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  1. A short reflection on moral notions in immunisation in the context EIW 2018 European Immunization Week 2018 raises awareness on vaccination as an individual right and a collective responsibility. Highlighting the importance of everyone’s role in protecting their community from dangerous, infectious diseases by choosing to get fully vaccinated is as relevant as ever with outbreaks of measles still occurring throughout the WHO European Region to this day. Immunisation with its enormous success story has been a pathfinder for universal health coverage. Examining immunisation from an ethical lense is detrimental because virtually every individual in this world is – or ought to be – reached by vaccination programmes and their health benefits. However, vaccine hesitancy, misinformation and the influence of anti-vaxxers is a real threat to achieving elimination. It is therefore extremely relevant to observe the roles of all stakeholders involved in immunisation processes and to evaluate how immunisation services can be as equitable, inclusive, acceptable and beneficial as possible - from a normative and ethics perspective, as moral underpinnings have been identified as a relevant element of vaccine hesitancy (Amin et al 2017). Herd immunity is a building block of disease prevention through vaccination. This year’s EIW reflects the importance of this concept and reminds individuals of their responsibility in protecting not only themselves, but also their community. The decision not to get fully vaccinated can have severe consequences to those who cannot get vaccinated themselves. Responsibility can indicate taking on a moral obligation. This indirect moral power of one party can be defined as a “person or institution contributing to a system without necessarily receiving direct individual benefit or observing others receiving benefit“. However in the context of immunisation, both service receivers and providers share burdens and risks as well as paramount individual and collective benefits. This relates closely to the concept of reciprocity, which in short is “the practice of exchanging things with others for mutual benefit”. An immunisation programme provides vaccinations as a part of disease prevention for the public and requires the participation and cooperation of the public to achieve better health for all. Acting upon this principle is based on a more general normative value of social cooperation for the public good. Reciprocity can generate strong bonds of solidarity among groups. Thus, immunisation is not just a moral obligation by one side. If services are well functioning (meaning equitable), it is a win-win situation for all involved, as vaccination risks are relatively low (especially compared to those of other health interventions and to those diseases vaccination prevents) and the burden of participating is also relatively small (of course, this is arguable depending on your standpoint), yet it brings about very immediate and long-term benefits for the individual and collectively. According to the conception of reciprocity for public health ethics, reciprocity “demands an appropriate balancing of the benefits and burdens of social cooperation necessary to obtain the good of public health. (…)” (Dawson, Upshur 2016). In the context of immunisation, reciprocity can be formulated as the following: First, that the vaccinee (A) “complies to active participation in the programme with the aim of disease prevention and (i.e., contribution to public good). Second, the authorities organising the vaccination (B) have an obligation to provide evidence-based information and free and safe vaccines for the participation in the immunisation programme and provide care for any potential adverse events following the vaccination. This may include, among other things, explanation of the procedure, explanation of risks, and providing accessible treatment” (Beeres et al 2018). A chain of health systems/authorities providing evidence-based, tailored and easily accessible information creates trust, which creates cooperation and collective action in a society. Results of a Swedish study on generalised trust and collective action in immunisation (Rönnerstrand 2015) supports the theoretical claim that trust stimulates cooperation in large-scale collective action. Also, the empirical investigation indicates that high trusting individuals are unconditional cooperators in collective action. This implies that trust may give rise to a willingness to vaccinate to protect others, even in the absence of obvious reciprocity. In the face of continuing measles outbreaks in the European Region, it is highly relevant that EIW 2018 stresses rights and responsibilities as key determinants in immunisation. I would like to encourage members of this forum to join a broader discussion on what role ethics, morals and justice play in this field and the implications on policies and policy makers this perspective can bring about. When people understand the importance and the benefits of immunisation, i.e. “are on board”, they can pass on this knowledge in their community. Here it is crucial that those providing the services take on their own responsibility and make vaccination and vaccination services as available, acceptable and accessible as possible. This goes especially for the provision of evidence-based and tailored information. Immunisation must be provided in an equitable manner to achieve better participation and compliance, and thus high immunisation coverage. Reciprocity not only requires that individuals should not be overly burdened by measures to protect public health, but also that individuals are supported in a way that allows them to fulfil their obligations” (Viens, Bensimon, Upshur 2009). References: Amin AB, Bednarczyk RA, Ray CE, Melchiori KJ, Graham J, Huntsinger JR, et al. Association of moral values with vaccine hesitancy. Nat Hum Behav. 2017;1(12):873–80. Available from: https://doi.org/10.1038/s41562-017-0256-5 Beeres, Dorien T., et al. "Screening for infectious diseases of asylum seekers upon arrival: the necessity of the moral principle of reciprocity." BMC medical ethics 19.1 (2018): 16. Rönnerstrand, Björn. Generalized trust and the collective action dilemma of immunization. Göteborg Studies in Politics 139, edited by Bo Rothstein, Department of Political Science, University of Gothenburg, Box 711, 405 30 Göteborg, Sweden. 142 pages. Salmon, D.A., Omer, S.B. Individual freedoms versus collective responsibility: Immunization decision making in the face of occasionally repeating values. Emerging Themes in Epidemiology. 2006;3:1-3. World Health Organization. "Ethical considerations in developing a public health response to pandemic influenza." (2007).
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