Public discussion in Montenegro about mandatory childhood immunisation has intensified in recent weeks. Contributing factors include the introduction of statutory provisions governing children's attendance at preschool institutions, proceedings before the Constitutional Court of Montenegro, and public statements by certain healthcare professionals questioning the justification for vaccination. Given that public trust in medicine is one of the most important public goods, which the medical profession has a duty to protect, the Committee on Ethical Issues and Deontology of the Medical Chamber of Montenegro considers it its professional obligation to recall the principles of contemporary bioethics, the relevant case law of the European Court of Human Rights, and international ethical standards governing the relationship between individual rights, public health and healthcare professionals' duties.

THE IMPORTANCE OF VACCINATION

Vaccination is not solely a matter of health policy. It is a matter of professional ethics, the protection of human rights, responsibility towards the most vulnerable members of society, and maintaining public trust in the medical profession.

Vaccination is one of the most significant, successful and safest public health interventions in the history of medicine. Immunisation has eradicated or almost eliminated diseases that claimed millions of lives over decades. The World Health Organization (WHO) estimates that vaccination prevents between 3.5 and 5 million deaths each year, protecting children and adults against more than thirty potentially fatal infectious diseases. A 2024 analysis by WHO and The Lancet found that immunisation programmes have saved at least 154 million lives over the past fifty years, equivalent to six lives every minute in each of those fifty years.

THE BIOETHICAL FRAMEWORK

Contemporary medical ethics rests on the principles of autonomy, beneficence, non-maleficence and justice, none of which is absolute. An individual's right to make decisions about their own health must be considered alongside the obligation not to endanger the health of others. This principle is one of the foundations for implementing public health measures. UNESCO's Universal Declaration on Bioethics and Human Rights (2005) further emphasises social responsibility, solidarity and the protection of vulnerable groups. The Council of Europe's Convention on Human Rights and Biomedicine (the Oviedo Convention) is founded on the protection of human dignity and the responsible exercise of rights in medicine. Contemporary bioethics therefore views vaccination not exclusively as a question of individual autonomy, but also as a means of protecting people who cannot be vaccinated for medical reasons and whose health depends on herd immunity.

Furthermore, international bioethical standards do not treat every vaccination as mandatory. They require mandatory vaccination to remain an exception, justified only when several conditions are met cumulatively:

• The disease poses a serious threat to population health.
• A safe and effective vaccine is available.
• The benefits of vaccination significantly outweigh the risks associated with the vaccine.
• No equally effective, less restrictive measures can achieve the same public health objective.
• The measure is proportionate to the risk posed by the disease it seeks to prevent.
• Medical exemptions exist for people who cannot be vaccinated.

These criteria provide the framework for assessing whether mandatory vaccination is justified. They are fully consistent with the principles of proportionality, necessity and the protection of public health, and Montenegro's regulatory framework fully meets these standards.

THE CASE LAW OF THE EUROPEAN COURT OF HUMAN RIGHTS

Of particular importance is the Grand Chamber judgment of the European Court of Human Rights in Vavřička and Others v. the Czech Republic (2021), which is now the leading European standard in this area. In that case, the Court unequivocally established that mandatory childhood vaccination constitutes a de facto interference with the right to private life under Article 8 of the European Convention on Human Rights, but that, under the same Article, such interference is justified, lawful, legitimate and may be necessary when it aims to protect population health and the rights of others.

The European Court of Human Rights specifically emphasised:

• That protecting public health is a legitimate aim of the state.
• That people who cannot be vaccinated for medical reasons depend on the herd immunity created by other members of the community.
• That states have a wide margin of appreciation in designing health policies.
• That mandatory vaccination does not entail physically forcing people to be vaccinated, but rather certain consequences prescribed by law, such as requirements for attendance in group settings or modest administrative sanctions, which the Court regarded as proportionate and preventive rather than punitive measures.
• That protecting the health of society's most vulnerable members is an expression of social solidarity.

The Court concluded that it is not disproportionate to expect individuals to accept the minimal risk associated with vaccination in order to protect a small number of particularly vulnerable people who cannot obtain that protection themselves. It stressed that human rights are inseparably linked to responsibilities towards other members of the community and that, in a democratic society, individual rights must be reconciled with the rights of others and the protection of public health.

DOCTORS' RESPONSIBILITY IN PUBLIC DISCOURSE

The Committee on Ethical Issues and Deontology considers that public advocacy by doctors of vaccine refusal is professionally and ethically questionable conduct that can undermine public trust in the medical profession and endanger public health.

The World Medical Association's International Code of Medical Ethics (WMA, 2022) provides that a doctor's fundamental duty is to act in accordance with the best available scientific evidence, contribute to improving public health, and avoid undermining trust in the medical profession through public statements. When doctors use their professional authority in public to promote medically unfounded claims or discourage measures that are standard in contemporary medicine, there is a real possibility of undermining trust in the healthcare system and endangering population health.

The International Code of Medical Ethics emphasises that doctors have a particular responsibility to provide the public with accurate, objective and scientifically grounded information, including when communicating through the media or social networks. In other words, doctors' freedom of expression is a more complex issue than the general freedom of expression enjoyed by any citizen. At a time when misinformation can endanger the health of thousands of people, a doctor's responsibility is not only to treat disease, but also to protect the truth on which contemporary medicine rests. This is not a restriction on freedom of thought, but an expression of the professional responsibility that the medical profession voluntarily accepts in the interests of its patients and society as a whole.

CONCLUSION

Protecting individual health and protecting public health are not opposing aims, but interconnected values. The highest level of human rights protection is achieved not by giving absolute priority to individual demands, but by striking a fair balance between individual freedoms and other members of the community's rights to life, health and safety, while consistently safeguarding constitutional values.

The Committee recalls that decisions concerning public health, particularly those involving the protection of children and the prevention of infectious diseases, must be based on the best available scientific evidence, internationally accepted medical standards and human rights principles, rather than on misinformation, pseudoscientific claims or current social pressures. In a democratic society, independent institutions have a responsibility to make decisions on the basis of facts, respecting proportionality, the protection of public health, the best interests of the child and the rights of the most vulnerable members of the community. This is precisely the standard confirmed by the European Court of Human Rights in Vavřička and Others v. the Czech Republic, which emphasised that rights coexist with responsibilities, and that the state is not merely empowered but obliged to protect public health when there are scientifically grounded and proportionate reasons to do so.

Appeal to all doctors and members of the Medical Chamber of Montenegro

The Committee on Ethical Issues and Deontology calls on all doctors, in public discourse just as in their direct work with patients, to act in accordance with the principles of evidence-based medicine, medical ethics and international professional standards. They should bear in mind that every public statement by a doctor affects public trust in the healthcare system and may have direct consequences for public health. The trust that society places in doctors is one of the most valuable public goods. Preserving it is not only the professional duty of each individual doctor, but the shared responsibility of the entire medical profession.