Few doctors, parents or medical ethicists would dispute the astounding potential of the new human papilloma virus vaccine -- it protects against infections that cause 70% of all cervical cancer and most genital warts.
"We use 'breakthrough' way too often, but this is a breakthrough," says Dr. Bradley Monk, an associate professor of gynecologic oncology at UC Irvine School of Medicine. "We are unbelievably enthusiastic to have a vaccine that prevents you from getting cancer."
But should it be mandatory?
In December, California Assemblywoman Sally Lieber (D-Mountain View) introduced a bill that would require girls entering sixth grade to receive the three standard doses of the HPV vaccine. Although state law permits parents to receive an exemption to required immunizations for medical, religious or personal reasons, the bill aims to ensure that most girls are vaccinated before they become sexually active. Similar bills have been introduced in 16 other states and the District of Columbia.
"Requiring vaccinations against a number of diseases for school enrollment gives us the best chance of controlling preventable diseases in society," Lieber says. "Young people deserve to be protected against these diseases."
Reaction to the bills has varied. Evangelical groups have strongly criticized the proposed mandates. Focus on the Family says such measures would violate parents' rights, although the group adds that the vaccine should be available for those who want it. An editorial in the Washington Post said a mandatory vaccine would save lives, while a Wall Street Journal editorial in July labeled the proposals coercion.
It is too early to tell how many of the bills will be approved. In Maryland, the chief sponsor of an HPV bill that appeared to have strong legislative backing withdrew the bill last week following criticism from parents and groups opposed to the legislation. In California, the bill introduced by Lieber has not been assigned to a committee. Lieber's office says that several organizations, including the NAACP, have registered their support.
Nor is it clear how many parents would favor mandating the HPV vaccine, although many appear to want their daughters vaccinated. In a recent phone survey of 522 parents in California whose daughters would be eligible for the vaccine, UC Berkeley public health researchers found that 75% would probably opt for the vaccine.
Those who favor mandating the vaccine point out that cervical cancer will strike about 11,150 women in the U.S. this year and claim an estimated 3,670 lives. (Globally, it is the second most-common cancer among women, according to the World Health Organization.) In short, they say, the vaccine will save lives.
Critics of these legislative efforts have a broad range of reasons for their objections. Some say a compulsory vaccination would tread on the value of abstinence before marriage that they instill in their children. Others fear that the vaccine might encourage promiscuity if youth view the vaccine as a talisman against all sexually transmitted diseases. And some doubt vaccine safety, in general.
The debate highlights the balance between government's obligation to safeguard the health of its people and the rights of individuals to make their own decisions about matters affecting their health and their children's health.
All vaccine mandates pose this dilemma. But the question of an HPV vaccine presents more medical and ethical wrinkles.
"School-based laws began in the 19th century, at about the same time as mandatory education laws," says James Colgrove, a medical historian at the Columbia University Mailman School of Public Health who recently wrote an article for the New England Journal of Medicine about the ethics and politics of HPV vaccination. "People realized that schools were breeding grounds for illness."
Because HPV is not spread through the germ incubator of the classroom, a mandatory vaccine would lack that rationale. Further, for the first time, vaccination policies would affect only one gender. "With a compulsory HPV vaccination, we really are kind of getting into a different territory," Colgrove says.
The FDA approved the vaccine, Gardasil, in June 2006. An advisory committee to the Centers for Disease Control and Prevention recommended that girls receive the vaccine at ages 11 or 12, and that it be given to girls and women through age 26 who have not received it. The vaccine is most effective if given before a girl becomes sexually active. (Women who have been vaccinated should still undergo routine cervical cancer screening.)