The ethics and politics of compulsory HPV vaccination.

n engl j med 355;23 www.nejm.org december 7, 2006 2389 to propose that vaccination be compulsory for girls entering sixth grade. Parents who objected would be able to opt out of the requirement under the same provisions that apply to other vaccinations. The bill passed the state senate by an overwhelming margin a week later and awaits consideration by the house. Other states are likely to follow Michigan’s lead. The development of Gardasil, Merck’s HPV vaccine, is of major public health importance. The vaccine protects against four strains of HPV, the most common sexually transmitted disease in the United States, including the two strains that cause most cases of cervical cancer. More than 6 million people in this country become infected with HPV every year, and nearly 10,000 women are diagnosed with cervical cancer. Because the vaccine has the greatest benefit when it is given before a person becomes sexually active, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommended that it be given routinely to girls at 11 or 12 years of age; it is not yet approved for use in boys. The committee took no position on whether vaccination should be required by law; such policy decisions are made by individual states. Moves to make the vaccine compulsory are sure to ignite a new round of polarizing debates. Controversy over the product began before it was licensed, when some religious conservatives expressed concern that the availability of a vaccine against a sexually transmitted disease would undermine abstinence-based prevention messages. Advocacy groups such as Focus on the Family ultimately came to support availability of the vaccine, but they remain opposed to mandating its use. In their view, such a requirement constitutes an attempt by the secular state to force a child to undergo an intervention that may be irreconcilable with her family’s religious values and beliefs. It is a mistake, however, to view the contrasting stances on HPV-vaccine mandates as solely, or even primarily, evidence of a conflict between science and religion. A more complicated dynamic will shape the ongoing discussion. On one side, support for legal The Ethics and Politics of Compulsory HPV Vaccination