How policymakers employ ethical frames to design and introduce new policies: the case of childhood vaccine mandates in Australia

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  • 1 University of Western Australia, , Australia
  • | 2 Oakland University, , USA
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Australian states exclude unvaccinated children from early education and care via ‘No Jab No Play’ policies, but some offer exemptions for the socially disadvantaged. Such mandatory vaccination policies provoke heated arguments about morality and potential downstream impacts, and the politics of which kinds of people get exempted from mandates are often fraught. Synthesising existing frameworks for considering the role of moral principles and rational-technical justifications in policymaking, we show how the same values can be the focus of both ‘rational-instrumental’ and ‘morality’ frames, while ‘pragmatic’ approaches are crowded out by high epistemic or moral certainty.

Abstract

Australian states exclude unvaccinated children from early education and care via ‘No Jab No Play’ policies, but some offer exemptions for the socially disadvantaged. Such mandatory vaccination policies provoke heated arguments about morality and potential downstream impacts, and the politics of which kinds of people get exempted from mandates are often fraught. Synthesising existing frameworks for considering the role of moral principles and rational-technical justifications in policymaking, we show how the same values can be the focus of both ‘rational-instrumental’ and ‘morality’ frames, while ‘pragmatic’ approaches are crowded out by high epistemic or moral certainty.

Introduction

In 2019, Western Australia became the third Australian state to introduce a ‘No Jab No Play’ (‘NJNPlay’) policy that excluded unvaccinated children from early education and care. A contemporaneous television report featured angry parents deprived of their ‘choice’ complaining that the policy was not ‘fair’. In an article for the state’s daily newspaper about the backlash to the programme, journalist Cathy O’Leary focused on the local Hughes family, whose newborn son Riley had once relied ‘on the goodwill and good sense of the wider community’ for his protection against disease. O’Leary detailed how Riley’s mother, Catherine Hughes, took to social media to echo concerns about children missing out on early education, but from a pro-vaccine point of view:

We wish we were able to buy [Riley] those tiny school uniforms… He doesn’t get the wonderful experience of kindy because he died from whooping cough before he was old enough to be vaccinated. There’s no choice for Riley and other children like him. Children in childcare deserve to be protected from serious, deadly and preventable disease. (O’Leary, 2019)

This vignette demonstrates the capacity for vaccination policy to impact the lives of individuals, to prompt political action, and to motivate diverse ethical arguments.

Ethics values are involved in all significant policy debates: people argue for or against policies because they believe that those policies promote or undermine important goals. However, Bacchi (2007) notes that policy scholars tend to explicitly address ethical considerations only when (putative) moral violations or moral obligations are at the centre of the policies under consideration. In other cases, scholarship tends to focus on whether and how particular policy instruments can advance goals, rather than on whether and why the goals are worth pursuing, or are worth pursuing at the costs that the policies impose. This focus on instruments rather than goals may obscure much of what is ethically significant in public policy debates.

Some scholars argue that some kinds of policies address ethical goals, obligations and prohibitions directly (Glick and Hutchinson, 1999; Permoser, 2019). Burlone and Richmond (2018) define ‘morality policies’ as addressing issues of first principle (hence not being about instrumental policy impacts), possessing technical simplicity, and being highly salient. Such policies respond to deep cultural cleavages surrounding fundamental ethical obligations or prohibitions (for example, abortion, gay rights, assisted dying) and are often privy to conscience votes (Bacchi, 2007; Permoser, 2019). But it is also possible to consider ‘morality’ as pertaining to framing, rather than to specific policy types. Mucciaroni (2011) and others (Burlone and Richmond, 2018; Burlone, 2020) focus on ways that agents frame values in their descriptions and evaluations of policies. Agents may place direct concern about moral behaviour or ethical outcomes at the centre of their advocacy. However, they may also utilise a ‘rational-instrumental’ frame that focuses on how the policy promotes broader ethical goals. Burlone and Richmond (2018) offer the example of positions on drug policies, which may either start from the first principles that drug use is immoral, or from a rational-instrumental frame of drug use as a public health problem (pp 318–19). We agree that this focus on framing better captures important distinctions between different kinds of ethics-engaged policymaking. The question of whether a particular policy debate is about morality or about the rational-instrumental promotion of ethical values depends not on facts about the policies themselves, but on the motivations, commitments, and statements of agents involved. Both ‘morality’ and ‘rational instrumentalist’ frames orient policy discussions around the pursuit of moral goals. But the former conceives of policies directly promoting morally right behaviours or morally good outcomes, while the latter conceives of policies acting as instruments that promote the right or the good in less direct ways.

Other public policy scholars have noted a distinction between two ideal types of approaches to crisis management: principled and pragmatic policymaking (see Ansell and Boin 2019; Boin and Lodge, 2021a and Boin and Lodge 2021b). Boin and Lodge distinguish between policy approaches that ‘adopt a single guiding principle’ (2021a: 1132) (the ‘principled approach’); and policy approaches that acknowledge uncertainty about likely outcomes or how various values may be implicated, but that conceive of policymaking as a kind of practical experimentation, subject to recalibration based on an approach’s success (the ‘pragmatic approach’). This distinction has been particularly useful for comparing governments’ approach to the ­COVID-19 pandemic. Some governments have approached the crisis with the intention of prioritising a single value and have therefore adopted a principled position (to either stay open to protect the economy, or to pursue public health restrictions and shutdowns to save lives). Others have refused to privilege a single value, navigating uncertainty by experimenting with various strategies. Boin and Lodge (2021a) suggest that the Netherlands and Germany employed a pragmatic approach to the first wave of COVID-19, initially attempting to remain ‘open’ before pivoting to soft lockdown and closures.

We can illustrate the relationship between these two distinctions (‘morality versus rational-instrumental frames’ and ‘principled versus pragmatic approaches’) by way of a two-by-two matrix (see Figure 1.) On the x-axis, with respect to values promotion, we apply the typology based on Burlone and Richmond (2018). A morality frame promotes values directly, generating obligations or prohibitions about what is to be done. Frames that instead draw upon values indirectly in promoting broader goals are rational-instrumentalist: they employ arguments about downstream effects, mobilising scientific or social science evidence or incorporating utilitarian reasoning.

Figure 1: The figure shows a two-by-two table and asks how the policy promotes values on the horizontal axis – directly or indirectly. It asks our degree of certainty about how the policy promotes values on the vertical access – high or low. The categories that sit within the table are explained within the text of the article itself so are not further explicated here.
Figure 1:

Conceptualising value promotion in policymaking

Citation: Policy & Politics 2022; 10.1332/030557321X16476002878591

The crisis management work of Boin and Lodge (2021a) pushes our categorisation into a second dimension by bringing in uncertainty as a variable, which we introduce on the vertical axis. Morality politics and rational-instrumentalist approaches both rely on a high level of certainty: we either know the single value that we wish to promote and seek to intervene on it in a direct way (morality politics), or else we rely upon existing data and utilitarian reasoning to achieve goals through policy instruments (rational-instrumental). But in a crisis context, we often possess insufficient knowledge about how to use policy to promote the goals we care about. Hence a ‘pragmatic’ approach emphasises experimentation, contingency and ongoing re-evaluation in the face of rapidly developing social, economic and political contexts. This is therefore a means for attempting to indirectly promote values through policies when one lacks good information about how policies will promote the values one cares about.

So if we now draw our attention to the distinction between the frames on the right-hand side of the figure, both rational-instrumental frames and pragmatic frames address the ways policies indirectly promote values. But they are distinguishable from each other by the degree of certainty they can mobilise regarding whether or how the policy will promote or undermine a particular value. In a setting of low epistemic certainty (such as a crisis), pragmatic frames help policymakers to navigate incomplete knowledge with humility by exploring policy options through trial and error. By contrast, rational-instrumentalist frames can draw upon high levels of knowledge and certainty about cause and effect of policies.

In contrast, Boin and Lodge’s (2021a) ‘principled position’ expresses confidence about the right thing to do, even when there is a great deal of uncertainty about the downstream effects. The moral certainty of this ‘principlism’ indicates that you can be certain about the right policies – even if you cannot be certain about their indirect effects – if your preferred policy interacts with the relevant values directly. (‘Regardless of what else we may not know, we do know that we should never do X or must always do Y.’) Accordingly, principlism is a morality frame and sits on the left side of our matrix.

Finally, it is not possible to directly promote a value through a particular policy while also being uncertain about the correct policy choice. To claim that a policy directly promotes a value is to say that it is intrinsic to the policy that it promotes the value, regardless of further outcomes. But if it is intrinsic to a policy that it promotes a value, then this requires certainty that the policy indeed promotes the value. Therefore the lower-left cell is populated by an empty set.

We can make a further distinction in how policymakers frame their advocacy or criticism of policies in terms of the groups for whom the relevant values are promoted or undermined. In particular, we can distinguish between policy takers (the policy targets) and society at large (Capano and Howlett, 2020).

This article applies these concepts to recent revisions to childhood vaccine mandate policies in Australia. The deliberate delay or refusal of childhood vaccines has received considerable attention in recent years (World Health Organisation, 2019), and the threat vaccine refusal poses fits the the definition of a ‘creeping crisis’ (Boin et al, 2020) in that it puts at risk ‘widely shared societal values or life-sustaining systems’ (p. 122). When community vaccination rates are high, immunisation policy achieves community protection (‘herd immunity’), which prevents the spread of disease to vulnerable individuals, such as newborn babies or the immune-compromised. This collective good is threatened when not enough people vaccinate, hence the appeal of more coercive policies in the form of childhood vaccine mandates.

Compared to Boin and Lodge’s (2021a) examination of crisis responses to COVID-19, the creeping crisis of childhood vaccine refusal permits higher levels of epistemic and moral certainty. The diseases involved are ones we have faced before, and we have locally eliminated or heavily controlled them through available technologies (vaccinations) and effective government policies (state-run mass vaccination programmes, sometimes underpinned by mandates). Furthermore, medical experts are well aware of the safety and efficacy of the vaccines, and social scientists have robust knowledge about the effects of different kinds of coercive pro-vaccine interventions, both from historical cases and international comparisons (Omer et al, 2019). Our communities’ long histories with routine childhood vaccines also encourage a high degree of certainty in most people’s judgements about both the morality of vaccination and vaccine refusal, but also about using coercion to promote immunisation. Accordingly, we would expect most policymakers to approach mandates for routine childhood vaccines from one of the two positions in the top row of our matrix (morality or rational-instrumental frames), because we anticipate higher levels of epistemic and moral certainty about such policies compared to policies responding to the COVID-19 pandemic, which presented new kinds of problems and created the possibility for novel kinds of policies.

There is another related factor, which is the impact of politicisation and what this means for pragmatic approaches. Vaccine policy has, with respect to the mobilisation of coercion, loitered in the bottom right quadrant in many countries for many years. There has been epistemic certainty about the benefits of vaccination itself, but moral and epistemic uncertainty about coercing non-compliers to participate. (Is it the right thing to do? And will it generate unintended consequences that undermine vaccination programmes?) Hence, for a long time it has been possible – and even preferred – to take a pragmatic approach using public funding, social norms, behavioural insights ‘nudges’, and even mandates with opt-outs to encourage high uptake of vaccines. For example, several American states made vaccine exemptions for personal belief more difficult to access in the last decade without eliminating them entirely (Lillvis et al, 2014).

Once political elites and populations become highly concerned about childhood vaccine refusal, as has recently occurred in Australia, France, Italy and California, moral and epistemic certainty increase regarding the benefits of making vaccination policy more coercive, and public discourse starts to articulate this as something that should happen. While the contributing factors to this phenomenon are beyond the scope of this article (see Attwell and Hannah, 2022), the effect of this increased certainty is the ‘crowding out’ of the pragmatic status quo. When restrictive mandates enter consideration in a jurisdiction, policymakers must now argue for or against their imposition, and draw upon either morality or rational-instrumental frames to do so. And if the existing policy is less ‘harsh’ on vaccine refusers than what is being proposed, then sticking with the pragmatic status quo of more gentle experimentation (as per what US states were doing) becomes problematic, since retaining space for vaccine refusal now looks like being ‘soft’ on vaccine refusal.

We can compare this to the ‘principled’ position regarding keeping the economy open that Boin and Lodge (2021a) explore with regard to COVID-19 pandemic crisis responses. An open economy is the default – it’s what we were doing before the pandemic hit. But in a context of crisis, adherence to this default position becomes a moral stand about the priority of economic functioning, compared to the (new) alternative moral position of saving lives through public health measures. In the context of childhood vaccine refusal, then, a politicised flare-up of the ‘creeping crisis’ can make existing pragmatic approaches less tenable, since (unlike with COVID-19) policymakers can claim to ‘know’ what should (morally) be done and the likely effects if actions are or are not taken.

We explore the relationship between pragmatic, rational-instrumental and morality approaches by analysing interviews with Australian policymakers involved in introducing state mandatory childhood vaccination policies. We identify and categorise the arguments they make for and against NJNPlay laws and their exemption components, looking at the frames they invoke and the groups to whom they apply these frames. In the case of childhood vaccine mandates, the focus of policy frames may be the policy takers, that is, the families whose children are not vaccinated (including recalcitrant parents who are deliberately not vaccinating their children) and by extension those children themselves. But policymakers may also invoke society at large as they frame vaccination policies: a range of other actors who may be in close proximity or very distant from the policy’s consequences, including other children attending childcare centres, parents, taxpayers and other fellow citizens.

We begin by introducing vaccination social science and applied ethics literature about mandatory childhood vaccination, since these sources provide many of the morality frames we would anticipate in policymakers’ accounts. Next, we introduce the mandatory policies employed in Australian states, before offering our substantive analysis and discussion.

Childhood vaccine mandates: a primer

Many governments have historically used mandates to ensure uptake of childhood vaccines (Gravagna et al, 2020), and more recently some have sought to optimise these instruments with what we might regard as a ‘pragmatic’ approach, for example, by tinkering with nonmedical exemptions policies or imposing moderate burdens on vaccine refusers. But some jurisdictions have recently sought to introduce or modify existing mandates to make them more restrictive (even coercive), to reach higher rates of vaccination coverage (Attwell et al, 2018a).

Ethicists have identified several moral reasons for governments to encourage or coerce vaccination in this way. Parents who do not vaccinate their children may place them at unacceptably high risk of harm (Bester, 2018), impose risks of infection on others (Navin, 2013), and fail to contribute to community protection (van den Hoven, 2012). Similarly, vaccine mandates protect the unvaccinated child (Pierik, 2018), prevent harm to others (Flanigan, 2014), protect the community (Pierik, 2017), and promote fair contributions to community protection (Giubilini, 2019).

Critics argue that parents might be better placed than the state to make decisions for their children (Navin, 2016), that liberty generally ought to be prioritised (Navin and Largent, 2017), and that mandates unjustly punish children for their parents’ decisions (Leask and Danchin, 2017). The design of mandates may produce iniquitous experiences, as wealthier parents escape being governed by such policies because they can weather financial losses or pay for alternative models of childcare (Leask and Danchin, 2017).

The applied ethics literature about vaccination and vaccine mandates is often abstract – it is usually detached from particular policies in specific locations (Navin and Attwell, 2019) – but we can nonetheless categorise some of the arguments in this literature using the distinction between ‘morality’ and ‘rational-instrumentalist’ frames (Burlone and Richmond, 2018).

Advocates of vaccine mandates appeal to morality frames when they invoke children’s rights to be vaccinated, other people’s rights not to be infected by unvaccinated children, or everyone’s duty to make a fair contribution to community protection. These are morality frames because the mandates are supposed to protect those rights or duties in a direct manner. Advocates use rational-instrumentalist frames when they invoke the indirect benefits associated with individual and community protection from disease, for example, greater economic growth. Some of these frames apply to policy takers, whereas others apply to the population at large.

In contrast, critics of vaccine mandates use morality frames when they invoke parental rights or children’s rights to access childcare and school. Again, these are morality frames because they point to the direct impact of the policy on those rights. And critics use rational-instrumentalist frames when they appeal to how mandates may contribute indirectly to long-term bad consequences for families and to declining trust in public health. Again, some of these frames apply to policy takers, while others apply to the population at large. (For example, we all suffer if distrustful anti-vaccine parents double down and become more committed to spreading misinformation, thereby generating more vaccine refusers).

Australia’s mandatory vaccination policies

Both the federal government and most Australian states have recently imposed restrictive vaccine mandates on Australian children. Federal financial assistance to families has been conditional on children being vaccinated since 1998 (Ward et al, 2013), but until recently parents were able to opt out with a Conscientious Objection form. In 2014, the government of New South Wales (NSW) introduced a vaccination requirement for childcare, but Conscientious Objectors could still enrol. In 2016, the federal government abolished Conscientious Objections (‘No Jab, No Pay’), and the state of Victoria introduced a vaccination requirement for childcare and early learning. The state of Queensland implemented an unusual policy enabling but not requiring childcare providers to exclude unvaccinated children. In 2018, NSW abolished its own Conscientious Objection and in 2019 Western Australia (WA) introduced a similar requirement to that of Victoria.

Thus, in the space of three years, three states imposed serious consequences on vaccine-refusing families linked to enrolment in childcare and early education, and an additional state (Queensland) made these consequences discretionary. Following our study, South Australia introduced its own policy.

Excluding Queensland, all of these ‘NJNPlay’ policies require children enrolling in early education and care to be fully vaccinated. Apart from the new South Australian policy, the policies did not remove children who were already enrolled, and do not exclude those who cease vaccinating after admittance. Medical exemptions are granted by the Commonwealth, and some states provide additional exemptions. Victoria and WA, whose policies were introduced by centre-left Labor governments, instituted exemptions for children who fit broad markers of economic disadvantage. NSW, governed by a centre-right Coalition government, utilises narrower markers of disadvantage; the new South Australian policy (also introduced by a Coalition government) initially had no exemptions; some were later added by bureaucrats.

Materials and methods

We compiled accounts of the development and implementation of NJNPlay in NSW, Victoria, Queensland and WA from academic publications, grey literature, policy documents, news reports and Hansards (transcriptions of parliamentary debates and committee meetings or hearings). All states with active childhood vaccine mandates at the time were included based on a most similar case study design as part of a larger research project. Two complementary motivations informed this larger study design. We sought to understand local variations – for this article, that meant considering the role of party-political ideology for elected officials involved in policy design, since party ideologies contain moral obligations and prohibitions. We also sought to build a general dataset of the attitudes and perspectives of individuals involved in designing policies of this type so that we could better understand cross-cutting issues, such as whether and how morality, rational-instrumentalist or pragmatic frames were employed.

The first author interviewed 31 current and former politicians, senior Health and Education bureaucrats, industry stakeholders, and academic and technical experts who were involved in introducing Australia’s first four state mandatory policies, had input into their design, or held special technical knowledge of processes and considerations. We asked a series of questions tailored for the participant’s specific role, including how they participated in the policy change, the reasons behind the change and their perspective on it, what data and beliefs the change based on, why the policy was designed the way it was, whether the participant perceived a tension in using early education to enforce vaccination compliance, and how exemptions should operate.

Participants were broadly split across the four states and across types of actor. Approximately a third were party-political actors from across the spectrum who had shaped their state’s policy, including from opposition. Table 1 lists participants and their roles. Following ethical approval under permit 2019/RA/4/20/5003, the first author recruited through her expert connections, publicly available information and snowballing. All participants provided informed consent and could elect anonymity, which most bureaucrats accepted, and most politicians refused. Given the small number of relevant bureaucrats in each state, we report their state and role only when required.

Table 1:

Interviewees All roles were current at time of interview, so “former” indicates the participant was no longer in that position at the time

NAMETitle/RoleState
Jillian SkinnerFormer Minister for Heath, NSW Liberal PartyNew South Wales
John RobertsonFormer Leader/Opposition Leader, NSW Labor PartyNew South Wales
Kerry ChantNew South Wales Chief Health OfficerNew South Wales
ANONYMOUSEducation BureaucratNew South Wales
ANONYMOUSEducation BureaucratNew South Wales
ANONYMOUSEducation BureaucratNew South Wales
ANONYMOUSSenior Health BureaucratNew South Wales
Claire HarveyDeputy Editor of the Sunday TelegraphNew South Wales
ANONYMOUSChildcare Peak Body RepresentativeQueensland
Jeannette YoungChief Health OfficerQueensland
Lisa McCoySenior Bureaucrat, Department of EducationQueensland
ANONYMOUSSenior Health BureaucratQueensland
Paul van BuynderPublic Heath Unit BureaucratQueensland
ANONYMOUSLabor Government Senior Policy AdvisorQueensland
ANONYMOUSEducation BureaucratVictoria
Nina SpringleFormer Member of Parliament, Victorian GreensVictoria
ANONYMOUSEducation BureaucratVictoria
ANONYMOUSSenior Health BureaucratVictoria
ANONYMOUSPublic Health BureaucratVictoria
ANONYMOUSChildcare Peak Body RepresentativeVictoria
Mary WooldridgeMember of State Parliament, Victorian Liberal PartyVictoria
ANONYMOUSChildcare Peak Body RepresentativeVictoria
ANONYMOUSSenior Education BureaucratVictoria
ANONYMOUSSenior Health BureaucratWestern Australia
ANONYMOUSHealth BureaucratWestern Australia
Alison XamonMember of State Parliament, West Australian GreensWestern Australia
Martin AldridgeMember of State Parliament, West Australian NationalsWestern Australia
Aaron StonehouseMember of State Parliament, Liberal DemocratsWestern Australia
ANONYMOUSBureaucrat, Department of CommunitiesWestern Australia
ANONYMOUSLabor Government Senior Policy AdvisorWestern Australia
ANONYMOUSVaccination Policy ExpertWITHHELD

Interviews were conducted face-to-face between April and December 2019, with a handful via Zoom. Interviews were professionally transcribed in full, and initially coded by the first author using NVivo 12. In Victoria, we were not able to interview the party in government; we instead analysed a comprehensive letter that the Minister sent to an academic who shared it with us, as the letter addressed several of our research questions. The second author read all material coded as pertaining to values and ethics, and both authors collaboratively refined the coding matrix. The first author then recoded the data and drafted the findings, also drawing on the documentary analysis. Both authors then interpreted the findings through the categories on the two-by-two table, as reported later in the article.

Results and analysis

We present a thematic account of the frames employed by policymakers to support or oppose vaccine mandates and exemption policies, beginning with participants’ overall approach to mandates, in which their promotion of values is framed from the point of view of broader society. We then explore the anticipated impact on policy takers through the design and operation of vaccine exemptions, since it is here that ethical objections are often raised. Throughout our analysis, we categorise when and how policymakers use morality or rational-instrumental frames. We also identify and consider their usage of pragmatic frames in light of our hypothesis that such frames become crowded out by moral and epistemic certainty about the benefits or costs of vaccination and/or mandates.

Vaccination is good and mandates boost rates

We noted in the introduction that there is high moral and epistemic certainty about vaccination as a practice; this was reinforced by our data. While participants invoked diverse motivations regarding vaccine mandates, almost all expressed a desire to increase vaccine coverage rates to benefit society at large. Policy actors generally imbued coverage rates and herd immunity with intrinsic benefits that largely remained unspoken. Herd immunity and high immunisation rates are also instruments for broader social goals (for example, reducing death and disease), but our policy actors often spoke of these phenomena as if they were the goals in themselves.

‘My position is… pro-immunisation and we need to strongly look at how to… get our numbers up and how to get to herd immunity levels.’ (Senior Policy Advisor)

As reflected in this comment, many participants depicted support for mandates as support for immunisation, demonstrating the bleed between epistemic certainty about vaccination and epistemic certainty about the merits of mandating it.

The rational-instrumental frame of ‘coverage-as-goal’ also, however, dovetailed with a morality frame of siding with science over what a policy expert described as ‘anti-vaccination activists and the loud, angry, abusive people online …[who] have helped to create the framing of these people being bad and deviant’. Victorian MP Mary Woolridge concurred with the moral view that ‘there was no sympathy for the conscientious objectors’, but also advanced the rational-instrumental frame linking vaccination to mandates: ‘immunisation is critical and we need to support it’.

This broad support for – and connection between – high vaccination rates and mandatory policies linked to a predominant belief among policymakers in all states. They regarded a substantial component of the under-vaccination problem to result from complacency and busy-ness, or to occur among what a senior health bureaucrat called the ‘logistically challenged’. Informants repeatedly told us that the purpose of their state’s policies was to increase vaccination rates across the population (thereby delivering benefits to the entire population), predominantly by cuing these families to get up to date with their immunisations.

There are, however, punitive aspects to these policies: children of committed vaccine refusers are excluded from childcare and early education. On this topic, informants again repeatedly told us that they and other policymakers did not expect the mandate to bring these policy takers around to vaccinating. ‘Vehement anti-vaxxers will find an alternative pathway that includes personalised daycare outside of formal systems, or whatever else’, a senior health bureaucrat explained, adding that he was ‘not concerned’ about that group ultimately remaining unvaccinated due to its tiny size.

These broad points illuminate three connected considerations underpinning how policymakers framed the ethics of vaccine mandates in Australian states.

  1. High vaccine coverage rates are the goal (they benefit the population at large).

  2. Mandate policies cue the complacent or ‘logistically challenged’ policy taker to vaccinate, thus helping to push coverage rates higher.

  3. Mandates are not expected to make refusers vaccinate, but these policy takers will nevertheless face consequences.

Three broad ethical problems

Our informants paid close attention to the potential downsides of ‘NJNPlay’ policies for policy takers, including those families who were unvaccinated by choice. Ethical considerations pertained to three broad areas, which included 1) concerns about all unvaccinated children’s access to early education, 2) special concern for socially disadvantaged children’s access to early education, and 3) some parents’ (lack of) choice with regard to vaccination, and the associated costs for those who still chose to not vaccinate. We unpack these issues thematically, as we can best demonstrate how policymakers employ multiple and competing frames when we connect those frames to policy details.

1. The importance of early childhood education and care

Almost all participants raised the importance of early childhood education, employing a rational-instrumentalist frame that focused on children’s future educational success and well-being. Victorian participants also described formal policies on inclusion, which some acknowledged were in open conflict with mandates that would exclude unvaccinated children.

Participants in all states were at pains to recognise early education as education (and, therefore, a means for promoting other goods) and not merely as care (which may have value merely for itself).

[I]t’s not crèche, it’s not babysitting. It’s actually education. (Nina Springle, former Greens MP, Victoria)

A senior health bureaucrat claimed that excluding children from early education was not simply going to be ‘inconvenient – Grandma has to watch the kid’, but there would be important downstream costs.

It’s like, no, this child might not do as well in first or second grade, which might then give them a label as a poor performing student, or even in their own mind, and set a trajectory that didn’t have to be that way if we weren’t so concerned about their vaccination status when they enrolled.

His rational-instrumentalist framing continued through his elaboration of further downstream consequences.

I mean, it was a profound thing for me to find this report from Australia about the benefit of early education services. Something to the effect of: there can be little doubt about the benefits of early education services on achievement in the first years of school.… And if you’re talking about societal change over generations, you certainly don’t want to disenfranchise people from achieving educationally… [I]t made me realise this isn’t just childcare going on, right, which is important ’cause parents gotta work and kids get socialized. This is about potentially denying children opportunities that could make their lives different down the road.

A subset of participants highlighted the impact of the denial of care on parents’ – and specifically mothers’ – workforce participation. (So, even when denial of care was discussed, it was within a rational-instrumentalist frame.) A Labor Party official who had been instrumental in designing Queensland’s ‘optional’ mandate cited workforce participation for mothers and single mothers as reasons to eschew a restrictive mandate that would compel organisations to exclude unvaccinated children. Victorian Greens MP Nina Springle also expressed concern for single mothers, while the state bureaucrat quoted earlier saw parents leaving the workforce as contributing to worse outcomes for children’s futures.

The biggest predictor of your health long term is your socioeconomic status. All over the world, you know, that’s what matters in the long term on average, and so we would not want to systematically make it harder for single mums or struggling families be able to get employed and work full time.

For many participants, bad outcomes for vulnerable and disadvantaged families were more important than the consequences that vaccine refusing families might face, justifying the exemptions we examine in the next section. However, a minority claimed that all children had a right to early childhood education. This invoked a morality frame, focusing directly on what government ought (not) to do, rather than on how we might indirectly best promote overall good outcomes.

[E]arly childhood education, in my opinion, should be treated as a right, not a privilege. So the idea that you… you shouldn’t privilege health over education, you need both. (Alison Xamon, Greens MP, WA)

There was also a repeated critique that, in denying the children of vaccine refusers access to early education, the government was wrongfully punishing them for their parents’ actions. This exact line – again invoking a morality frame of the rightness or wrongness of individual actions – was used by several respondents, even if they ultimately supported the policy excluding such children.

2. Early education for socially disadvantaged children – the importance of exemptions

The Labor Health Minister of Victoria explained a concern that was common to many participants, that is, the special importance of early childhood education for socially disadvantaged children and the need for exemption categories aimed at protecting such children:

The Victorian Government recognises the benefits of participation in early childhood education and care, particularly for vulnerable and disadvantaged children. The No Jab, No Play legislation recognises this by including a ‘grace period’ provision, where vulnerable children can be enrolled even if their immunisations are not up to date. (Jill Hennessy, personal communication, 29 October 2015, emphasis added)

Concern for disadvantaged children also informed local policy actors’ reticence to make Queensland’s discretionary mandate binding. Childcare peak bodies and bureaucrats there were reluctant to apply blanket exclusions that would have an impact on vulnerable children, particularly because childcare is a way that such children can remain visible to and engaged with state authorities who can apply oversight to their care at home. A senior policy advisor explained that due its underfunded public health system, ‘Queensland does not have the same level of effective community maternal and infant health services’ as other states. Vaccine access issues could be particularly detrimental for families with no exemptions for disadvantaged children included in the state’s policy model. Thus, making exclusions optional for institutional operators was an alternative way of ensuring that people on the ground could consider a family’s broader position as context for their vaccination status.

In contrast to the Queensland model, the other three states’ binding mandatory policies permit specific categories of children to enrol even if they are not fully vaccinated. Participants’ support for extending exemptions to vulnerable children usually followed a rational-instrumentalist frame, citing data about the importance of early childhood education for promoting the long-term interests of disadvantaged children.

You’ll see some articles in [newspaper] this morning talking about the need for early intervention with our most vulnerable children. And it’s no good intervening at high school, and it’s no good intervening at primary school. It has to be earlier. That’s when the intervention should happen, and that will give children the best possible chance in life in those systems. (Education Bureaucrat)

All interviews addressed the distinction between children who are under-vaccinated for reasons of disadvantage or systemic injustice, and those who are unvaccinated because of parental refusal (Bedford et al, 2018). That disadvantaged children were not intended to be excluded from care and education under ‘NJNPlay’ policies was already implicit in the exemption categories some states introduced, but was also sometimes made explicit by interviewees:

They’re also the families and the demographics that actually need the education most. (Nina Springle, former Greens MP,  Victoria)

Almost all participants identified a disadvantaged child’s access to education as being more valuable than their vaccination status.

I’m glad that people with Healthcare Cards, who are most likely to come from a lower socioeconomic background… are also not gonna be denied early childhood education [because they can get an exemption]. If you did that, you would be well and truly ensuring that you could entrench generational disadvantage. What a terrible outcome that would be. (Alison Xamon, Greens MP, WA)

We don’t want the policy to be causing children to be further disengaged from early childhood education. That objective has been something that we’ve wanted to keep front of mind, and to enshrine. That the policy can both increase immunisation, while keeping young children engaged in their early childhood education, particularly for those that are most vulnerable. (Senior Education Bureaucrat)

Yes, we want them vaccinated, but I think we’re recognising children in circumstances that… are experiencing social disadvantage and, yeah, it’s better to get them at school, at kindy, than not. (Health Bureaucrat)

If I look holistically at the needs of the individual, someone who’s vulnerable and… education stands as a significant issue then, you know, I think we had to be pragmatic in terms of finding a way to not do harm to those people. (Senior Policy Advisor)

In the discussions outlined earlier, there was a dominant rational-instrumentalist framing of education as important for disadvantaged children’s well-being, but also a suggestion that it was intrinsically morally wrong to promote public health by (potentially) harming disadvantaged children. The problem was not just that denying access to early education compounds such children’s disadvantage, but also that hurting the vulnerable violates an absolute moral prohibition: These children are among the protected classes whose interests left-leaning politics aims to prioritise and whose violation can never be tolerated. (Two of these quotes are from public health bureaucrats – a profession with left-leaning tendencies – and two are from politicians from left-of-centre political parties.)

Some participants went so far as to apply an ‘educational rights’ language exclusively to these policy takers. The state of Victoria applies a Charter of Human Rights and Responsibilities to all new legislation by way of a formal review. A senior health bureaucrat explained that the Charter:

accepts that there are vulnerable groups who can be disadvantaged in a public space, and you have to make special effort sometimes to ensure that they’ve got an equitable access to support. And in this case, it’s support to make sure that you’re not losing your right to education. (Our emphasis)

This bureaucrat’s framing of education as a right appeared only in the context of social disadvantage; he supported excluding children who were unvaccinated by choice.

Although there was generally broad consensus about the merits of exempting disadvantaged children from being excluded from education and care, politicians from the political right disagreed. Their reasons become clearer when we recognise that the worries about compounding social disadvantage described earlier can be both rational-instrumentalist and morality-invoking. From the point of view of the Australian political right, broader social goals include equal treatment under the law, without special provisions for disadvantaged persons. So, a rational-instrumentalist frame for discussing mandates among members of this political constituency tends to be sceptical of special exemptions, and focuses instead on broad-based efforts to promote public health for the wider community, which mandates (without exemptions) can achieve. However, at the same time, rejecting special treatment for disadvantaged persons may be a part of a morality frame that conservative politicians see as benefiting society at large. They may hold absolute objections to violations of formal equality, even in the name of substantive equity.

The political right in Labor-governed states with wider classes of exemption (Victoria and WA) has been quite preoccupied with the idea that exemptions might be exploited by refusers, or that the policy’s benefits might be undermined by allowing too many exemptions. (The former frame speaks to the morality politics of fairness or avoiding cheating, while the latter invokes a rational-instrumentalist frame of effectiveness. Both invoke threats to the community at large.) Former Victorian Shadow Health Minister Mary Woolridge criticised broad exemptions as creating a ‘back door [to enrolment] of a much wider group’. In 2018, her party failed to pass an amendment to utilise ‘much narrower markers of disadvantage’. Throughout the Victorian parliamentary debates and during our interview, Woolridge maintained a forensic focus on impact, emphasising data and numbers, expressing frustration that the so-called grace period was actually a permanent exemption, and highlighting the risk of potential abuse of exemption categories by refusers (Parliament of Victoria, 2018).

In WA, Liberal Democrat Aaron Stonehouse held the balance of power in the Legislative Council (Upper House), giving him influence beyond his party’s relative representation. Stonehouse ultimately supported NJNPlay, but employed a morality frame focused on broader society to resist the categorisation that the exemptions enacted.

I don’t like the idea of sort of singling out specific groups… everybody should be treated equally under the law. And so I don’t like the idea of, you know, one special class of people are a special protected class, and they should get special rights, while everybody else is treated differently.… So I dislike sort of racist policies in that sense, but I also dislike sort of, you know, well, you know, you tick certain intersectional boxes, therefore you get some special privilege…. I’d rather just everybody treated equally.

In framing special exemption categories for disadvantaged persons as ‘racist’, Stonehouse clearly invokes a morality frame.

However, focusing now on all participants and ‘NJNPlay’ policies across the states, to the extent that the exemption policies offered (variable) protection to the early education access of disadvantaged children, the remaining issue was the question of vaccination choice for non-disadvantaged parents, and the appropriateness of constraining this choice for these policy takers.

The vexed question of choice and coercion (for some)

A minority of participants regarded their states’ policies as unjustly coercive of parents who did not want to vaccinate, invoking a morality frame about freedom. One bureaucrat said that making people vaccinate did not sit well with him. Libertarian MP Stonehouse was uncomfortable with ‘stick’ approaches because of his moral values. However, he also invoked a rational-instrumentalist frame about efficacy on policy takers, citing concern about ‘unintended consequences’ arising from governments using the ‘stick’ on a cohort of society who were already ‘don’t trust the government… or authority’. The risk was that the policy would ‘drive these people away further’.

Far-left WA Greens MP Alison Xamon also invoked rational-instrumental frames and morality frames focused on parental freedom, but she was one of the few participants who additionally advanced a pragmatic approach in her responses, attempting to circumvent the need for moral absolutism in vaccination policy. To the limited extent that participants advanced pragmatic approaches rather than purporting to draw on strong moral or technical certainty that the policy would achieve a goal, Xamon was definitely the most expressive. This, accompanied by her transparency about her personal and political motivations, enabled us to thoroughly analyse how she employed different frames.

Before we go into this further, however, we note that three other participants – fellow Green Nina Springle, a senior Health bureaucrat, and a senior policy advisor – also employed pragmatic frames for the policies which they were involved in designing. Specifically, all three reflected on the nuances and delicate balancing acts of the competing values and goals they were being asked to consider. All reflected upon the imperfect nature of government policies to reconcile and solve these problems. As actors who had not initiated their state’s policy but were nevertheless tasked with making it as optimal as they could, all were grappling with how to counterbalance competing needs, interests and goals.

Returning now to our closer analysis of Xamon, she described the importance of aligning to scientific evidence and not giving the public any reason to depict her as an anti-vax sympathiser. In Australia, pockets of vaccine refusal linked to alternative lifestyles have a ‘green left’ character (Attwell et al, 2018b; Smith et al, 2019). However, as the Australian Greens aspire to national political significance and as the population broadly supports vaccine mandates (Smith et al, 2019), the party has clear reasons to support ‘NJNPlay’ policies. Xamon, like most other interviewees, also believed that the policy would lift vaccination rates by motivating complacent policy takers, or those who had been impeded from accessing vaccinations by failings of the health system.

Xamon had been a ‘vaccine variator’, delaying some of her children’s vaccines. However, she ultimately felt compelled to support NJNPlay. She also wanted to protect parental choice, but her position led to a torrent of abusive messaging from some of her party’s supporters.

I have all the feels about how this legislation was handled, because those thoughtful and considered and loving parents who just wanted to be able to have some degree of choice… were completely drowned out by the abusive shrill conspiracy theorists, who then also decided to pile on against me as the only person in the entire parliament, in both Houses, who wanted to be able to maintain some degree of choice for parents.

Her concern about choice – as a fundamental and intrinsic value and right held by parents – invokes a morality frame. But like Stonehouse, Xamon also framed her worries using rational-instrumentalism, with concern about ‘unintended consequences’ of restricting parental choice.

Stonehouse and Xamon also used morality framing to represent that parents’ freedom to choose was valuable. The former argued that parents would have better intentions than ‘faceless bureaucrats’ who often failed children, while Xamon respected the ethic of care provided by parents

who were fully breastfeeding their children, who were raising their children with organic foods, and doing everything possible to try to maintain maximum health for their children, whilst being screamed at [for not vaccinating] by people who might be feeding their baby Diet Coke.

Xamon here seems to claim that parental freedom is instrumentally valuable for children’s well-being, especially if parents exercise freedom in the ways that her Green consistency often does. But, Xamon’s invocation of ‘good parents’ and ‘bad parents’ situates her commitment to parental freedom as part of a tribalistic culture war: non-vaccinating parents valiantly pursue wellness for their children, while it may be vaccinators who are neglectful and wrong (Attwell et al, 2018b).

Xamon additionally invoked a pragmatic approach couched in support for the earlier status quo of Australia’s non-coercive vaccination policies. Rather than embracing mandates and punishing vaccine refusers, government could have achieved its vaccine coverage goals via alternative means.

I think any government that chooses to go straight to coercive health measures before looking at every other evidence-based early intervention and prevention measure around public health is failing its citizens… It’s lazy public policy… And I keep coming back to the science around this. With herd immunity, the optimal vaccination rate is ninety five percent. I truly believe you could achieve that ninety five percent through other health measures, without resorting to coercive health measures.

Xamon’s claim that the goals of NJNPlay admitted of some ‘wiggle room’ – only needing to attain 95% coverage to protect herd immunity – informed her pragmatic reasoning regarding which kinds of exemptions should be available, and whether a personal belief exemption should have been included. Whether exemptions were right or wrong depended not on the goodness of vaccination or the value of parental liberty, but on whether the number of likely exemptions would be consistent with still achieving the goal of disease reduction. (Other informants also adopted this kind of frame for discussing exemptions, including the centre-right politician Mary Woolridge, who nevertheless fought hard to limit them.)

Xamon was ultimately concerned that parents who might want to delay vaccinating their children would be denied the choice to do so. Accordingly, she considered that exemptions based on disadvantage, while welcome, were also somewhat arbitrary, since exempted children might well be robust enough to be vaccinated and should be vaccinated. This critique echoed what other informants told us. That is, Xamon wanted exemptions to promote children’s well-being, rather than to be proffered as an immediate consequence of (some) parents’ rights or as a necessary response to social disadvantage.

This position, however, also fed directly into Xamon’s morally-framed concerns about choice inequity for the middle bracket of the population, who earned too much to be on a Healthcare Card (and hence be exempt) but were not wealthy elites whose resources could buy them other care options.

These people have no choice. The government has said: ‘No, we’re not gonna give you any choice over your kids. We’ll let people on a Healthcare Card or wealthy people have choice, but you can get stuffed.’ It’s shocking.

It should be noted here that while the Greens in Australia take a strong view on protecting the disadvantaged, their voters are wealthier and more privileged than average, meaning that Xamon’s moral framing – that special exemptions for disadvantaged children are unfair to the middle-class while the wealthy can find their own alternatives – is politically expedient, as well as connected to her own personal history.

Other participants were more comfortable with vaccine mandates offering no exemptions for personal beliefs, as all the state ‘NJNPlay’ policies have ultimately done. A senior bureaucrat drew a rational-instrumentalist distinction between ‘what you are free to do within your own private space with your own family’ and the risk of disease transmission in a public setting.

Labor Party affiliates in different states argued that governments needed to make decisions for majorities, not minorities. From one point of view, this invokes a rational-instrumentalist frame: what matters is the well-being of the broader public. But political majoritarianism may also express a morality frame, according to which politics should not track the views of deviants, but of the mainstream (utilitarianism).

We spend far too much time in politics dealing with minorities rather than majorities… You know, people talk about civil rights and all this sort of stuff. Well, what about the civil rights of the twenty-nine over the thirtieth? (John Robertson, former Labor opposition leader, NSW)

Claire Harvey, the deputy newspaper editor whose ‘No Jab No Play’ campaign in New South Wales initiated the cascade of state and federal policies, invoked morality framing to insist that ‘NJNPlay’ ultimately fell short of compulsion. ‘You’ve still got choice… I think people have the right to be conscientious objectors if they want to.’ However, people’s ‘rights’ should not be the only consideration for policy: ‘I just don’t think they should be rewarded for that choice… I don’t think that’s something government should accommodate.’

Discussion and conclusions

Our findings have implications for how public policy scholars engage with ethics and values in policymaking, as well as for the ‘growth area’ of vaccine mandate policies already advancing apace for COVID-19 vaccines (Attwell et al, 2021).

We sought to analyse and categorise how policymakers frame arguments about policy introduction and design in the case of state-level vaccine mandates in Australia. Synthesising prior work on ‘morality’ versus ‘rational-instrumental’ frames and crisis response analysis contrasting ‘principled’ and ‘pragmatic’ approaches, we advanced the following thesis. Frames that prioritise a specific moral value or a ‘principled’ position, as well as frames advancing rational-instrumental policy benefits, are likely to be employed when policymakers have high certainty about which values are going to be implicated, which value they want to advance, and how the policy will make that happen. When there is low certainty about any of these things, policymakers may instead follow a ‘pragmatic’ path that eschews privileging any particular value and experiments with a variety of responses. Childhood vaccination draws upon stable, settled science around which a range of coherent moral positions have developed; the benefits of early education are also widely known. As we explored policymakers’ framings on NJNPlay policies, we expected to find minimal pragmatism and plenty of moral and rational-instrumental framings.

We found the moral and rational-instrumental frames we expected to, on both sides of the debate, and even in pursuit of the same values. However, it was striking that participants usually spoke about the benefits of NJNPlay policies only through the rational-instrumental frame of increasing immunisation rates for the wider community.

By contrast, most of our subjects expressed their concerns about NJNPlay through both rational-instrumentalist and moral frames, addressing their arguments towards both policy takers and society at large. They reported particular concerns about children’s access to care and early education. This was sometimes given a morality frame, according to which children have a fundamental right to these goods, aligning with connected moral preferences to protect valued political constituencies or to not punish children. But it was also sometimes given a rational-instrumental frame informed by social science, such that children who do not receive high-quality early childhood education may risk lifelong negative consequences. Parental rights were also sometimes invoked in both kinds of frames, as was protection of the access to childcare and early education for disadvantaged groups.

Exemption policies in some states have sought to address some of these concerns. Participants often invoked morality frames in the discussion of these exemptions, but they frequently interwove rational-instrumental frames as well. Supporters of exemptions for disadvantaged families often used rational-instrumentalist frames emphasising children’s future well-being and morality frames focused on equity. However, exemption policies for economic disadvantage troubled right-leaning politicians, whose concerns drew upon rational-instrumentalist frames about undermining the policy’s effectiveness as well as moral opposition to intersectionality and the valorisation of formal equality under the law.

Moral concerns about parental autonomy and the state’s capacity to make the best decisions about children were raised by critics on both the left and the right. However, others suggested that NJNPlay mandates were consistent with parental liberty: parents could still refuse to vaccinate, and the public nature of childcare and educational institutions rendered vaccination a public, rather than a private matter. Similar reasoning is now ubiquitous for COVID-19 vaccine mandates for adults, especially for governments and publics already attuned to public policies designed to suppress disease transmission in public spaces (Attwell et al, 2021).

We found little evidence of pragmatic frames expressed in support for retaining the less or non-coercive state vaccination policies that preceded ‘NJNPlay’. A minority of our respondents did articulate nuances attempts to solve the complex problem of undervaccination without invoking overarching moral obligations or prohibitions. However, by and large they appeared compelled to grapple with the big question of supporting or opposing restrictive mandates, and then the similarly significant question of how to best set up exemptions to serve particular policy goals or moral ends. Moral and rational-technical frames dominated here.

Future work could consider how policymakers frame mandates for COVID-19 vaccinations. Unlike childhood vaccinations, there remain significant unknowns about the longer-term efficacy of these vaccines as individual immunity wanes, and against new strains. This reduces certainty about how effectively mandatory vaccination policies can promote particular values – perhaps we might see greater articulation of pragmatic frames here. Another research focus could involve examining why governments frame their vaccination policies in different ways. We have focused on the ‘how’ rather than the ‘why’ here, although we have suggested that policymakers’ certainty about how policies advance values is a key constraint. We know that vaccination policies, including mandates, are informed by path dependency (McCoy, 2019) as well as functional and political pressures (Attwell and Hannah, 2022). Future work exploring the moral frames used to justify vaccine mandates can examine more systematically the interplay between the historical policy legacies of past practices and contingent factors relating to crises.

Funding

Katie Attwell is a recipient of a Discovery Early Career Researcher Award funded by the Australian Research Council of the Australian Government (DE19000158). She leads the ‘Coronavax’ project which is funded by the Government of Western Australia. All funds were paid to her institution. Funders are not involved in the conceptualisation, design, data collection, analysis, decision to publish, or preparation of manuscripts.

Acknowledgements

The authors thank Shevaun Drislane for her research assistance, and Glenn Savage for his role in the Victorian interviews. Julie Lee, Vaille Dawson and Frank Beard provided welcome support. All participants are gratefully thanked for their time and input. The authors acknowledge the two anonymous reviewers whose comments on an earlier version of this article helped us to improve it.

Conflict of interest

Katie Attwell is a specialist advisor to the Australian Technical Advisory Group on Immunisation.

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    • Search Google Scholar
    • Export Citation
  • Attwell, K. and Hannah, A. (2022) Convergence on coercion: functional and political pressures as drivers of global childhood vaccine mandates, International Journal of Health Policy and Management, Forthcoming, doi: 10.34172/IJHPM.2022.6518.

    • Search Google Scholar
    • Export Citation
  • Attwell, K. and Navin, M.C. (2019) Childhood vaccination mandates: scope, sanctions, severity, selectivity, and salience, Milbank Quarterly, 97(4): 9781014. doi: 10.1111/1468-0009.12417

    • Search Google Scholar
    • Export Citation
  • Attwell, K., Navin, M.C., Lopalco, P., Jestin, C., Reiter, S. and Omer, S.B. (2018a) Recent vaccine mandates in the United States, Europe and Australia: a comparative study, Vaccine, 19(36): 737784.

    • Search Google Scholar
    • Export Citation
  • Attwell, K., Smith, D.T. and Ward, P.R. (2018b) ‘The Unhealthy Other’: how vaccine rejecting parents construct the vaccinating mainstream, Vaccine, 36(12): 162126. doi: 10.1016/j.vaccine.2018.01.076

    • Search Google Scholar
    • Export Citation
  • Attwell, K., Rizzi, M., McKenzie, L., Carlson, S.J., Roberts, L., Tomkinson, S. and Blyth, C. (2021) COVID-19 vaccine mandates: an Australian attitudinal study, Vaccine.

    • Search Google Scholar
    • Export Citation
  • Bacchi, C. (2007) The ethics of problem representation: widening the scope of ethical debate, Policy and Society, 26(3): 520. doi: 10.1016/S1449-4035(07)70112-1

    • Search Google Scholar
    • Export Citation
  • Bedford, H., Attwell, K., Danchin, M., Marshall, H., Corben, P. and Leask, J. (2018) Vaccine hesitancy, refusal and access barriers: the need for clarity in terminology, Vaccine, 36(44): 655658. doi: 10.1016/j.vaccine.2017.08.004

    • Search Google Scholar
    • Export Citation
  • Bester, J.C. (2018) Not a matter of parental choice but of social justice obligation: children are owed measles vaccination, Bioethics, 32(9): 61119. doi: 10.1111/bioe.12511

    • Search Google Scholar
    • Export Citation
  • Boin, A. and Lodge, M. (2021a) Responding to the COVID-19 crisis: a principled or pragmatist approach?, Journal of European Public Policy, 28(8): 113152. doi: 10.1080/13501763.2021.1942155

    • Search Google Scholar
    • Export Citation
  • Boin, A. and Lodge, M. (2021b) The attractions and limitations of pragmatist crisis management: a discussion in light of COVID-19 experiences, LSE Public Policy Review, 1(4): 1-8.  doi: 10.31389/lseppr.22

    • Search Google Scholar
    • Export Citation
  • Boin, A., Ekengren, M. and Rhinard, M. (2020) Hiding in plain sight: conceptualizing the creeping crisis, Risk, Hazards & Crisis in Public Policy, 11(2): 11638.

    • Search Google Scholar
    • Export Citation
  • Burlone, N. (2020) Value-based issues and policy change: medical assistance in dying in four narratives, Social Policy and Administration,  54(7): 1096-1109 .

    • Search Google Scholar
    • Export Citation
  • Burlone, N. and Richmond, R.G. (2018) Between morality and rationality: framing end‑of‑life care policy through narratives, Policy Sciences, 51:  31334. doi: 10.1007/s11077-018-9320-x

    • Search Google Scholar
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  • 1 University of Western Australia, , Australia
  • | 2 Oakland University, , USA

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