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Vaccination remains one of the most economical and effective interventions for preventing an array of infectious diseases and the associated disabilities and deaths as well as fostering public health. However, the use of vaccines raises a number of ethical issues at the local and global level of discourse and praxis. This entry attempts to enumerate and ﬂesh out some of the pressing aspects of these issues in their principlist and global ethical dimensions as they affect children, selected groups of adults, and humanity in general.
Developed by scientists like Edward Jenner and Louis Pasteur in the 1790s, vaccination as a means of enhancing host resistance to infectious diseases remains one of the most effective and economical public health tools for preventing morbidity. It is a biomedical exercise as well as a form of social intervention which has not only ensured the eradication of smallpox from the garden of human experience but continues to save millions of lives across the globe (Afolabi and Afolabi 2013). The esthetic appeal of vaccination centers around the idea that exposure to the antigenic part of an infectious agent elicits an immune system response which ultimately confers protection against the infection or disease of interest. Its logic and scientiﬁc appeal therefore lies in the notion that every (or most) vaccinated person will mount an effective immune response. This is further linked to the general safety of vaccines in comparison to most pharmaceutical and biological agents (Jacobson et al. 2003) used to medically combat same or similar kinds of infections/ diseases.
However, while vaccination enables the public health and social control of an array of infectious diseases, it elicits a number of ethical issues. These are associated largely with issues of autonomy, paternalism, beneﬁts versus risks, justice, and rights. These issues likewise echo the core tensions between balancing individual versus population health needs which are central to public health ethics. A relevant point of departure should therefore relate to the beneﬁts and risks of vaccination in general. It is important to state that there are some nontraditional forms of vaccination that do not focus on protection and prevention from infectious diseases. Some of such vaccines, for instance, seek to ameliorate the addictive effects of psychoactive substances such as tobacco and cocaine (Young et al. 2012). This entry however does not engage ethical themes related to these.
The Benefits And Risks Of Vaccination
The principlist rhetoric of beneﬁcence and non-maleﬁcence has featured prominently in the discussion of the medical beneﬁts and risks of vaccination.
Beneficence In Vaccination
The principle of beneﬁcence focuses on the welfare of others. The other-centric nature of the healing professions therefore warrants that beneﬁcence – in the healthcare context – focuses on those served by the system: patients and potential patients. For Beauchamp and Childress (2013), beneﬁcence serves as a moral ideal which supports a number of prima facie rules such as (1) protecting and defending the rights of others, (2) preventing harm from occurring to others, (3) removing conditions that will harm others, (4) helping persons with disabilities, and (5) rescuing people that are in danger.
On this conceptual note, Beauchamp and Childress delineate the conceptual boundaries between obligatory and nonobligatory beneﬁcence. The latter kind of beneﬁcence applies to healthcare because entering into the health professions inherently incurs certain obligations to be speciﬁcally rendered to the clients with whom the professionals have to do their healing business. It applies also to the families/relatives of sick people who have obligations to help restore the health of their loved ones during illness episodes. Lastly, it applies to the governments of societies who are obligated to treat healthcare as an important goal of public policy and take afﬁrmation steps and actions to provide it to those who need it (Green 2005).
Applied to the sphere of vaccination, the principle of obligatory beneﬁcence (POB) has some implications. It foists a moral burden on healthcare professionals and scientists alike to develop, make available, and dispense effective vaccines to those who need it as a form of preventive public health measure. In the family network context, it behooves fathers, mothers, and/or guardians to facilitate and encourage the process of vaccination for their little children or wards (for childhood vaccine-preventable diseases or VPDS) as well as teenage children (for gender-speciﬁc vaccines such as human papilloma vaccine or HPV). Lastly, the obligatory beneﬁcence of governments explains why some countries in Africa such as Ghana, India, Nigeria, and Zimbabwe have public immunization days in which vaccines are freely administered to those at risk and why countries such as the United States have laws that prohibit school participation for certain categories of unvaccinated children.
In other words, the POB spurs certain categories of people (including health professionals, family members/guardians, and governments) to act for the good of a speciﬁc group of people around them (including children and young adults and the elderly) who may potentially be in harm’s way or the path of potential infection so as to foster the collective well-being of the society in particular and the global community in general. The context of measles may be used to brieﬂy illustrate the importance (and perhaps, necessity) of the principle of obligatory beneﬁcence. Measles accounts for more mortality than any other VPD, and in 2004, an estimated 454,000 people died from it (Afolabi and Afolabi 2013). Being a contagious condition, this statistic sheds a practical insight into how the application of the POB vis-à-vis vaccination helps foster the lifesaving telos of healthcare and how its neglect has severe public health consequences at the local and global planes.
Non-Maleficence In Vaccination
It would seem that since medicine or healthcare has a lifesaving telos, discussions about non-maleﬁcence and harm should hardly arise. However, how one construes harm and what speciﬁc aspects of healthcare are under consideration determine the validity of such a position. Harm may be construed as hindering or shortchanging another party’s interests. But since individuals in societies have diverse and differing interests and because an individual’s interests may even conﬂict across time periods, it is inevitable that the hindering of interests alone does not sufﬁce in determining harm. Some forms of harms may thus be justiﬁable even if they result in setbacks to another party’s interests. These include the amputation of a gangrenous leg, punishment of physicians for negligence or incompetence, and some forms of animal research (Beauchamp and Childress 2013). The principle of non-maleﬁcence has thus come to be conceptualized in more speciﬁc moral terms. According to Beauchamp and Childress (2013), these are associated with a number of rules including: (1) do not kill, (2) do not cause pain or suffering, (3) do not incapacitate, (4) do not deprive others of the goods of life, and (5) do not impose the risks of harm.
Applied to vaccination, the principle of non-maleﬁcence would stipulate that little overall harm come to those that receive vaccines. Hence, the beneﬁts of receiving vaccines (protection from disease for individuals and herd immunity for the community and ultimately the society) ought to outweigh whatever harms may result, at the individual and collective level. This is however the ideal picture of vaccines. Vaccines, when examined in more speciﬁc details, are not entirely safe public health interventions. For instance, there is always an attendant possibility that some children who receive oral polio vaccine may develop vaccine-acquired polio (Afolabi and Afolabi 2013). From a public health policy perspective, the ethical concerns raised by the context in which harm may come as a consequence of vaccination underscore the need to deﬁne, identify, justify, and share beneﬁts and unavoidable harms that may come to the fore when the common good is being negotiated. In other words, they show how striving to ensure beneﬁt and avoid harm is not completely feasible in relation to vaccination (Hann and Peckham 2010). On the other hand, the principle of non-maleﬁcence also applies to public health practitioners. Withholding effective vaccines from individuals and communities in need of such would constitute a form of harm.
At the same time, administering vaccines to a child with thymoma in whom seroconversion will likely not occur (but the risk of vaccine reaction) constitutes an act of harm. As a result, withholding vaccine in such context would constitute an act of beneﬁcence.
Since the health professional-patient relationship is known to foster preferential consideration from physicians to patients or nurse to patients, the contextual determinants of how vaccine may or may not serve particular clients or patients provide a means of simultaneously realizing the public health goals of vaccines while limiting potential harms to individual interests. While this may be true for Euro-American contexts where vaccines are usually administered by primary healthcare physicians or other professionals who have ample access to patients’ records, this is hardly the case in other parts of the globe. In West Africa, for instance, vaccines are usually not dispensed by those in existing professional relationships with the populace. In Nigeria, community health workers and other ad hoc staff are usually hired to administer vaccines during public immunization days (Afolabi and Afolabi 2013). That arrangement therefore eliminates the possibility of negotiating the biologically nuanced aspect of vaccination in relation to particular individuals, which raises the general public health risk of vaccination in places where such arrangement operates. On the other hand, traditional vaccination schemes ignore genetically encoded unique individual variations in response to biologic agents. Up to six doses of hepatitis B vaccine are, for instance, required in some individuals to induce a protective antibody unlike in the majority where two or three doses are adequate (Poland et al. 2008). This connotes another potential risk – related to vaccine failure and a false sense of protection – associated with vaccine use.
Beneficence Versus Non-Maleficence In Vaccination
Balancing the beneﬁts and harm embedded in vaccination echoes the traditional dilemmas – trumping individual good by consideration of social interests – inherent in public health ethics. A number of frameworks are often employed in resolving these including utilitarianism, liberalism, and communitarianism. Utilitarianism as a consequentialist notion justiﬁes actions, policies, and motives by recourse to derived values and beneﬁts, maximizing well-being and welfare (Holland 2007). Since it focuses on population level health needs, vaccination as a public health intervention often appears inherently utilitarian.
Liberalism and communitarianism are antithetical theories employed to justify socially embedded courses of action. Depending on the social context, they however afford a route for navigating public health issues including vaccination. Liberalism centers on the idea of individual autonomy, choice, and freedom from an undue secondparty constraint. Applied to the sphere of vaccination, this implies that the beneﬁts of health interventions are best determined by the individual. This however becomes worrisome when one considers that person A might choose to engage in certain activities (for instance, refusal to be vaccinated against a virulent virus) that signiﬁcantly endangers person B. Lastly, communitarianism considers the social nature of life, institutions, and relationships as a requisite guide to moral reﬂection and action. It therefore locates the process of determining appropriate course of actions within the social space (Holland 2007). An appeal to communitarianism, for instance, may facilitate enforcing mandatory vaccination to ensue herd immunity.
Individual And Collective Interests In Vaccination
Although individuals and targeted segments of society encompass recipients and beneﬁciaries of vaccination schemes, the interests of these two groups may conﬂict, depending on speciﬁc contexts. At the core of this are often issues related to personal decisions to refuse or to receive vaccines and how each strand of choice has attendant public health sequelae, which ultimately elicit concerns about fairness on the individual and social planes. These issues reﬂect the ideas of autonomy and justice.
Autonomy In Vaccination
Autonomy embeds three core elements: intentionality, understanding, and non-control (Beauchamp and Childress 2013). In other words, being autonomous entails being able to decide for or against a course of action following ample comprehension of the related pros and cons and without any undue external inﬂuence. In the context of vaccination, individuals such as children, adults, and the elderly are the ultimate recipients of vaccines. To be sure, while the right to accept vaccines fosters herd immunity, the right of refusal potentially skews the potential for accomplishing herd immunity, hence, posing a risk to collective societal interests. But if someone refuses vaccine on the basis of fear of potential adverse reaction (as have been observed to be a factor shaping vaccine rejection in Latin American countries such as Brazil), their refusal constitutes an autonomous decision. As such, a major debate in public health policy revolves around the extent to which it is right or good to limit or allow individual liberty for the sake of protecting the liberties of others. The contexts of childhood vaccination, vaccination against HPV (human papilloma virus), and compulsory vaccination in healthcare professionals may be explored to further engage this theme.
In the context of children, different countries employ different approaches to engage the ethical quandary of autonomy (which is usually the prerogative of parents). Parts of the United States, for example, have since 1809 used the policy of compulsory immunization program as a criterion for allowing and excluding children from enrolling in school. This still operates today such that mandatory immunization constitutes a condition for enrolment into daycare and school. In rights-driven and individualistic societies, vaccination and other public health policies that speciﬁcally target autonomy are often problematic. However, the utilitarian import of policies like this becomes clear when examined in the light of actual cases. In the 1970s, a measles outbreak occurred in Los Angeles County which led authorities to initiate vaccination exercises. At the end of this, about 50,000 out of 1.4 million students were found to be unimmunized. Consequently, these were excluded from attending school, a step which led to a huge drop in the number of measles cases (Colgrove 2010).
Some countries, however, do not exclude unvaccinated children from school. For instance, the Nigerian government speciﬁcally uses information via newspaper, radio, and television to raise awareness about the societal beneﬁts of vaccination and how participation fosters societal interests. The country anchors her policy on the logic that better understanding will nudge parents to allow their children get vaccinated. While this has been largely successful, it has repeatedly encountered setbacks in the northern region of the country, thereby contributing to the spread of VPDs such as polio and measles (Afolabi and Afolabi 2013). This has intra and international ethical implications, which will be addressed later in the entry.
In the context of young adults, different kinds of vaccination elicit different ethical issues. The vaccination of female teens (usually between ages 10 and 16) with proprietary vaccines such as Gardasil and Cervarix, for instance, raises issues not only related to individual female health (in terms of their present and future lives) but also potentially affects the lives of males (or females, depending on the sociopolitical context) with whom they have or will have coital relationships. Indeed, unvaccinated but coitally active females personally face the risk of HPV and possibly cervical and oral cancer in later years (if they are not in monogamous relationships) and also increase the public health impact of the spread of HPV to other male and female members of the society. Hence, deciding to get vaccinated fosters individual and collective public health interests. Some suggestions have been made in relation to including boys in vaccination schedules for HPV since they also constitute a possible foci of infection (and equally face the risk of disease manifestation including oropharyngeal cancer and warts), transmission, and consequently pose a source of public health risk to society (Hancocks 2014).
Whereas the refusal of HPV vaccine (by polycoitally active persons or those who might later choose to be so inclined) potentially poses public health risk to society, there are currently no mandatory laws compelling vaccination. To be sure, the normative undertones of HPV vaccination have sometimes been grounds upon which some parents refuse the participation of their wards as it is perceived that getting vaccinated (and by implication acquiring a means of protection against a sexually transmitted infection) may motivate teenagers into further exploring their sexualities. Nevertheless, this shows the need to merge epidemiologic, ideological, and political calculations with ethical insights in properly navigating the ramiﬁcations of HPV vaccination (Colgrove 2006).
Lastly, healthcare professionals and students in-training (such as those taking anatomy practical classes or on clinical rotations in hospitals) require vaccination against a number of viruses for which they are at high risk of infection. These include hepatitis B or HBV and the inﬂuenza virus. Healthcare workers including surgeons, pathologists, dentists, and nurses working in hemodialysis and oncology units are at a higher risk of contracting HBV infection through skin cuts, which may not be readily noticeable. Also, medical/clinical laboratory professionals, phlebotomists, and others who collect blood samples from patients face an increased risk of accidental needle punctures. Vaccination thus offers not only a means of protecting the lives of the professionals concerned but also serves to protect colleagues, patients, and the society at large. In short, it constitutes a means of enabling professionals to keep to one of the fundamental ethos of the healing professions: primum non nocere or do no harm. The refusal of vaccination by health professionals thus entails subjecting patients in particular and other members of society in general to preventable risk of infections. Refusal on grounds of autonomy is speciﬁcally difﬁcult to exercise because doing so constitutes not being allowed to practice clinical medicine or nursing, for instance. On the other hand, while vaccination against inﬂuenza in ﬂu-prone regions has a similar logic, mandating this has increasingly attracted protests by some health workers in the United States and Canada. In some other countries such as Israel, ﬂu vaccination for health workers is voluntary but well received by health workers.
Justice In Vaccination
Justice entails increasing utility in a mutually fair and harmonious atmosphere that is open to contextual values and needs (Beauchamp and Childress 2013). It also involves carrying out and/or resolving transactions in a fashion that presents the least burdens to all parties concerned. Applied to vaccination, justice can be said to be served when children, teenagers, and adults who pose one kind of public health risk or the other get vaccinated to prevent greater societal harm or to forestall spending taxpayers’ or personal money on expensive treatments. There are therefore two sides to justice in relation to vaccination: personal and social.
Personal justice entails deciding to accept vaccines or allow one’s child to accept vaccines (such as oral polio vaccine or HPV) in other to avoid future occurrence of a disease which will be more costly in economic, social, and psychological terms. In other words, it entails choosing the least burdensome option. Another type of personal justice occurs when vaccines are autonomously refused. This relates to not deriving beneﬁts at the expense of those who participate in vaccination, that is, not proﬁting from herd immunity. Theoretically, beneﬁting from herd immunity is however not as clear cut as often assumed because it is possible to be unvaccinated but beneﬁt from natural immunity due to previous natural exposure to the infectious agent of interest. Hence, people may refuse vaccinations and neither harm social interest nor beneﬁt from herd immunity.
Social justice in relation to vaccination, on the other hand, involves encouraging citizens or mandating them to receive vaccines in order to forestall public health outbreaks of VPDs – the least burdensome option from society’s perspective. Personal and social justice are however difﬁcult to balance. For instance, attempting to force resisting communities to comply with vaccination schemes is problematic partly because the beneﬁts being offered are not completely uncontestable (Dawson, and Verweij 2009) and partly because only selective social privileges may be denied those who refuse vaccination, for instance, enrolment in daycare and elementary schools.
The issues hitherto elaborated relate to the traditional notion of vaccine use as a public health resource. However, with the emerging ﬁeld and praxis of vaccinomics, other ethical issues increasingly come to the fore in the arena of vaccination. Vaccinomics examines the inﬂuence of immune response gene polymorphisms on the heterogeneity of humoral, cell-mediated, and innate immune responses to vaccines at both the individual and population levels (Poland et al. 2008). This emerging science thus redeﬁnes the public health as well as the ethical connotations related to vaccination. A major way in which it does this relates to the reconceptualization of individual and societal risk in relation to speciﬁc vaccines. For instance, vaccinomics embeds the possibility that vaccinated individuals would not necessarily shape herd immunity. At the same time, unvaccinated individuals will beneﬁt less from herd immunity in an era of vaccinemics enabled rational vaccine development and design. All of these come with attendant implications for the notions of justice, autonomy, beneﬁcence, and non-maleﬁcence. Vaccinomics likewise raise the act and rule utilitarian distinctions that come to fore when there are alternative public health policies (in this context, traditional and personalized vaccines) with different beneﬁts. For less-developed world economies, issues related to access speciﬁcally arise vis-à-vis vaccinomics. For instance, the lack of ﬁnancial incentives for Big Pharma to produce these vaccines for countries in the south would both inﬂuence accessibility as well as whether or not ethical issues related to vaccinomics will arise in such parts of the globe.
Other issues of ethical import related to vaccination concern bioterrorism with its attendant import on national and global security, as well as pandemics and epidemics. Especially of concern is the use of smallpox and botulinum toxins as biological weapons. Since smallpox has been eradicated in 1979 and vaccine schedules for it no longer exist, the potential for the use of the causative agent (the variola virus) or its modiﬁed versions as weapons leaves a large segment of societies and nations vulnerable. Although the bioterrorism threat has stimulated some production of new generations of smallpox vaccines, large-scale studies are still required to determine the safety of such vaccines and the correlation of the newer immunologic surrogate markers to protective immunity and its traditional markers (Wiser et al. 2007). Depending on their speciﬁc nature and locale, vaccination in the context of epidemics and pandemics may throw up novel quandaries related to resource allocation, triage, and circumventing phases of clinical trials to accelerate vaccine testing. For instance, the recent Ebola outbreak in some parts of West Africa raised issues about prioritizing recipients of the limited available Zmapp (speciﬁcally, rationing among infected patients versus infected African health workers versus infected American health workers) as well as issues on testing (balancing the risk of not-well-tested experimental vaccines in infected patients versus giving such patients supportive therapy).
Lastly, while some countries such as the United states have clear-cut health policies on treatment regimen and possible compensation in instances of vaccine reactions, the absence or ambiguity of this in some other countries engenders some ethical concerns about the overall social justice embedded in vaccination.
Global Bioethical Dimensions
There are a number of global bioethical dimensions that are associated with vaccination. While refusal to participate in vaccination may enable some individuals to draw beneﬁts from herd immunity and some to draw from natural immunity, for other categories of the unvaccinated, this facilitates the continued spread of VPDs. Such a scenario has been implicated in the spread of wild polio from parts of the West African Sahara to Central Africa and the Middle East (Afolabi and Afolabi 2013). Although some international travel regulations often include country-speciﬁc vaccine requirements for communicable diseases such as yellow fever, meningitis, and cholera, cases of autonomous refusal of vaccination in one part of the globe potentially engender issues of global justice. This is especially true in light of the fact that travels across national borders do not only occur by conventional and monitored means as well as the fact that some countries enforce vaccine requirements only for longer stays such as travel for study, work, and permanent residency.
Whereas the traditional ethical issues associated with vaccination have been largely examined in the light of the principlist framework, other kinds of moral lenses raise some unique sets of issues, hence, yield different analyses. For instance, within the ubuntu ethical precept prevalent in most parts of Africa, the conﬂicts between individual and collective interest would hardly arise. This is because common good is seen to be intertwined with individual good; in other words, the logic of “I am because we are; we are, therefore I am” presupposes that individuals have ontologically derived moral obligations to make sacriﬁces for the sake of society. Hence, if individual and social ﬂourishing are meshed together, then balancing the autonomous and social interests as well as balancing individual and social justice would not elicit the same tenor of ethical tensions seen in the Western individualistic contexts. Perhaps, one context where there might be global moral consensus is the sphere of mandatory vaccination for life-threatening infectious diseases such as Ebola.
Lastly, culture and religious ideologies may also shape the moral context of vaccination. For example, vaccination schemes in Northern Nigeria were hindered in 2006 under the moral guise of religion in which the vaccination against polio and measles was seen as antithetical to the Islamic religious obligation for procreation due to a perceived but erroneous belief (peddled by religious authorities) that antifertility drugs had been included in the Western-procured vaccines. Therefore, accepting vaccination not only became immoral but collective religious interests or group autonomy effectively trumped individual autonomy to the extent that very few people participated in the exercise (Afolabi and Afolabi 2013). Finally, it has been reported that African-American populations are prone to expressing concerns over certain types of vaccination.
For instance, the possibility that vaccinated female teens would perceive themselves as being protected from HPV and consequently become prone to promiscuity or engaging in unprotected coital activities has been a factor shaping the participation of this group in HPV vaccine schemes (Scarinci et al. 2007). Such apprehension however becomes understandable against the historical backdrop of the shocking research and public health abuses such as forced sterilization which the group has hitherto experienced.
The ethical tensions related to vaccination have local and global dimensions which revolve around questions of beneﬁts and harm(s), autonomy, and justice and how these impact societal interests. Some of these moral issues however become either less strident or nuanced in non-individualistic parts of the globe and in some cultural and religious contexts. On the other hand, the emerging science of vaccinomics with its promise of personalized vaccines will ultimately reconceptualize individual and societal risks and beneﬁts in relation to speciﬁc vaccines as well as generate novel ethical dimensions to the debates on vaccination.
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