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We are pleased to have received such a varied set of commentaries on our target article, “Pox Parties for Grannies? Chickenpox, Exogenous Boosting, and Harmful Injustices” (Malm and Navin 2020), an...

Schools and school districts are key to U.S. vaccination policies: They communicate immunization enrollment requirements and enforce them during registration. This article presents a mixed-methods study of how Michigan’s 537 districts communicate about vaccine mandates through public-facing websites. It reports the results of a qualitative analysis ( n = 50) of websites from Southeast Michigan and a quantitative analysis of all ( n = 537) Michigan’s district websites. School district websites engage in diverse health promotion practices surrounding immunization, from encouraging vaccination to neutral messaging and to encouraging exemptions. Most provide scant immunization information and few promote the importance of immunization for individual and community health. We recommend that school nurses, district staff, and health authorities collaborate to ensure that school district communication promotes immunization and does not promote nonmedical exemptions. This can lead schools to embrace immunization as an essential activity for their own functioning rather than as an unwelcome requirement imposed by outside agents.

Some societies tolerate or encourage high levels of chickenpox infection among children to reduce rates of shingles among older adults. This tradeoff is unethical. The varicella zoster virus (VZV) causes both chickenpox and shingles. After people recover from chickenpox, VZV remains in their nerve cells. If their immune systems become unable to suppress the virus, they develop shingles. According to the Exogenous Boosting Hypothesis (EBH), a person's ability to keep VZV suppressed can be 'boosted' through exposure to active chickenpox infections. We argue that even if this hypothesis were true, immunization policies that discourage routine childhood varicella vaccination in order to prevent shingles for other people are unethical. Such policies harm children and treat them as mere means for the benefit of others, and are inconsistent with how parents should treat their children and physicians should treat their patients. These policies also seem incompatible with institutional transparency.

Background: Previous research shows that pediatricians inconsistently utilize the ethics consultation service (ECS). Methods: Pediatricians in two suburban, Midwestern academic hospitals were asked...

To identify psychological antecedents of COVID-19 vaccine hesitancy among healthcare personnel (HCP). We surveyed 4603 HCP to assess psychological antecedents of their vaccination decisions (the '5 Cs') for vaccines in general and for COVID-19 vaccines. Most HCP accept vaccines, but many expressed hesitancy about COVID-19 vaccines for the psychological antecedents of vaccination: confidence (vaccines are effective), complacency (vaccines are unnecessary), constraints (difficult to access), calculation (risks/benefits), collective responsibility (need for vaccination when others vaccinate). HCP who were hesitant only about COVID-19 vaccines differed from HCP who were consistently hesitant: those with lower confidence were more likely to be younger and women, higher constraints were more likely to have clinical positions, higher complacency were more likely to have recently cared for COVID-19 patients, and lesser collective responsibility were more likely to be non-white. These results can inform interventions to encourage uptake of COVID-19 vaccines in HCP.

The development of bioethics in the late Twentieth Century parallels the development of human rights discourses. Both intellectual movements have ideological roots in a reckoning with the tragedy of the Holocaust and both invoke conceptions of human dignity that have sometimes been accused of being vague or empty and therefore useless. However, despite its ambiguity, human dignity plays an important role in both discourses. In particular, we argue that bioethics scholars can learn from how advocates of human rights have balanced their idealized and abstract conceptions of dignity (and other values) with a focus on how real-world personal and institutional moral failures can inform efforts to promote human rights. We argue that a reengagement with the horrors of the Holocaust can supplement and motivate a critical, real-world bioethics, one that is responsive to the personal and institutional failures of our time and which provides practical guidance undernon-idealconditions.

According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient refusals can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call comparative DMC. We describe how patients may possess burdens-based DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or goals-based DMC for refusal if they have an overriding goal that is inconsistent with treatment. The overridingness of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve.

We agree with Emily Walsh (2020) that the current preferences of patients with dementia should sometimes supersede those patients’ advance directives. We also agree that consensus clinical ethics g...

Policy Points We offer the first systematic conceptual framework for analyzing the operation of mandatory vaccination policies. Our multicomponent framework facilitates synthesis judgments on single issues of pressing concern to policymakers, in particular, how mandatory vaccination policies motivate people to vaccinate. We consider the impact of each component of our framework on persons who remain unvaccinated for different reasons, including complacency, social disadvantage, and more or less committed forms of refusal. Context In response to outbreaks of vaccine-preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as "vaccine mandates." However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context-specific instruments. Their legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. Methods In this paper, we introduce a taxonomy for classifying real-world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). Findings A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute-salience-which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. Conclusion Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments.

Two core questions in pediatric ethics concern when and how physicians are ethically permitted to intervene in parental treatment decisions (intervention principles), and the goals or values that should direct physicians' and parents' decisions about the care of children (guidance principles). Lainie Friedman Ross argues in this issue of The Journal of Clinical Ethics that constrained parental autonomy (CPA) simultaneously answers both questions: physicians should intervene when parental treatment preferences fail to protect a child's basic needs or primary goods, and both physicians and parents should be guided by a commitment to protect a child's basic needs and primary goods. In contrast, we argue that no principle-neither Ross's CPA, nor the best interest standard or the harm threshold-can serve as both an intervention principle and a guidance principle. First, there are as many correct intervention principles as there are different kinds of interventions, since different kinds of interventions can be justified under different conditions. Second, physicians and parents have different guidance principles, because the decisions physicians and parents make for a child should be informed by different values and balanced by different (potentially) conflicting commitments.

In the past thirty to forty years, clinicians and bioethicists have expanded the scope for children's participation in decision-making about their medical care, often under the banner of "pediatric assent." The success of this movement was signaled perhaps most strongly by the creation of American Academy of Pediatrics guidance on pediatric assent in 1995. We agree with the AAP that both the best interests of the child patient and the need to respect the child patient are reasons to take seriously children's treatment preferences. However, we argue that the AAP could provide a stronger and more stable ethical foundation for pediatric assent. Current policy documents invoke a conception of respect that is grounded in autonomy and cannot apply in most cases of pediatric assent. We argue that the mere fact that children have treatment preferences is a reason to support pediatric assent. We defend this claim by focusing on the importance of what we have called "capacity for preferences." The notion of capacity for preferences underscores that the moral value of a patient's preferences is not reducible to considerations of either autonomy or best interests.

Background In US states, childhood immunization mandates are enforced for school registration by front-line school staff, usually secretaries. Despite substantial changes to mandate policies in several states and many countries, little attention has been paid to the people who enforce them. This qualitative pilot study aimed to uncover beliefs, attitudes, and practices regarding immunization governance of Michigan school staff. Method Front-line administrative workers from Michigan schools and district offices were solicited by email. Sixteen were interviewed remotely. Results Front-line school staff believed in vaccines, but did not advocate for vaccination while registering children. Instead, they sought low-friction bureaucratic transactions, privileging the collection of data over the promotion of public health goals. This revealed a mismatch between the goals of the front-line staff who enforce vaccine mandates in schools and the goals of the policymakers who created school vaccine mandates. Conclusions This study found low mobilization of front-line enforcers of mandates in public-facing school administration roles, a problem likely to afflict the majority of American states with the ‘mandates + exemptions’ model of immunization governance. Schools would have stronger incentives to promote vaccination if state funding were better tied to immunization compliance. Front-line staff could better enforce vaccine mandates if they were provided with resources and training about vaccine promotion.

One part of our argument relies on the distinction between requesting inappropriate care (which, per AMA guidance, would make nonacceptance of potential patients permissible) and refusing appropriate care (which would not, by itself, make nonacceptance of potential patients permissible). Vaccine refusers are doing the latter, not the former. Dr. Terk claims this distinction doesn’t make a moral difference. We disagree. First, to be clear, by ‘appropriate care’ we mean the standard of care, defined as minimally competent care; by ‘inappropriate care’ we mean something falling below the standard of care. The distinction we draw—between physicians not offering inappropriate care and physicians tolerating parental … E-mail: navin{at}oakland.edu

Purpose The purpose of this study was to delineate a scoring system to maximize the ethical allocation of proton beam therapy (PBT) and determine what factors are associated with receipt of PBT, including the role of specific insurance providers. Methods and Materials Our scoring system was developed in collaboration with a multidisciplinary panel of experts. Patients submitted for PBT consideration were assigned a score by committee at a weekly peer-reviewed session at a time when our center was operating at capacity. Univariate analysis and multivariable analysis of initial and final insurance response were performed. Results One hundred ninety-seven patients were prospectively reviewed. Ninety-three percent of patients with Medicaid coverage, 88% of patients with Medicare, and 78% of patients with private insurance were ultimately approved for PBT. Median time to final insurance response was 12 days (interquartile range, 9-18 days) for patients who were ultimately denied PBT coverage. Having primary provider C (odds ratio [OR], 14; 95% confidence interval [CI], 1.20-1.96; P = .033) or third party providers A (OR, 4.22; 95% CI, 1.71-10.9; P = .002) or B (OR, 5.28; 95% CI, 1.56-17.2; P = .006) was significantly associated with final insurance denial for PBT on univariate analysis. Total score (OR, 0.79; 95% CI, 0.67-0.90; P = .002) and having coverage through third party provider A (OR, 24.2; 95% CI, 9.51-68.9; P Conclusions Our scoring system was significantly associated with receipt of proton beam therapy. Certain insurance providers are less likely to approve PBT for patients, all else being equal. Such a scoring system could be implemented effectively at other PBT facilities, and additional work is needed in ensuring patients with the most to gain from PBT will be approved by their insurance providers.

* Abbreviation: AAP — : American Academy of Pediatrics Vaccine refusal forces us to confront tensions between many values, including scientific expertise, parental rights, children’s best interests, social responsibility, public trust, and community health. Recent outbreaks of vaccine-preventable and emerging infectious diseases have amplified these issues. The prospect of a coronavirus disease 2019 vaccine signals even more friction on the horizon. In this contentious sociopolitical landscape, it is therefore more important than ever for clinicians to identify ethically justified responses to vaccine refusal. The American Academy of Pediatrics (AAP) says dismissing families who continue to refuse vaccines is an “acceptable option,”1 but some practices have gone further by not accepting vaccine refusers as patients at all.2,3 The phenomenon of nonacceptance has been underexplored; in both empirical studies and ethics analyses, researchers largely focus on dismissal.4–7 In this article, we first criticize arguments for nonacceptance that invoke a supposed right to choose one’s patients. We then argue that nonacceptance is problematic because (1) some of its motivations are intrinsically immoral, (2) it does not appear to accomplish some of its goals, and (3) even when nonacceptance does accomplish its goals, it fails to appropriately balance the various values it implicates. Throughout the article, we engage with the existing ethics literature about dismissal and conclude that even if dismissal is sometimes justifiable, nonacceptance is not. Some may argue that nonacceptance is ethically justified because they believe the clinical relationship is fundamentally a free association between clinicians and patients, as the American Medical Association Code of Medical … Address correspondence to Mark C. Navin, PhD, Department of Philosophy, Oakland University, 746 Mathematics and Science Center, 146 Library Dr, Rochester, MI 48309-4479. E-mail: navin{at}oakland.edu

The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer’s disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions.

Michigan’s introduction of mandatory counseling for nonmedical exemptions was associated with decreased nonmedical exemption rates. However, while each of Michigan’s 45 local health departments made its own decisions about how to conduct immunization counseling, differences in the burdensomeness of counseling programs was not associated with greater or lesser changes in exemption rates. Data from a survey of Michigan local health departments (online, October 2015), epidemiological data from Michigan’s Department of Health and Human Services (online, various dates), and social and economic data from the American Community Survey (online, various dates) were used in models explaining change in county-level nonmedical exemption rates. Counties that first required an education session after the December 2014 rule change had a 30% greater reduction in their nonmedical exemption rates for 2015 than did counties that already required education sessions. Michigan’s experience with vaccination waiver education suggests that imposing burdens on nonmedical waiver applicants decreases nonmedical waiver rates. It also indicates there may be a burden threshold beyond which incremental increases in inconvenience do not further reduce exemption rates. Thus, in a context of hyper-politicization and austerity, health departments may be wise to avoid implementing additionally burdensome processes that are politically or economically expensive to administer. Keywords: Immunization, Public health, Nonmedical exemption, Vaccine

The rise of populist politics raises pressing questions both about the nature of populism, and about relationships between populism and democratic institutions. For example, is populism a monolithic phenomenon, or does the label cover multiple kinds of political movements which share some common elements, perhaps only superficially? Is populism an essential element of democracies, even sometimes a virtue of such governments, or does its invocation of a monolithic demos (‘the people’) signify a fundamentally anti-democratic worldview? And what about the interaction between truth, democracy, and journalistic integrity in the context of populist politics? While the history of anti-democratic advocacy (famously illustrated by Plato) has often highlighted the tendency of democratic politics to prioritize popularity over truth, the development of social media—and evolving norms of journalistic communication and public political discourse—raise these worries in new forms. Are democracies even any more effective than other forms of government at revealing truth or effectively addressing its implications through policies? Or if they are somewhat inimical to truth, particularly in their more populist forms, could they be improved through modification? Finally, are elements of populism particularly distinctive of some allegedly democratic political cultures more than others?

We worried that our article (Navin and Wasserman 2017) would be uninteresting. We thought our task was perhaps too small: complementing (and complimenting) recent AAP guidelines (Katz, Webb, and AA...

Two new documents from the Committee on Bioethics of the American Academy of Pediatrics (AAP) expand the terrain for parental decision making, suggesting that pediatricians may override only those parental requests that cross a harm threshold. These new documents introduce a broader set of considerations in favor of parental authority in pediatric care than previous AAP documents have embraced. While we find this to be a positive move, we argue that the 2016 AAP positions actually understate the importance of informed and voluntary parental involvement in pediatric decision making. This article provides a more expansive account of the value of parental permission. In particular, we suggest that an expansive role for parental permission may (1) reveal facts and values relevant to their child's treatment, (2) encourage resistance to suboptimal default practices, (3) improve adherence to treatment, (4) nurture children's autonomy, and (5) promote the interests of other family members.

This paper builds on previous research about the potential downsides of food sovereignty activism in relatively wealthy societies by developing a three-part taxonomy of harms that may arise in such contexts. These are direct opposition, false equivalence, and diluted goals and methods. While this paper provides reasons to resist complacency about wealthy-world food sovereignty, we are optimistic about the potential for food sovereignty in wealthy societies, and we conclude by describing how wealthy-world food sovereignty can be a location of either transnational solidarity or (at least) nonharmful forms of cooptation.

* Abbreviation: AAP — : American Academy of Pediatrics More than 20 years ago, the pioneering pediatric ethicist William Bartholome1 wrote a fiery letter to the editor of this journal because he thought a recently published statement on pediatric assent, from the Committee on Bioethics of the American Academy of Pediatrics (AAP), showed insufficient respect for children.2 That AAP statement, like its 2016 update, asserts that pediatric assent should be solicited only when a child’s dissent will be honored.3,4 Bartholome1 objected that pediatricians should always solicit children’s assent and that they should acknowledge and apologize when they treat children over their objections even when they must do so to promote children’s best interests. We think Bartholome1 was right. In this brief commentary, we elaborate on his perspective about the moral value of pediatric assent, and we suggest improvements to the corresponding clinical guidance. The AAP grounds the moral value of pediatric assent by noting, “We are obliged to act out of fundamental respect for other persons by virtue of their personal autonomy.” But in drawing on the concept of autonomy, the AAP invokes too narrow a conception of respect. Indeed, the AAP acknowledges that many children “lack the agency required to be truly autonomous agents.”3 If respect is grounded … Address correspondence to Jason Adam Wasserman, PhD, William Beaumont School of Medicine, Oakland University, ODH 412, 586 Pioneer Dr, Rochester, MI 48371. E-mail: wasserman{at}oakland.edu

In a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions (NMEs) to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and Savulescu give insufficient weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally.

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or abstract away from the diverse values that are relevant to the ethical justifications of particular political communities' vaccine-mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine-mandate policies implicate various values.

When a patient lacks decision-making capacity, then according to standard clinical ethics practice in the United States, the health care team should seek guidance from a surrogate decision-maker, either previously selected by the patient or appointed by the courts. If there are no surrogates willing or able to exercise substituted judgment, then the team is to choose interventions that promote a patient's best interests. We argue that, even when there is input from a surrogate, patient preferences should be an additional source of guidance for decisions about patients who lack decision-making capacity. Our proposal builds on other efforts to help patients who lack decision-making capacity provide input into decisions about their care. For example, "supported," "assisted," or "guided" decision-making models reflect a commitment to humanistic patient engagement and create a more supportive process for patients, families, and health care teams. But often, they are supportive processes for guiding a patient toward a decision that the surrogate or team believes to be in the patient's medical best interests. Another approach holds that taking seriously the preferences of such a patient can help surrogates develop a better account of what the patient's treatment choices would have been if the patient had retained decision-making capacity; the surrogate then must try to integrate features of the patient's formerly rational self with the preferences of the patient's currently compromised self. Patients who lack decision-making capacity are well served by these efforts to solicit and use their preferences to promote best interests or to craft would-be autonomous patient images for use by surrogates. However, we go further: the moral reasons for valuing the preferences of patients without decision-making capacity are not reducible to either best-interests or (surrogate) autonomy considerations but can be grounded in the values of liberty and respect for persons. This has important consequences for treatment decisions involving these vulnerable patients.

Introduction Little is known about associations between the reasons parents refuse or delay vaccines for their children, their responsiveness to vaccine counseling, and their children's vaccination status at various ages. Since 2015, Michigan has required parents to attend education sessions at local health departments to receive nonmedical exemptions. This requirement provides an opportunity to study otherwise opaque aspects of vaccine refusal. Methods In 2017 and 2018, researchers analyzed a combined data set that included electronic medical records (n=4,098) generated by one Michigan health department during 2015 immunization education sessions, and immunization records from an August 2016 report of the Michigan Care Improvement Registry immunization registry. Analyses employed difference of proportions and ANOVAs to explore group differences in vaccination behaviors after education sessions and on-time vaccination status at various ages. Results Children whose parents stated a commitment to an alternative schedule at the education session subsequently received a vaccine their parents had refused at a much higher rate (39.2%) than did children whose parents refused for reasons of religion (4.4%), concerns about the risks of vaccines (8.1%), or beliefs that vaccines provide little benefit (10.5%). Conclusions Different reasons for refusal are associated with different patterns of vaccination behavior. Furthermore, results suggest that education sessions may overcome vaccine refusal in some cases, and that distinct refusal reasons mark real differences in parental motivations regarding vaccination choices. These differences in parental motivations may indicate the existence of different sites for potential pro-vaccination interventions.

Religious exemptions policies raise issues of personal information privacy. If applicants for religious exemptions must demonstrate that the laws to which they object impose special burdens on them, then there is a good reason to require applicants to disclose the religious convictions that lead them to object. But how much personal information privacy is it reasonable for the state to violate in order to assess applications for religious exemptions? In some cases, very little personal information—perhaps amounting only to the fact of one’s denominational membership—may be necessary for representatives of the state to determine whether someone objects for a religious reason. Privacy violations seem justified in these cases of effective minimal mandated disclosure. However, in many cases no amount of mandated personal information disclosure will enable representatives of the state to determine whether an objector has a religious objection. Privacy violations are unlikely to be justified when they do not result in disclosure of the kind of information necessary to assess whether objectors have religious objections.

Background In response to recent outbreaks of vaccine-preventable diseases and concerns around vaccine refusal, several high-income countries have adopted or reformed vaccine mandate policies. While all make it more difficult for parents to refuse vaccines, the nature and scope of ‘mandatory vaccination’ is heterogeneous, and there has been no attempt to develop a detailed, comparative systematic account of the possible forms mandates can take. Methods We compare the construction, introduction/amendment, and operation of six new high profile vaccine mandates in Australia, France, Germany, Italy, California, and Washington. We rank these policies in order of their relative restrictiveness and analyze other differences between them. Results New mandate instruments differ in their effects on behavior, and with regard to their structure, exemptions, target populations, consequences and enforcement. We identify diverse means by which vaccine mandates can restrict behaviors, various degrees of severity, and different gradations of intensity in enforcement. Conclusion We suggest that politico-cultural context and vaccine policy history are centrally important factors for vaccine mandate policymakers to consider. It matters whether citizens trust their governments to limit individual freedom in the name of public health, and whether citizens have previously been subjected to vaccine mandates. Furthermore, political communities must consider the diverse mechanisms by which they may construct vaccine mandate policies; whether through emergency decrees or ordinary statutes, and how (or whether) to involve various stakeholder groups in developing and implementing new vaccine mandate policies.

Privacy is widely valued, especially in individualistic cultures, because people want to control access to their bodies and to information about their personal choices. Privacy can promote a variety of goods. It can protect intimacy among friends and colleagues and create trusting relations of tolerance among strangers. Privacy can promote dignity, since it can be embarrassing to disclose secret or unconsidered thoughts or opinions, or to reveal one’s naked body or other private spaces. Privacy can also contribute to our individuality, self-respect, and autonomy; and privacy can protect us from a wide array of emotional or psychological harms associated with unwanted publicity. Privacy can also further important political and legal goods, including property rights, fraud prevention, and non-discrimination.

This book offers a comprehensive investigation of privacy in the modern world. It collects 16 papers that look at this essential topic from many facets, from the personal to the technological, from the philosophical to the legal. The contributors examine such issues as the value of privacy protection, the violation of spreading personal falsehoods, the digital rights of children, an individual's right to be forgotten from internet search engines, and more. The organization of the volume helps provide a nuanced understanding of this often controversial topic. Coverage starts with key concepts before moving on to explore personal information privacy and the impact of new technologies. Next, the papers consider privacy in different contexts. These include work, sex, family, crime, and religion. This structure enables greater engagement with the difficult questions about privacy. Readers will gain deep insight into the core concepts of privacy as well as its application to everyday life. This interdisciplinary volume brings together an international team of scholars. They provide a broad combination of expertise in law, philosophy, and political science. Overall, this thought-provoking examination will appeal to interested readers in both academia and practice.

Background In 2015, Michigan implemented an education requirement for parents who requested nonmedical exemptions from school or daycare immunization mandates. Michigan required parents to receive education from public health staff, unlike other states, whose vaccine education requirements could be completed online or at physicians’ offices. Methods and Findings Results of focus group interviews with 39 of Michigan’s vaccine waiver educators, conducted during 2016 and 2017, were analyzed to identify themes describing educators’ experiences of waiver education. The core theme that emerged from the data was that educators changed their perception of the purpose of waiver education, from convincing vaccine-refusing parents to vaccinate their children to promoting more diffuse and forward-looking goals. Conclusions Michigan, and other communities that require vaccine waiver education, ought to investigate whether and how waiver education contributes to public health goals other than short-term vaccination compliance. Research shows that education requirements can decrease nonmedical exemption rates by discouraging some parents from applying for exemptions, but further studies are needed to identify ways in which waiver education can promote other public health goals, while minimizing costs and burdens on staff.

The United States may justifiably exclude unvaccinated aliens, perhaps even under the assumption of Open Borders, according to which people should generally be permitted to settle in countries of their choosing. Furthermore, there are good reasons to endorse the Centers for Disease Control and Prevention's (CDC's) current vaccination-related exclusion criteria, which were last revised in 2009. I frame my discussion around CDC's 2008 decision to permit immigrant girls and women to be excluded if they were not vaccinated against human papillomavirus (HPV)-a decision that was quickly reversed and that led to the 2009 revisions to CDC's vaccination-related immigrant exclusion criteria.

Some communities that exempt parents from vaccine mandates have recently reformed their exemption policies by eliminating nonmedical exemptions, allowing nonmedical exemptions only for parents who object to vaccination for religious reasons, or making exemptions more difficult to obtain. We argue against eliminating nonmedical exemptions because there are weighty moral reasons to offer these exemptions and because eliminating them will likely have unfortunate social and political consequences. We also argue against allowing nonmedical exemptions only for parents who object to vaccination for religious reasons, on the grounds that doing so is likely to be unfair or ineffective. We conclude that nonmedical exemptions should (continue to) be available to people who object for both religious and secular reasons, and that the best way to decrease exemption rates is to make the application process more burdensome. We illustrate our arguments with examples of recent policy changes in three US states.

Many advocate practices of ‘local food’ or ‘locavorism’ as a partial solution to the injustices and unsustainability of contemporary food systems. I think that there is much to be said in favor of local food movements, but these virtues are insufficient to immunize locavorism from criticism. In particular, three duties of international ethics—beneficence, repair and fairness—may provide reasons for constraining the developed world’s permissible pursuit of local food. A complete account of why (and how) the fulfillment of these duties constrains locavorism will require extensive empirical evidence about the relationship between agricultural demand-led industrialization, international trade (rules), and local food practices. In this paper I can only gesture at some of this evidence and, for that reason, my policy prescriptions are merely provisional. Instead, the upshot of this paper is that advocates of locavorism ought to be attentive to the empirical-dependence of the moral permissibility of their projects. As local food ‘scales up’—and comes to be embraced as a goal of political communities—these concerns should receive even greater attention.

Conscientious objectors to military service are either general objectors or selective objectors. The former object to all wars; the latter object to only some wars. There is widespread popular and political support in western liberal democracies for exemptions for general objectors, but currently there is little support for exemptions for selective objectors. Many who advocate exemptions for selective objectors attempt to build upon the strength of support that is enjoyed by exemptions for general objectors. They argue that selective objectors – like general objectors – sincerely believe that it would be deeply morally wrong for them to fight in the wars to which they object. I argue that a stronger moral case for exemptions for selective objectors relies upon a different claim: selective objections are often accurate. It is often immoral to fight in the wars to which selective objectors object. While some advocates of exemptions for selective objectors have identified accuracy as a reason for of...

Recent increases in the rates of parental refusal of routine childhood vaccina- tion have eroded many countries' "herd immunity" to communicable diseases. Some parents who refuse routine childhood vaccines do so because they deny the mainstream medical consensus that vaccines are safe and effective. I argue that one reason these vac- cine denialists disagree with vaccine proponents about the reasons in favor of vaccination is because they also disagree about the sorts of practices that are conducive to good rea- soning about healthcare choices. Vaccine denialists allocate epistemic authority more democratically than do mainstream medical professionals. They also sometimes make truth ascriptions for nonepistemic reasons, fail to recognize legitimate differences in ex- pertise and competence, and seek uncritical affirmation of their existing beliefs. By fo- cusing on the different epistemic values and practices of vaccine denialists and main- stream medical professionals, I locate my discussion of vaccine denialism within broader debates about rationality. Furthermore, I argue that gender inequality and gendered con- ceptions of reason are important parts of the explanation of vaccine denialism. Accord- ingly, I draw upon feminist work—primarily feminist social epistemology—to help ex- plain and evaluate this form of vaccine refusal.

Accurately measuring vaccine acceptance is important, especially under current conditions in which misinformation may increase public anxiety about vaccines and politicize vaccination policies. We integrated substantive knowledge, conceptualization and measurement expertise, and survey design principles to develop an instrument for measuring vaccine acceptance across the general public. Given this broad goal, we expect our novel instrument will complement, rather than replace, existing instruments designed specifically to measure parents' vaccine hesitancy. Our instrument measures five key facets of vaccine acceptance: (1) perceived safety of vaccines; (2) perceived effectiveness and necessity of vaccines; (3) acceptance of the selection and scheduling of vaccines; (4) positive values and affect toward vaccines; and (5) perceived legitimacy of authorities to require vaccinations. We report results of analyses demonstrating the reliability and validity of this instrument. High Cronbach's alpha values for five sub-scales and for the full scale indicate the instrument's reliability, and the consistent performance of expected predictors (i.e., trust in biologists, conspiratorial ideation, and political ideology) demonstrates the instrument's construct validity. Further, scientific reasoning increases vaccine acceptance among liberals but decreases vaccine acceptance among conservatives, which is consistent with motivated cognition. Also, trust in biologists has a stronger positive effect on vaccine acceptance among conservatives than among liberals, signaling a potentially promising means to reduce political polarization on vaccines and increase vaccine acceptance across the general public. We end by identifying key ways that public health researchers, science studies scholars, and health practitioners may employ the full (or short) version of our vaccine acceptance instrument.

Techniques from behavioral economics-nudges-may help physicians increase pediatric vaccine compliance, but critics have objected that nudges can undermine autonomy. Since autonomy is a centrally important value in healthcare decision-making contexts, it counts against pediatric vaccination nudges if they undermine parental autonomy. Advocates for healthcare nudges have resisted the charge that nudges undermine autonomy, and the recent bioethics literature illustrates the current intractability of this debate. This article rejects a principle to which parties on both sides of this debate sometimes seem committed: that nudges are morally permissible only if they are consistent with autonomy. Instead, I argue that, at least in the case of pediatric vaccination, some autonomy-undermining nudges may be morally justified. This is because parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and because the interests of both the vaccinated child and other members of the community can sometimes be weighty enough to justify autonomy-infringing pediatric vaccination nudges. This article concludes with a set of worries about the effect of pediatric vaccination nudges on parent-physician relationships, and it calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges.