MPH 510 Week 3 Ethical Choices in Public Health Decisions Example

Twenty-One Days Out of School: Weighing an Exclusion Order for Unvaccinated Children After a Measles Case With Two Public Health Ethics Frameworks

[Student Name]

University of Phoenix

MPH/510: Public Health Professional Practice

Week 3 Assignment

[Instructor Name]

[Date]

The county, school, case and decisions are composites written for a model paper; ethical frameworks and research findings come from the sources cited.

Late on a Thursday in March, the laboratory confirmed measles in a second-grader at an elementary school in a composite southern Colorado county. The child had attended school for three days while contagious. School records showed 41 of the school's 380 students had no documented measles vaccine, most because of nonmedical exemptions. The county health department had legal authority to exclude unvaccinated, exposed students for 21 days after their last exposure. The question for the director was not whether she could, but whether she should. This paper analyzes that choice.

The Values in Tension

Several values pulled in different directions. Protecting children and others from a serious, highly contagious disease. Respecting parents' choices about their children's health. Children's right to education. Fairness to the unvaccinated children, who had no say in the decision. And the public's trust in the health department.

Why a Framework

Public health ethics differs from clinical ethics because it concerns populations and often imposes burdens on some people to protect others. A structured framework helps make such decisions consistent and transparent.

Framework One: Six Questions

An ethics framework for public health asks six questions: What are the public health goals of the proposed program? How effective is it in achieving them? What are the known or potential burdens? Can burdens be minimized, and are there alternative approaches? Is the program implemented fairly? And finally, what would a fair weighing of the gains against the costs look like (Kass, 2001)?

Goals

The goal was to prevent further measles cases among unvaccinated children and, through them, among infants too young to be vaccinated and people with weakened immune systems in the community.

Effectiveness

Measles spreads to most susceptible people exposed to it. Excluding unvaccinated, exposed students during the incubation period prevents them from becoming infected at school and spreading the virus to others there, though it cannot prevent exposure elsewhere.

Burdens

The burdens were real: 21 days of missed school for 41 children, lost work for parents arranging child care, possible stigma for families identified as unvaccinated and the risk that heavy-handed action would harden some parents against vaccination.

Minimizing Burdens and Alternatives

Less restrictive alternatives existed. Unvaccinated students who received measles vaccine within 72 hours of first exposure could return immediately. The school could provide remote learning materials. The department could keep individual families' names confidential.

Fairness

The burden fell on children who had not chosen their vaccination status. Fairness required minimizing their losses, not penalizing them, and applying the same rule to all exposed unvaccinated students regardless of exemption type.

Balance

Weighing benefits and burdens, the potential harm of an uncontrolled outbreak, including hospitalizations and deaths among vulnerable people, outweighed 21 days of disrupted school, especially if burdens were minimized.

The Parents' Perspective

The director spoke with several parents before deciding. Some had chosen exemptions after reading claims about vaccine safety online; others had simply missed appointments during a move. One mother said her son had a mild reaction to an earlier vaccine and she was afraid. Hearing these reasons reminded the department that exemptions reflect a range of situations, from firm beliefs to logistics, and that respectful conversation could change some decisions.

The Legal Authority

State law authorizes local health departments to exclude susceptible students from school during an outbreak of a vaccine-preventable disease. Legal authority establishes that the department may act, but not that it should. Ethics asks the second question, and the department treated the legal power as a floor, not a justification.

Who Else Was at Risk

The school shared a building with a preschool program serving infants and toddlers, some too young for measles vaccine. Two staff members were pregnant, and one student was receiving chemotherapy. These people could not protect themselves through vaccination, which strengthened the case for limiting exposure at school.

Framework Two: Justifying Conditions

A second analysis of public health ethics proposes five conditions that must be met to justify overriding values such as liberty: effectiveness, meaning the action is likely to protect public health; proportionality, meaning benefits outweigh the infringed values; necessity, meaning the infringement is needed to achieve the goal; least infringement, meaning the least restrictive effective option is chosen; and public justification, meaning officials explain and justify the infringement to those affected (Childress et al., 2002).

Applying the Conditions

Exclusion was likely effective, proportionate given measles' severity, necessary because exposed susceptible children could transmit the disease and least infringing if paired with the vaccination option, remote learning and confidentiality. The fifth condition, public justification, required the department to explain its reasoning openly.

The Population Stakes

Exemptions affect whole communities, not only exempted children. A national analysis found that states that easily granted nonmedical exemptions and states that allowed personal belief exemptions had higher exemption rates, and that easier granting was associated with 53% higher pertussis incidence after adjusting for demographics (Omer et al., 2006). A family's exemption can feel private, but the disease it risks does not stay private.

The Decision

The director issued the exclusion order for the 41 students, effective Friday, with three conditions to minimize burdens: any student vaccinated within 72 hours of first exposure could return, the school would provide learning packets and daily online check-ins and the department would not release any family's name.

Explaining the Decision

The department called every affected family before the order took effect, explaining the risk, the reason for exclusion, the vaccination option and the support available. A public statement described the case, the exclusion and the reasons, without identifying the child or families.

Results

Fourteen families chose vaccination within 72 hours and their children returned. One excluded child developed measles at home during the exclusion period and did not expose classmates, which the director saw as the clearest evidence that exclusion had worked. No further cases occurred at the school, and the preschool in the same building had none.

What the Department Would Do Differently

In review, staff noted that the school's exemption rate had been rising for five years and that no one had spoken with the school's families about it before the outbreak. The department now shares kindergarten exemption data with each school every fall and offers vaccination clinics and conversations with a nurse before problems arise, so that exclusion is less likely to be needed.

Reflection

The decision imposed real burdens on children who did not choose them. The frameworks helped the department reduce those burdens and explain the choice, which preserved more trust than an unexplained order would have.

Conclusion

Excluding unvaccinated children from school pits protection of the community against liberty, education and fairness. A six-question framework and five justifying conditions led the department to an exclusion order paired with the least restrictive supports possible and open public explanation. Evidence that easier exemptions increase disease showed why the burden was justified.

References

Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D., & Nieburg, P. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medicine & Ethics, 30(2), 170-178. https://doi.org/10.1111/j.1748-720X.2002.tb00384.x

Kass, N. E. (2001). An ethics framework for public health. American Journal of Public Health, 91(11), 1776-1782. https://doi.org/10.2105/AJPH.91.11.1776

Omer, S. B., Pan, W. K. Y., Halsey, N. A., Stokley, S., Moulton, L. H., Navar, A. M., Pierce, M., & Salmon, D. A. (2006). Nonmedical exemptions to school immunization requirements: Secular trends and association of state policies with pertussis incidence. JAMA, 296(14), 1757-1763. https://doi.org/10.1001/jama.296.14.1757