Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

The HPV Vaccine: Should State Governments Use Policy To Make the Vaccination Mandatory?- Jenny Vaccaro

The HPV vaccine called Gardasil, manufactured by Merck, is effective in treating the two most common forms of the Human Papillomavirus. Texas Governor Rick Perry issued an executive order without legislative approval in 2007 mandating Gardasil be given to all girls beginning sixth grade. Later that year, the Texas legislature overruled Governor Perry's order, forbidding mandatory vaccination until at least 2011. More than 18 states are considering making the HPV vaccine mandatory for pre-adolescent girls (1).

Since Governor Rick Perry decided to campaign to make the HPV vaccine mandatory and also accept donations from Merck, his political science ethics must be questioned. If legislated this public health intervention would use Power-Coercion Theory to force the vaccination upon powerless minors. Once the minors receive the forced vaccination they will be protected from some but not all types of HPV. The way the vaccine is promoted only allows for education about how one is protected from HPV but it does not discuss the risks of other sexually transmitted diseases. The mandatory HPV vaccination is a bad health intervention because it uses law to force youths to get treatment against their will, it allows politicians to use their power in a unethical manor, and it gives minors a false sense of security against STD’s which could do more harm then good.

Power-Coercion Theory

The first reason why the HPV mandated vaccine would fail is due to the use of Power-Coercion Theory, which does not account for a patients right to refuse treatment. Robert Chin suggests that when people endowed with political power use “power-coercive strategies in effecting change” that is beneficial to them, they do not consider how it will affect those with out power (2). This supports the notion that using power-coercion to force young girls to get the HPV vaccine does not take into account their personal rights as a patient or the parent’s rights to decide what is best for their own children. The patient’s bill of rights says that the patient has the right to refuse treatment and thus a minor’s parent has the right to refuse their treatment (3). Since this health intervention is not addressing a public health emergency, “coerced vaccination is not justified” (4).

The HPV vaccine health intervention also does not take into account a minors’ religious affiliation. If the youth comes from a Mormon family or a Scientology background, which do not believe in the use of some medicines, the mandatory vaccination will go against their religious beliefs. This becomes a separation of church and state issue where government cannot interfere with religious institutions (5). Therefore legislators cannot make the vaccine mandatory for young girls when it could violate their religious beliefs. Currently 48 states allow parents to refuse vaccinations due to their religious beliefs (6). Along with religious beliefs comes the issue of immorality. Some people believe that they should not have sexual intercourse before they are married. Therefore they would not want to get the vaccination due to this belief and they should not be mandated to do so.

Many conservatives also feel that the vaccine will undermine their abstinence only programs if it is mandated (6). Conservatives think that the health intervention sends the message to young girls that it acceptable to have sex before marriage. These conservatives believe that the vaccine should be only be promoted by the science community and that there is no place for political involvement. This concern “inspired 100 lawmakers to write to the CDC to warn about playing politics with what should be purely scientific judgments”(6).

Lack of Safe Sex Education

Another reason that making the HPV vaccine mandatory is problematic because it relies on treating HPV but not any other safety measures such as safe sex. The HPV vaccine only protects young girls from two forms of HPV and not all types of HPV in which there are over 100. When the Texas legislators tried to make the vaccine mandatory, they did not address the need for safe sex education. Since primary care physicians could be administering the vaccine it is suggested that they also be mandated to provide sexual education and counseling (7). This combination could add to the effectiveness of the vaccine, as it is demonstrated that physicians feel there is great need for “active and aggressive sexual risk taking counseling for adolescent patients” (7).

Along with not being properly educated, young girls can gain a false sense of security regarding sexual behavior after they are vaccinated. This sense of security happens because the girls feel that the vaccination will protect them from all diseases since they have not been told otherwise. Many parents think that it is inappropriate to discuss sex with their young daughters and this might add to the minor’s lack of information about the vaccine. The CDC defines disinhabition as “an increase in unsafe behaviors in response to perceptions of safety caused by introduction of a preventive or therapeutic intervention” (8). Many people agree that disinhabition will be an outcome of this health intervention and that other STD’s and cervical cancers could drastically increase in incidence as a result.

The HPV mandated vaccine does not take into account Risk Factor Models. Young girls are constantly exposed to the social pressure to engage in risky sexual behavior from their peers. As demonstrated above that with out protection such as birth control and education, they will succumb to the immense pressure to fit in and participate in risky sexual behavior. The result of this pressure is pregnancy and disease (9). This model indicates that the government must provide educational programs along with the HPV vaccine if they want to have good outcomes from the public health intervention.

Bad Political Science Ethics

The HPV mandated vaccine might encourage bad Political Science Ethics, when politicians accept donations from the company that supplies the HPV vaccine; it creates a plethora of ethical issues. It would seem that the drug companies are creating public health interventions for their own monetary gain and not for the good of public health. When companies try to create public health interventions they commonly do not factor in the behavioral reasons for the health problem. They do not care to understand the reasons behind why young girls have unprotected sex, but they simply try to capitalize on this risky behavior.

Nationwide it will cost 800 million dollars per year to vaccinate young girls. This creates huge incentives for Merck to get the vaccination mandated. “Merck PAC has spent $74,250 in a single day to influence elections in five states. It directed 60 percent of that money to 82 candidates in Texas” (10). These donations were all made after Governor Rick Perry had issued the executive order mandating the vaccination. Merck is spearheading the campaign to make the vaccination mandatory and this creates a huge ethical issue in regards to state governments doing what is best for the public’s health.

The government has not addressed several questions about long-term implications of the health intervention. Gardisial has completed few clinical trails on the health effects of the vaccine. In one trial that was preformed they only followed up with the preadolescent girls for 18 months. No information was documented on how long the vaccine will last and the effects to young girls sex practices. There is little data on how this vaccine will interact with other vaccines (11). Along with this lack of long-term data is the fact that Gardisail is the most expensive vaccine that is recommended for this health intervention (11). All of these facts make the proposed health intervention appear less about people’s health and more about a pharmaceutical company’s greed and politicians unethical political behavior.

Implications for the Future

The main issue for why government should not be allowed to mandate the HPV vaccine is that this is a disease that is linked to behavior (9). Young girls do not get HPV by sitting next to a person in class who is coughing and is sick. HPV is contracted through unprotected sexual intercourse. This behavior might be caused by several factors such as low self-esteem. The behavior itself must be addressed as the most important component of the HPV public health intervention.

The HPV vaccination should not be made mandatory but rather should be offered to adolescent girls in their school systems. This way all types of girls from different backgrounds and socio economic statuses would have access to the vaccination. Information would be sent to the parents regarding the pros and cons of the vaccination. The school systems should offer education along with health programs to teach young girls about risky sexual behavior and how to protect themselves. The girls receiving the vaccine should also be informed about all aspects of the vaccination and its limitations of protection.


It is obvious that using bad political science ethics, Power-Coercion Theory, and not using other safety measures when making the HPV vaccine mandatory are all poor methods in this health intervention. These methods can actually do more harm then the good of the health intervention. It would be morally and ethically wrong to mandate that preadolescent girls get vaccinated to prevent HPV with out addressing the social issues that accompany it.


1. Wikipedia. HPV Vaccine. Available from: http://en.wikipedia. org/wiki/HPV_vaccine

2. Bennis, Warren, Berne, Kenneth, Chin, Robert, Correy, Kenneth. “The Planning of Change.” 1976, USA.

3. Minnesota’s Patients Bill of Rights. Avaible from:

4. Lo, Bernard. HPV Vaccine and Adolescents’ Sexual Activity. 2006. BMJ. 332,7550:1106-1107.

5. Wikipedia. Separation of Church and State. Available from:

6. Colgrove, James. The Ethics and Politics of Compulsory HPV Vaccination. 2007. NEJM. 23, 355:2389-2391.

7. Sussman, Andrew, Helizer, Deborah, Sanders, Margaret, Urqueita, Brisa, Salvador, Melina, and Ndiaye, Khadidiatou. HPV Cervical Cancer Prevention Counseling with Younger Adolescents: Implications for Primary Care. 2007. Annals of Family Medicine. 5,4:298-304. Available from:

8. Gibbs, Nancy. Defusing the War Over the “Promiscuity” Vaccine. 2006. Time. Available from:,8599,1206813,00.html

9. Edberg, Mark. Essentials of Health Behavior. Sudbery: Jones and Bartlett, 2007.

10. Allen, Terry. Mercks Murky Dealings: HPV Vaccine Lobby Backfires. 2007. CorpWatch. Available from:

11. Lippman, Abby, Melnychuk, Ryan, Shimmin, Carolyn, Boscoe, Madeline and BJ. Human Papillomavirus, Vaccines and Women’s Health: Questions and Cautions. 2007. CMAJ. 177(5). Available from:


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