
Radio’, but the potential threat posed by Bird Flu reminds us that there
are real dangers.
Immunisation takes us into even more difficult territory. Unlike
confinement, immunisation depends on an ‘invasion’ of the person. It also
depends on ‘herd immunity'
to be fully effective. In other words when the proportion of vaccinated people
in a population exceeds a given percentage, the spread of the disease is
effectively stopped - to the benefit of the unvaccinated as much as the
vaccinated. This percentage depends on the disease and the vaccine, but 90% is
not uncommon. Failure to take up immunisation thus places at risk not just that
individual, but also every other un-immunised person – including people who may
be allergic, too young or too old.
The classic recent example of this was the debate over MMR, where
because of fears about a relationship between the vaccination and autism,
vaccination levels in some areas of the country have fallen well below the herd
immunity level, with consequent increase in infection rates.
Even with high vaccination levels those affected by measles are
not evenly
distributed.
Where vaccination is widely
practiced, as in the United States since 1962, measles has continued to occur
in poorly immunized subgroups that are characterized by low educational level
and economic status, very young age, or religious beliefs forbidding acceptance
of vaccine. Ultimate success of a systematic immunization program requires knowledge
of distribution of susceptibles by age and subgroup and maximal effort to
reduce the concentration of susceptibles throughout the community rather than
aiming to reach any specific proportion of the overall population.
The vulnerable sub-groups described above presumably do not choose
to be vulnerable and the low take up of MMR vaccine in these groups is not in
general related to concerns about side effects. By contrast parents who do choose
not to immunise thier children are doing so because of specific fears about the MMR vaccine.
In doing so they are effectively deciding that the risk
of adverse effects to their child from the combined injection outweighs the
risk of contracting Measles, Mumps or Rubella including the increase in
that risk as a result of the decline in herd immunity.
If these fears are unfounded, as is almost certainly the case,
then these calculations are erroneous and are increasing the general risk of
infection for all children. Setting those particular concerns aside for the
moment however, it must be recognised that there will still be some cases of an adverse
reaction. In those circumstances would it be legitimate to make vaccination
compulsory?
It seems to me that for low levels of adverse reaction the case
can be made but it is by no means clear-cut. The number of children aged 10 and
under in the UK in 2001 was slightly over 8m. Assuming for the moment an
adverse reaction rate of 1 in 100,000 children, this would mean 80 children
would suffer across the country as a result of the MMR injection if every one
of the 8m were given the vaccine. An outbreak of measles triggered by the
vaccination rate falling below the herd immunity level would almost certainly
lead to many more than that suffering serious illness including blindness.
While I don’t think the science of herd immunity is disputed, I
suspect that parents withholding their children from MMR are underestimating
the risk of contracting the diseases against which it protects, are probably
not factoring in at all the increased risk due to loss of herd immunity, and are almost certainly overestimating the risk of adverse reaction to
the vaccine. It is easy to say they are acting irrationally, but the essence of
this sort of decision is not just about risk, but also about where that risk
falls. If they overestimate the risk of an adverse reaction it is a risk
nevertheless that affects their child, while the risk of contracting the
disease is a risk spread across all children. The choice of perspective on the
decision affects the decision itself.
I’m not sure where this leaves my original questions. We appear to
have a situation where individuals acting as rationally as possible in
situations of imperfect knowledge nevertheless produce outcomes that are not
optimal for themselves or for society as a whole. Is this of itself enough justification for compulsion?
