Table 2 Steps of applied ethical reasoning; own source, inspired by[40–42]

1. Identify and frame in own words: What is the underlying moral conflict?

Can a parents’ right to not have an intervention done with their child be overridden by the state (for someone else’s good)? Furthermore: Can parents exercise their will on behalf of their children?

2. Identify and frame in ethical words: Which ethical principles are relevant, how can they be specified and might they be in conflict to each other?

Overall, the principles respect for autonomy and health maximisation seem to be affected and seem to mutually exclude each other. But one also has to ask whose autonomy is at stake. Parents’ autonomy – but what about the future autonomy of children? Furthermore, the immunising doctor might be indecisive whether to advocate for autonomy, health maximisation or non-maleficence.

3. Zoom further in: Do I have all relevant information? Can I get more background information to understand all particularities?

What are the potential side effects of measles immunisation? How severe are measles for children? About how many persons (to be vaccinated against their parents’ will) can be protected, which effect would such an immunisation programme have on the incidence of measles and which side-effects could actually be prevented?

4. Are alternative solutions feasible with less moral issues/costs?

Can there be alternative approaches to mandatory measles immunisation? Can one raise immunisation rates by informing, advertising, setting incentives for parents?

5. Further Specification: Do the specifications change with more information?

If there are alternative ways that are less infringing on the respect for autonomy but rather support the health maximisation and the protection of those who cannot be immunised (ensuring non-maleficence), then these alternatives have a higher moral value.

6. Weighing: Are all conflicting principles and their specifications still of equal value?

If other measures (incentive setting, education campaigns for immunisation) can be successfully implemented elsewhere, mandatory immunisation seems less necessary. Yet, autonomy of the parents (who are safeguarding the autonomy of their children) attains even more weight.

7. What do I conclude from the specification and weighing? What would be my solution to the problem?

Mandatory measles immunisation would – in this very particular situation – not be necessary in order to achieve best health and given that it would infringe autonomy of parents (and allegedly of children), it should not be applied.

8. Integrity: Can I personally accept the conclusion drawn?

It seems to be a suitable solution to – at least first – try other measures, rather than being in charge of forcing parents and children to have children’s bodies ‘invaded’ against their ‘guards’ will.

9. Act and convince: I act according to my judgment and convince colleagues and others also based on ethical reasoning.

I try to find resources within my professional budget and start action to promote immunisation with other means.