Research project and Power point

  This special project entails submission of a position paper encompassing research and readings of scholarly articles and a Power Point summary presentation. This research project should be a minimum of 15 pages and written in proper APA forma

Based on your research of Gardasil and the controversy surrounding cervical cancer vaccination, explain the issues surrounding this ethical controversy. What values are in conflict regarding this issue? What ethical leadership lesson do you take from this controversy?

Your power point submission should be 15 – 20 slides summarizing your report. Slides should be tasteful, professional, and not too wordy.

PEER REVIEWED ARTICLES ONLY!

Perspective

T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

december 7, 2006

n engl j med 355;23 www.nejm.org december 7, 2006 2389

to propose that vaccination be
compulsory for girls entering
sixth grade. Parents who objected
would be able to opt out of the
requirement under the same pro-
visions that apply to other vacci-
nations. The bill passed the state
senate by an overwhelming mar-
gin a week later and awaits con-
sideration by the house. Other
states are likely to follow Michi-
gan’s lead.

The development of Gardasil,
Merck’s

HPV

vaccine, is of major
public health importance. The vac-
cine protects against four strains
of HPV, the most common sexu-
ally transmitted disease in the
United States, including the two
strains that cause most cases of
cervical cancer. More than 6 mil-

lion people in this country become
infected with HPV every year, and
nearly 10,000 women are diag-
nosed with cervical cancer. Be-
cause the vaccine has the greatest
benefit when it is given before a
person becomes sexually active,
the Advisory Committee on Im-
munization Practices of the Cen-
ters for Disease Control and Pre-
vention recommended that it be
given routinely to girls at 11 or 12
years of age; it is not yet approved
for use in boys. The committee
took no position on whether vac-
cination should be required by law;
such policy decisions are made by
individual states.

Moves to make the vaccine
compulsory are sure to ignite a
new round of polarizing debates.

Controversy over the product be-
gan before it was licensed, when
some religious conservatives ex-
pressed concern that the avail-
ability of a vaccine against a sex-
ually transmitted disease would
undermine abstinence-based pre-
vention messages. Advocacy groups
such as Focus on the Family ulti-
mately came to support availabil-
ity of the vaccine, but they remain
opposed to mandating its use.
In their view, such a requirement
constitutes an attempt by the sec-
ular state to force a child to un-
dergo an intervention that may be
irreconcilable with her family’s
religious values and beliefs.

It is a mistake, however, to
view the contrasting stances on
HPV-vaccine mandates as solely,
or even primarily, evidence of a
conf lict between science and re-
ligion. A more complicated dy-
namic will shape the ongoing dis-
cussion.

On one side, support for legal

The Ethics and Politics of Compulsory HPV Vaccination

James Colgrove, Ph.D., M.P.H.

On September 12, 2006, 3 months after the Food and Drug Administration licensed a vaccine
against human papillomavirus (HPV), Michigan
lawmakers became the first in the United States

P E R S P E C T I V E

n engl j med 355;23 www.nejm.org december 7, 20062390

requirements is strongly inf lu-
enced by the perception of HPV as
a women’s health issue. The severe
consequences that the disease may
have for women lends urgency to
the effort to maximize use of the
vaccine through all policy means,
including mandates. Women in
Government, a Washington-based,
bipartisan organization of female
legislators, is leading a push to
make HPV vaccination compulso-
ry in every state. The group has
issued recommendations for en-
suring that the vaccine is acces-
sible and affordable, including a
recommendation that states add
it to their Medicaid programs and
encourage private health plans to
cover it. The group follows in the
tradition of breast-cancer activ-
ists, who have mobilized through
many political channels to com-
bat an illness that disproportion-
ately burdens women.

On the other side, opposition
to mandates will come from a far
wider range of constituencies than
just religious conservatives wor-
ried about threats to teenagers’
sexual abstinence. Vaccine require-
ments — even generally well-
accepted laws covering “classic”
childhood diseases such as polio,
measles, and pertussis — have
been resisted in recent years on
a wide range of philosophical, po-
litical, scientific, and ideological
grounds.

During the past two decades,
in the face of a sharp increase in
the number of recommended pe-
diatric vaccines, unproven theo-
ries alleging connections between
vaccines and illnesses including
autism, diabetes, and multiple
sclerosis have been spreading. A
social movement involving diverse
participants has challenged the
safety of vaccination and mount-
ed attacks in courtrooms and leg-
islatures on compulsory vaccina-

tion laws. Forty-eight states allow
parents who object to vaccination
on religious grounds to excuse
their children from requirements,
and 20 of those states also allow
exemptions for parents who have
secular philosophical concerns.1
Approximately 1 to 3% of U.S.
children are excused by their par-
ents from vaccine requirements,
though the rate varies from state

to state; schools in a few commu-
nities have exemption rates as
high as 15 to 20%. Activists have
sought to liberalize the circum-
stances under which parents may
opt out of vaccine requirements,
a trend that ref lects the wide
variation in people’s reasons for
rejecting vaccines: devotion to
“natural” or alternative healing,
libertarian opposition to state
power, mistrust of pharmaceuti-
cal companies, belief that vaccines
are not as safe as experts claim,
and conviction that children re-
ceive more shots than are good
for them.2

Laws making vaccination com-
pulsory raise unique ethical and
policy issues. High levels of herd
immunity protect all members of
the community, including those
who cannot receive vaccines be-
cause of medical contraindica-
tions. This protection provides a
justification for compulsion. The
availability of religious or philo-
sophical exemptions mitigates

concern about governmental in-
trusion on individual decision
making. Opinions vary, however,
about the permissible scope of ex-
emptions. Data show that schools
with exemption rates as low as
2 to 4% are at increased risk for
disease outbreaks and that chil-
dren who have been exempted
from vaccine requirements have
a much greater risk of acquiring
infectious diseases than their vac-
cinated peers.1 Minors have a right
to be protected against vaccine-
preventable illness, and society has
an interest in safeguarding the
welfare of children who may be
harmed by the choices of their
parents or guardians.

Bioethicists, who generally hold
the values of patient autonomy
and informed consent to be pre-
eminent, tend to be skeptical about
compulsory vaccination laws. Not
surprisingly, some have expressed
wariness about or opposition to
mandating HPV vaccination.3,4 Be-
cause HPV is not casually trans-
missible, they argue, there is a
less compelling rationale for re-
quiring protection against it than
against measles or pertussis, for
instance; in the absence of poten-
tial harm to a third party, such
laws may be considered unaccept-
ably paternalistic. Similar concerns
have been raised about school-
based requirements for vaccina-
tion against hepatitis B: because
the virus spreads primarily among
sexually active people and injec-
tion-drug users, some parents ar-
gued that the vaccine should be
given only to those groups rather
than to all children. Such target-
ing of the vaccine, however, proved
to be less effective than universal
vaccination in reducing the inci-
dence of the disease.

A large body of evidence dem-
onstrates that school-based laws
are an effective and efficient way

The Ethics and Politics of Compulsory HPV Vaccination
HPV

n engl j med 355;23 www.nejm.org december 7, 2006

P E R S P E C T I V E

2391

of boosting vaccine-coverage rates.
Requiring HPV vaccination by law
will almost certainly achieve more
widespread protection against the
disease than will policies that
rely exclusively on persuasion and
education. In the view of advo-
cates, this effectiveness provides
a clear justification. “The only
way to ensure that as many girls
as possible receive the HPV vac-
cine is to require it before they
enter middle school,” said Bev-
erly Hammerstrom, the Michi-
gan state senator who introduced
the legislation. Whether such a
mandate might extend to boys,
should the product be approved
for such use, remains uncertain.

A critical question is whether
achieving a higher level of cov-
erage justifies the infringement
on parental autonomy that com-
pulsory vaccination inevitably en-

tails. Different ethical frameworks
that accord varying weights to
communitarian and individualis-
tic values will lead to contrasting
answers to this question.

Ethical and epidemiologic
analyses are essential to decisions
about mandating the HPV vaccine;
so are political calculations. Any
new vaccine that a state adds to
its list of requirements must be
judged in the context of both the
increasingly lengthy and complex
regimen of vaccines that children
now receive and the possibility
that additional mandates may in-
flame grassroots opposition, be it
religious, philosophical, or ideo-
logical.5 Although issues of reli-
gion and adolescent sexuality have
dominated the discussion, the
move to require HPV vaccination
raises broad questions about the
acceptability of mandatory pub-

lic health measures, the scope of
parental autonomy, and the role
of political advocacy in determin-
ing how preventive health mea-
sures are implemented.

Dr. Colgrove is an associate research scien-
tist at the Center for the History and Ethics
of Public Health, Department of Sociomed-
ical Sciences, Mailman School of Public
Health, Columbia University, New York.

Salmon DA, Teret SP, MacIntyre RC, Salis-
bury D, Burgess MA, Halsey NA. Compulso-
ry vaccination and conscientious or philo-
sophical exemptions: past, present, and
future. Lancet 2006;367:436-4

2.

Colgrove JK. State of immunity: the poli-
tics of vaccination in twentieth-century
America. Berkeley: University of California
Press, 2006.

Zimmerman RK. Ethical analysis of HPV
vaccine policy options. Vaccine 2006;24:
4812-20.

Lo B. HPV vaccine and adolescents’ sexu-
al activity. BMJ 2006;332:1106-7.

Temte JL. Should all children be immu-
nised against hepatitis A? BMJ 2006;332:
715-8.

1.

2.

3.

4.

5.

The Ethics and Politics of Compulsory HPV Vaccination

Exploring the Uses of RNAi — Gene Knockdown
and the Nobel Prize
René Bernards, Ph.D.

The Nobel Prize in Physiology or Medicine was awarded this
year to Andrew Fire (Stanford Uni-
versity School of Medicine) and
Craig Mello (University of Massa-
chusetts Medical School) for their
discovery of a new form of gene
silencing. Nearly 9 years ago, Fire
and Mello and their colleagues
reported that exposing cells of the
nematode Caenorhabditis elegans to
double-stranded RNA resulted in
specific and efficient gene silenc-
ing.1 They also observed that
double-stranded RNA is far more
potent than sense or antisense
RNA in silencing the gene that
shares its sequence, and they
dubbed the silencing process “RNA
interference” (RNAi). Because
RNAi rarely leads to the complete
abrogation of gene expression,

its effect is often described as a
“knockdown” of gene expression.
At first glance, RNAi seems sim-
ilar to the antisense approach to
gene silencing, but it is far more
effective and has a different mech-
anism.

In plants and nematodes, the
introduction of long double-
stranded RNA into a cell leads
to its cleavage into shorter frag-
ments. These fragments are pow-
erful silencers of gene expression
and are therefore called “small
interfering RNA” (siRNA). They
are recruited into a protein com-
plex that positions the antisense
strand so that it acts as a snare
for the RNA transcript to which
it is complementary. Once bound
to this snare, the RNA transcript
is cleaved by the complex and is

degraded (see diagram). In lower
organisms, RNAi is thought to
function as a primitive immune
system, protecting against viruses
(which often generate double-
stranded RNA as replication inter-
mediates) and transposable ele-
ments (also known as “jumping
genes”).

In most mammalian cells, long
double-stranded RNA provokes an
interferon response as part of an
antiviral defense. This interferon
response induces a global shut-
down of protein synthesis, thus
precluding the use of long double-
stranded RNA for specific gene
silencing. This obstacle can be
overcome by using short double-
stranded RNA (less than 30 base
pairs in length), which evades the
radar of the mammalian interfer-

KG605 Ethics and Leadership: an Interdisciplinary Perspective

GUIDE TO WRITING A POSITION PAPER

Below is a guide to assist you with creating your position paper for the final project (Gardasil case study

position paper) for the Ethics and Leadership class.

A position paper presents one side of an arguable opinion about an issue. The goal of a position paper is

to convince the audience that your opinion is valid and defensible. Ideas that you are considering need

to be carefully examined in choosing a topic, developing your argument, and organizing your paper. It is

very important to ensure that you are addressing all sides of the issue and presenting it in a manner that

is easy for your audience to understand. Your job is to take one side of the argument and persuade your

audience that you have well-founded knowledge of the topic being presented. It is important to support

your argument with evidence to ensure the validity of your claims, as well as to refute the counterclaims

to show that you are well informed about both sides.

Step 1: How should I analyze the issue and develop an argument?

Once your topic is selected, you should do some research on the subject matter. While you may already

have an opinion on your topic and an idea about which side of the argument you want to take, you need

to ensure that your position is well supported. This means that you will need to do some research on the

topic. Listing the pro and con sides of the topic will help you examine your ability to support your

counterclaims, along with a list of supporting evidence for both sides. Supporting evidence includes the

following:

Directories, encyclopedias, handbooks, in-depth studies, books, government reports,

Government web sites, scholarly articles, academic journals, newspapers, magazines,

government agencies and, institute reports, and web sites (note that Wikipedia is not a

reliable or acceptable source!!)

Many of these sources can be located online through a library catalogue and electronic databases, or on

the Web. You may be able to retrieve the actual information electronically or you may have to visit a

library to find the information in print. You do not have to use all of the above supporting evidence in

your papers. This is simply a list of the various options available to you.

Step 2: Consider your audience and determine your viewpoint

Once you have made your pro and con lists, compare the information side by side. Considering your

audience, as well as your own viewpoint, choose the position you will take.

Considering your audience does not mean “playing up” to the professor. To convince a particular person

that your own views are sound, you have to consider his or her way of thinking. If you are writing a

paper for a sociology professor obviously your analysis would be different from what it would be if you

were writing for an economics professor. You will have to make specific decisions about the background

information you should supply, and the details you need to convince that particular reader.

In determining your viewpoint, ask yourself the following:

•Can you manage the material within the specifications set by the instructor?

•Does your topic assert something specific, prove it, and where applicable, propose a plan of action?

•Do you have enough material or proof to support your opinion?

Organization of your Position Paper

Sample Outline

I. Introduction

___A. Introduce the topic

___B. Provide background on the topic to explain why it is important

___C. Assert the thesis (your view of the issue). More on thesis statements can be found below.

Your introduction has a dual purpose: to indicate both the topic and your approach to it (your thesis

statement), and to arouse your reader’s interest in what you have to say. One effective way of

introducing a topic is to place it in context – to supply a kind of backdrop that will put it in perspective.

You should discuss the area into which your topic fits, and then gradually lead into your specific field of

discussion (re: your thesis statement).

II. Counter Argument

___A. Summarize the counterclaims

___B. Provide supporting information for counterclaims

___C. Refute the counterclaims

___D. Give evidence for argument

You can generate counterarguments by asking yourself what someone who disagrees with you might

say about each of the points you’ve made or about your position as a whole. Once you have thought up

some counterarguments, consider how you will respond to them–will you concede that your opponent

has a point but explain why your audience should nonetheless accept your argument? Will you reject

the counterargument and explain why it is mistaken? Either way, you will want to leave your reader with

a sense that your argument is stronger than opposing arguments.

When you are summarizing opposing arguments, be charitable. Present each argument fairly and

objectively, rather than trying to make it look foolish. You want to show that you have seriously

considered the many sides of the issue, and that you are not simply attacking or mocking your

opponents.

It is usually better to consider one or two serious counterarguments in some depth, rather than to give a

long but superficial list of many different counterarguments and replies.

Be sure that your reply is consistent with your original argument. If considering a counterargument

changes your position, you will need to go back and revise your original argument accordingly.

III. Your Argument

___A. Assert point #1 of your claims

_____1. Give your educated and informed opinion

_____2. Provide support/proof using more than one source (preferably three)

___B. Assert point #2 of your claims

_____1. Give your educated and informed opinion

_____2. Provide support/proof using more than one source (preferably three)

___C. Assert point #3 of your claims

_____1. Give your educated and informed opinion
_____2. Provide support/proof using more than one source (preferably three)

You may have more than 3 overall points to your argument, but you should not have fewer.

IV. Conclusion

___A. Restate your argument

___B. Provide a plan of action but do not introduce new information

The simplest and most basic conclusion is one that restates the thesis in different words and then

discusses its implications.

Your Thesis Statement:

A thesis is a one-sentence statement about your topic. It’s an assertion about your topic, something you

claim to be true. Notice that a topic alone makes no such claim; it merely defines an area to be covered.

To make your topic into a thesis statement, you need to make a claim about it, make it into a sentence.

Look back over your materials–brainstorms, investigative notes, etc.–and think about what you believe

to be true. Think about what your readers want or need to know. Then write a sentence, preferably at

this point, a simple one, stating what will be the central idea of your paper.

Here is an example:

– Original Subject: an important issue in my major field

– Focused Topic: media technology education for communication majors

– Thesis: Theories of media technology deserve a more prominent place in this University’s

Communication program

Or if your investigations led you to a different belief:

– Thesis: Communication majors at this University receive a solid background in theories of media

technology

It’s always good to have a thesis you can believe in.

Notice, though, that a sentence stating an obvious and indisputable truth won’t work as a thesis such as

“This University has a Communication major”.

This is a complete sentence, and it asserts something to be true, but it is a statement of fact. A good

thesis demands some proof. Your job is to show your reader that your thesis is true.

The objective is to logically and persuasively support your thesis in the body of your essay. A thesis is the

evolutionary result of a thinking process, not a miraculous creation. Formulating a thesis is not the first

thing you do after reading the essay assignment. Deciding on a thesis does not come first. Before you

can come up with an argument on any topic, you have to collect and organize evidence, look for possible

relationships between known facts (such as surprising contrasts or similarities), and think about the

beneath-the-surface significance of these relationships. After this initial exploration of the question at

hand, you can formulate a “working thesis,” an argument that you think will make sense of the evidence

but that may need adjustment along the way. In other words, do not show up at your TAs office hours

expecting them to help you figure out your thesis statement and/or help organize your paper unless you

have already done some research.

Writing with style and clarity

Many students make the mistake of thinking that the content of their paper is all that matters. Although

the content is important, it will not mean much if the reader can’t understand what you are trying to

say. You may have some great ideas in your paper but if you cannot effectively communicate them, you

will not receive a very good mark. Keep the following in mind when writing your paper:

Diction

Diction refers to the choice of words for the expression of ideas; the construction, disposition, and

application of words in your essay, with regard to clearness, accuracy, variety, etc.; mode of expression;

and language. There is often a tendency for students to use fancy words and extravagant images in

hopes that it will make them sound more intelligent when in fact the result is a confusing mess.

Although this approach can sometimes be effective, it is advisable that you choose clear words and be

as precise in the expression of your ideas as possible.

Paragraphs

Creating clear paragraphs is essential. Paragraphs come in so many sizes and patterns that no single

formula could possibly cover them all. The two basic principles to remember are these:

1) A paragraph is a means of developing and framing an idea or impression. As a general rule, you

should address only one major idea per paragraph.

2) The divisions between paragraphs aren’t random, but indicate a shift in focus. In other words you

must carefully and clearly organize the order of your paragraphs so that they are logically positioned

throughout your paper. Transitions will help you with this.

Transitions

In academic writing your goal is to convey information clearly and concisely, if not to convert the reader

to your way of thinking. Transitions help you to achieve these goals by establishing logical connections

between sentences, paragraphs, and sections of your papers. In other words, transitions tell readers

what to do with the information you present them. Whether single words, quick phrases or full

sentences, they function as signs for readers that tell them how to think about, organize, and react to

old and new ideas as they read through what you have written.

Transitions signal relationships between ideas. Basically, transitions provide the reader with directions

for how to piece together your ideas into a logically coherent argument. They are words with particular

meanings that tell the reader to think and react in a particular way to your ideas. In providing the reader

with these important cues, transitions help readers understand the logic of how your ideas fit together.

Here are some examples of transition expressions: also, in the same way, just as … so too, likewise,

similarly

Plagiarism and academic honesty

Plagiarism is a form of stealing; as with other offences against the law, ignorance is no excuse. The way

to avoid plagiarism is to give credit where credit is due. If you are using someone else’s idea,

acknowledge it, even if you have changed the wording or just summarized the main points.

To avoid plagiarism, you must give credit whenever you use

•another person’s idea, opinion, or theory;

•any facts, statistics, graphs, drawings–any pieces of information–that are not common knowledge;

•quotations of another person’s actual spoken or written words; or

•paraphrase of another person’s spoken or written words.

For more information on King Graduate School’s policies regarding academic honesty, please refer to

your course outline, to the KGS catalog or consult King Graduate School Administration. Remember that

ignorance is no excuse.

SOURCES

The information included in this document “Guide to Writing a Position Paper” was adapted from the

following sources:

Guilford, C.(2001). Occasions for Argumentative Essays. Writing Argumentative Essays. Retrieved August

26, 2002 from the World Wide Web: http://www.powa.org/argufrms.htm Previously adapted from:

Hairston, M. (1982) A Contemporary Rhetoric (3rd ed.). Boston: Houghton Mifflin.

Northey, M. (1993). Making Sense: a student’s guide to research, writing, and style (3rd ed.). Toronto:

Oxford University Press.

UHWO Writing Center (1998) Writing a Position Paper. Retrieved August 26, 2002 from the World Wide

Web: http://homepages.uhwo.hawaii.edu/~writing/position.htm

UNC-CH Writing Center (2000). Constructing Thesis Statements. August 26, 2002 from the World Wide

Web: http://www.unc.edu/depts/wcweb/handouts/thesis.html

UNC-CH Writing Center (2000). Effective Academic Writing: The Argument. Writing Center Handouts.

Retrieved August 26, 2002 from the World Wide Web:

http://www.unc.edu/depts/wcweb/handouts/argument.html

HPVVaccine Controversy: Ethics, Economics, and Equality
By Tanya Donahou, MD/MPH candidate,

Boston University Schools of Medicine and Public Health, Class of 2013

Introduction and Background

The debate over the Human Papillomavirus (HPV) vaccine represents a collision of two

of the most controversial topics in healthcare in America, mandatory vaccination and teenage

sexuality. Unsurprisingly, the argument is very politicized, in part due to state governments

attempts to make the vaccine mandatory upon school admission for all

girls.

The arguments for

and against the vaccine can largely be broken down into either ethical or economic issues, with

the ethical issues split between concerns about the morality of a vaccine for a sexually

transmitted infection and the question of parental rights in regards to mandatory vaccination.

Further controversy has emerged over whether boys should receive the vaccine to protect them

from the other diseases caused by HPV, and to decrease the sexual transmission of HPV to girls,

who will later be at risk for cervical cancer. Despite support for the HPV vaccine by the

American Academy of Pediatrics, the American Cancer Society, the Centers for Disease Control

and Prevention, and other medical societies, there are still many controversial issues of HPV

vaccination to be resolved.

Human Papillomavirus (HPV) and Cervical Cancer at a Glance

HPV in the US
1,3

• Over 100 types of HPV

• Types 16 & 18 cause 70% of cervical cancer

• Types 6 & 11 cause 90% of genital warts

• 6 million HPV infections per year – 15% of
the population*

• ½ of HPV infections are in 15-25 year olds

• Sexually transmitted – most common STI

Cervical Cancer in the US
1,2

• 9700 cases diagnosed per year

• 3700 deaths per year

• 500,000 precancerous cervical lesions
identified per year

• Median age of diagnosis is 47 years old

• HPV is a “necessary precedent to cervical
cancer”

4

*This is likely an underestimate because HPV infections often clear quickly and without health consequences.
3

Vaccines have been developed to prevent infection by certain strains of HPV. Cervarix

protects against types 16 and 18, and Gardasil protects against 16 and 18, as well as types 6 and

11.
1,3
This paper will focus on Gardasil as it has been approved for longer and is the vaccine

Donahou 2

most often referenced in the literature. Gardasil has been shown to be 100% efficacious in

preventing persistent HPV infections from types 6, 11, 16, and 18.
1
This translates into the

potential to prevent at least 70% of cervical cancer if the immunity conferred by the vaccine

persists. There is not enough follow-up data yet to determine for how long protections lasts and

if a booster vaccine is needed.
1

The vaccine is considered very safe, however injection site adverse experiences, like

redness, pain, and swelling, are very common.
1
Safety in pregnancy is still under review and the

vaccine is not recommended in early pregnancy. The vaccine is currently recommended for girls

ages 11-12, with catch-up vaccination in girls aged 13-26.
5
The recommended age is based on

the statistics of sexual debut in the US, with one quarter of females reporting being sexually

active by the age of 15.
1
Because the vaccine is most effective when given before any exposure,

the recommended age of vaccination is set low to ensure that all girls are vaccinated before

sexual debut.
1
The clinically indicated age of vaccine is one of the contested aspects of Gardasil,

but it will not be explored in this paper.

The Controversy: Mandatory HPV Vaccination – Ethics

The ethics are multi-faceted with arguments falling on both sides of the line. One major

concern about making the HPV vaccine mandatory is that it infringes on parent’s autonomy in

raising their children, especially in regards to values about sexual behavior.
4
There is concern

among some parents that by giving a child a vaccine for a sexually transmitted infection at the

age of 11 or 12, we are giving them “implicit permission to engage in risky sexual behaviors.”
4

However, there has been no evidence to support this concern.
4
In fact it has been shown that

adolescents are relatively unaware of HPV, and that fear of HPV or STIs in general has very

little effect on their decision of whether or not to engage in sex.
4

Donahou 3

Further rebuttal of infringement on parental autonomy focuses on a cost-benefit ethical

analysis. How much parental control is really lost due to mandatory vaccination? It seems a

small price to pay for preventing a terrible disease that ends the life of women in their prime, and

also causes significant distress in half a million women a year with precancerous lesions, who

often must undergo multiple procedures.
2,1

The benefit of the HPV vaccine falls under the very

basic ethic of using accepted medical technology to prevent serious diseases whenever possible,

in order to minimize pain and suffering. Vaccines have long been accepted as an excellent way

to prevent dangerous diseases from striking our citizens, and unlike advanced cervical cancer,

some of these disease have effective treatments and yet the vaccine is still deemed necessary.
6

The value of a vaccine that prevents cancer should be relatively self-evident, and this vaccine is

considered a major public health milestone.
4

Further, there is a historical precedence in public health where a small infringement on

personal autonomy is considered permissible when it will result in a large benefit for the

population. Mandatory vaccination is one of those situations, in which our government and our

citizens have accepted that parents should give up their right to refuse vaccination, except on

religious grounds, because of the benefit of herd immunity that protects our nation’s children. It

is not often that our nation countenances interference in the parent-child relationship, but when

not stepping in will lead to dire consequences, like cervical cancer, and the intervention is as

relatively minor, it is reasonable and justified for public health to intercede for the child’s benefit

at the expense of the parent’s preference.

Questions of power extend to the school, with many feeling that it is an overextension of

a school’s authority to mandate a vaccine for a disease that cannot be caught in the classroom,

and is the result of “promiscuous but preventable behavior.”
4
It is true that the HPV vaccine is

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different from most other vaccinations that are required by schools, where it can be argued that

the mandated vaccines are a safety issue based on contagiousness within the school setting.

However, hepatitis B is “overwhelmingly a sexually transmitted infection,” yet it has been part

of the vaccines required by schools for over a decade.
7,1
This is because the best way to increase

vaccination rates is to make a school mandate.
1
Time and again it has been shown that school-

based mandates are very effective in increasing rates of vaccinations, as seen in Hepatitis B

vaccination rates, which increased dramatically after it became mandatory for school.
2,1

Further usefulness of school mandates are that they increase availability of a vaccine.
1

As stated by Ohri et al., “school mandates motivate policy makers and implementers to improve

vaccine access for underserved populations.”
2
This is achieved through the federal Vaccine for

Children Program, which provides free vaccines to all eligible children through the age of 18.
1

Hepatitis B again provides a good example, with its disparity “virtually eliminated…following

recommendation for universal…vaccination.”
1
Since cervical cancer has a significant heath

disparity, with those of low socioeconomic status (SES) bearing 80% of the burden of the disease

in the US, it is important to note that a school mandate has the potential to reduce this disparity.
1

A very different ethical concern is that the vaccine only prevents 70% of cervical cancer,

which means that surveillance via Pap smears must continue.
4
It is proposed that some women

who are vaccinated may develop a false sense of security and forego the recommended

screening.
4,8
Thus, vaccination may lead to a paradoxical rise in cervical cancer incidence, which

is possible if less than 70% of the population is screened.
8
Harper et al. notes that “willful lack

of screening participation is already occurring in our youngest women.”
8
Further false security

can occur if the protection of the vaccine is limited, especially if it lasts less than 15 years.
8

Women may not realize that they need a booster to retain immunity, and, coupled with less

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screening, they could actually be at a increased risk of cervical cancer after the vaccine. This

argument against the vaccine raises the need for education by health care professionals when

giving the vaccine, and the need to continue to address cervical cancer risk during office visits.

However, the need for a booster is not a sufficient reason to not give the primary vaccine.
7

Mandatory HPV Vaccination – Economics

The economics of mandatory HPV vaccination center largely on the price and cost-

effectiveness of the vaccine. The vaccine costs $360 for the three recommended doses.
2
This

price is prohibitive for some families, and there is some concern that the price of the vaccine will

increase the health disparity of cervical cancer by creating an even larger gap in preventative

services based on SES.
1,2
This issue highlights the need for inclusion of the vaccine in the

federal Vaccine for Children Program and mandated insurance coverage of the vaccine, although

there may still be some families that cannot afford the vaccine or are uninsured and do not

qualify for the federal vaccine program.
1,4,2,3

It may be necessary to include an exclusion clause

for economic hardship in any legislation that mandates the vaccine, so that children who cannot

receive the vaccine for monetary reasons are still permitted to attend school.

Opponents of the mandatory HPV vaccination also argue that because cervical cancer is

not highly prevalent at 8.1 per 100,000 women and the majority HPV infections clear without

health sequelae, that it is not cost effective to use this expensive vaccine in all women, especially

when they will still have to continue cervical cancer screening.
9,4
This argument is put best by

Vamos et al., “a vaccine that offers incomplete protection against a virus, and in turn for a

disease that is classified as “rare” in the [US] and that may, in fact, never develop at all as a

pathological condition, constitutes inadequate medical justification for mandate.”
4
However,

there have been multiple cost-effectiveness analyses of the HPV vaccine and they have found

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that vaccination of girls at age 12 is $3,000-$24,300 per quality-adjusted life year, which is

considered very cost-effective for a vaccine.
2,1

Additionally, it becomes even more cost-

effective when genital wart prevention is taken into account.
2,1
To put this in context, according

to Vamos et al., “some authorities estimate the economic burden of HPV infections and their

sequelae to cost $5 billion per year in the United States alone.”
4
In addition to the monetary cost,

it is important when considering cost-effectiveness data to factor in quality of life and the

improvement in women’s lives when they do not have to fear what will be found on their Pap

smears. Taking all of this into account, it is clear that the HPV vaccine is cost-effective in the

prevention of cervical cancer in women.

HPV Vaccination for Boys – Equal Protection

The other significant controversy around the HPV vaccine is whether boys should also

receive the vaccine. This debate is based on two different sets of reasoning, first, the need to

protect males against other HPV-related disease. Second, vaccinating males would lead to

increased protection of females against cervical cancer. Males are at risk of anal, penile, oral,

and certain head and neck cancers caused by HPV, aside from the risk of genital warts.
1,10

Interestingly, males actually have a higher burden of oral HPV disease, at about three times the

rate of women.
10
The reason this matters is that oral HPV infection (with type 16, which is most

common) puts an individual at a 50-fold increased risk of oropharyngeal squamous cell

carcinoma.
10
Of note, this type of cancer has increased in incidence by 225% in recent years.

10

Unfortunately, it has not yet been proven that the vaccine prevents oral HPV infection. Despite

the likelihood that the vaccine prevents this oral cancer, it will need to be confirmed by

research.
10

Based on the need for males to have protection from other HPV-related diseases, the

Donahou 7

American Academy of Pediatrics now recommends vaccination of males aged 11-12, with catch-

up vaccination for boys ages 13-21, and up to 26 years for men who have sex with men.
5

The other issue is further protection from HPV for females via vaccination of males.

Despite the common-sense rationale of this idea, male HPV vaccination has not been found to be

cost effective in preventing female cervical cancer, especially if female vaccination rates are

high.
11,1

This reasoning by itself is not considered sufficient for requiring boys to be vaccinated.
1

Conclusion

After reviewing the multiple arguments for and against mandatory HPV vaccination, my

final thoughts are that the HPV vaccine should be mandated for all children at the age of 12. The

HPV is effective at preventing the multiple sequelae of HPV infection in both males and females,

it is cost-effective, and it does not increase risky sexual behaviors. Despite its lack of

contagiousness in the school setting, the best method for ensuring that children receive the HPV

vaccine is by school mandate, which will increase the percentage receiving the vaccine and make

the vaccine more accessible to those of low SES. Currently, no states have passed legislation

mandating HPV vaccination for school admission, although 29 states are presently considering

school-mandated HPV vaccination bills.
12
Further research is needed about the duration of

protection by the vaccine, and education about continuing screening via Pap smears will need to

be part of the vaccination process. While parents will be giving up a small amount of their

autonomy, it is accepted that there are times when it is more important for public health to

protect the child than to honor the parent’s inclination. Further, the vaccine should be viewed as

an opportunity for parents to discuss sexual morals and safe sexual behavior with their children

before any the child has made the decision to become sexually active. The HPV vaccine is a

significant public health milestone, and we, as a field, need to work at correcting misconceptions

Donahou 8

about the vaccine and work with governments to pass HPV vaccine mandates for all boys and

girls.

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Works Cited

1. Saslow D, Castle EC, Cox JT, Davey DD, Einstein MH, Ferris DG, Goldie SJ, Harper
DM, Kinney W, Moscicki AB, Noller KL, Wheeler CM, Ades T, Andrews KS,
Doroshenk MK, Hahn KG, Schmidt C, Shafey O, Smith RA, Partridge EE, Garcia F.
“American Cancer Society guideline for human papillomavirus (HPV) vaccine use to
prevent cervical cancer and its precursors.” CA: A Cancer Journal for Clinicians
2007;57(1):7-28.

2. Ohri LA. “HPV vaccine: Immersed in controversy.” The Annals of Pharmacotherapy
2007;41(11):1899-1902.

3. Hutchinson DJ, Klein KC. “Human Papillomavirus disease and vaccine.” American

Journal of Health-System Pharmacy. Nov 2008;65:2105-2112

4. Vamos CA, McDermott RJ, Daley EM. “The HPV vaccine: Framing arguments FOR and
AGAINST mandatory vaccination of all middle school girls.” Journal of School Health
2008;78(6):302-309

5. The American Academy of Pediatrics, Committee on Infectious Diseases. “Policy
statement: HPV vaccine recommendations.” Pediatrics 2012;129(3):602-605.

6. Bloom DE, Canning D, Weston M. “The Value of vaccination.” World Economics
2005;6(3):15-39

7. Haber G, Malow RM, Zimet GD. “Editorial: The HPV vaccine mandate controversy.”
Journal of Pediatric Adolescent Gynecology 2007;20:325-331

8. Harper D, Nieminen P, Paavonen J, Lehtinen M. “Correspondence: Cervical cancer
incidence can increase despite HPV vaccination.” The Lancet 2010;10:594-595.

9. Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Waldron W, Altekruse SF,
Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS,
Feuer EJ, Cronin KA, Edwards BK. SEER Cancer Statistics Review, 1975-2008, National
Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2008/, based on
November 2010 SEER data submission, posted to the SEER web site, 2011. Accessed
online on 4/2/12 http://seer.cancer.gov/statfacts/html/cervix.html#incidence-mortality

10. Gillison ML, Broutian T, Pickard RK, Tong ZY, Xiao W, Kahle L, Graubard BI,
Chaturvedi AK. “Prevalence of oral HPV infection in the United States, 2009-2010.”
JAMA Published online January 26, 2012. http://jama.ama-
assn.org/content/early/2012/01/23/jama.2012.101.abstract

11. Patel K, “Would worldwide vaccination of both males and females against human

papillomavirus be a worthy investment? Mcgill Journal of Medicine. 2009;12(2):131

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12. Hanson, K. “HPV vaccine.” National Conference of State Legislatures Updated March
2012. http://www.ncsl.org/issues-research/health/hpv-vaccine-state-legislation-and-
statutes.aspx