We've got a shot against cancer. Will we take it?

Arthur Caplan, Ph.D. • E-mail

The announcement of a new vaccine to prevent cervical cancer is great news — the chance to save the lives of thousands of women each year. But it also creates some tough moral choices.

First, the vaccine is not cheap. Merck says the cost will probably be about $300. That raises three key questions: who to vaccinate, when and who will pay?

Every year cervical cancer kills about 3,700 American women. Cervical cancer is now known to be caused by a virus, the human papilloma virus (HPV), which is transmitted through intimate sexual activity. 

Both men and women carry the virus but obviously only women get cervical cancer. So the first priority from a public health point of view is to focus on vaccinating women.

One unknown is how long the new vaccine will protect against the nasty strains of HPV. The best estimate is five years.

This means the best time to vaccinate is just before women become sexually active. And that is why this new cervical cancer vaccine is sure to be ethically controversial.

Some conservative religious groups and family-values advocates believe that the best way to prevent any sexually transmitted disease is to teach young people to be abstinent until marriage. They don’t want HPV vaccine offered to young women because it will encourage, in their view, sexual promiscuity. Or they only want the vaccine discussed by parents not in schools or in the doctor’s office. But there is a big flaw in this reasoning.

Even though a woman may remain chaste until marriage she may marry someone who wasn’t.  She would still be at risk of infection. Given that risk, the case for getting schools, doctors, public health departments involved even if you are someone who wants to keep all talk of sex in the home starts to become very strong. 

Who decides?
That leads to the next big ethical question the new vaccine raises. If it is young women who can benefit the most from getting vaccinated, then should HPV vaccination be mandatory or voluntary. And should a young woman have the right to decide for herself if she wants the vaccine or should her parents decide? Or should everyone be involved? 

Pediatricians, other physicians, public health officials and nurses who provide medical care to teenage girls will now have to answer these questions. 

In most states, doctors are legally permitted to prescribe contraceptives to adolescent girls who specifically ask that their parents not be informed. Doctors are also legally permitted to treat sexually transmitted infections in teenage patients without their parents’ permission.  The rationale in both cases is the same. From a public health perspective, it is better for doctors to be able to help all sexually active teenagers prevent unwanted pregnancies and sexually transmitted infections, including those girls who would not seek medical care if parental permission was required. Shouldn’t we treat the new HPV vaccine the same way?  I think so.

Right now, doctors must have a parent’s consent to administer a vaccination. What should a doctor do when her 14-year-old patient whom she has been taking care of since she was a toddler comes for a visit without her mother and says she may become sexually active with her boyfriend? The best thing to do is to make sure the girl gets the vaccine. Legally, however, the doctor cannot administer HPV or any vaccine without a parent’s consent. Knowing what teenagers are like do we want to continue to insist that parental permission is always required when it comes to HPV vaccine? I don’t think so.

Suppose we can agree that every young woman should get vaccinated against HPV. And we might even agree that parental permission ought to be required unless the young woman seeks out the vaccine on her own and directly requests that her parents not be told.  One huge problem still remains. Who is going to pay for all these shots?

MORE FROM BREAKING BIOETHICS

Breaking Bioethics Section Front

Details, schmetails: Think big on health care Opinion: Did Steve Jobs’ wallet cut organ wait? Opinion: Court has the right to insist on chemo Do DNA patents spur science or stifle it? Both Opinion: Off-label meds bring unknown dangers Opinion: Superfood surprise? The dish on gene foods New IVF dilemmas make old fears seem quaint Opinion: Medical road trips not worth the cost Opinion: Save your hide — skip the tanning bed Opinion: 'Blade Runner' ruling subverts nature of sport Breaking Bioethics Section Front   Add Breaking Bioethics headlines to your news reader: