Compulsory childhood vaccination
RELEVANT LEGAL FRAMEWORK AND PRACTICE DOMESTIC LAW AND PRACTICEDomestic lawCharter of Fundamental Rights and Freedoms (Constitutional Law no.2/1993 Coll.) Domestic lawCharter of Fundamental Rights and Freedoms (Constitutional Law no.2/1993 Coll.) Charter of Fundamental Rights and Freedoms (Constitutional Law no.2/1993 Coll.) Domestic lawCharter of Fundamental Rights and Freedoms (Constitutional Law no.2/1993 Coll.) Charter of Fundamental Rights and Freedoms (Constitutional Law no.2/1993 Coll.) Charter of Fundamental Rights and Freedoms (Constitutional Law no.2/1993 Coll.) 65. In so far as relevant, Article 4 provides: “1. Duties may be imposed only on the basis and within the bounds of the law and only if the fundamental rights and freedoms of the individual are respected. 2. Limitations may be placed upon fundamental rights and freedoms only by the law and under the conditions prescribed in [this Charter].” 66. Pursuant to Article 7 § 1: “The inviolability of the person and of his or her private life shall be guaranteed. It may only be restricted in the cases provided for by law.” 67. The relevant part of Article 15 § 1 reads as follows: “Freedom of thought, conscience and religious conviction shall be guaranteed. ...” 68. Under Article 16 § 1: “Everybody has the right to manifest freely his or her religion or faith, alone or jointly with others, privately or in public, through religious service, instruction, religious practice, or religious rites.” 69. Article 31 provides that: “Everyone shall have the right to the protection of his or her health. Citizens shall have the right, on the basis of public insurance, to free health care and to health aids under the conditions provided for by law.” 70. As to the scope of the second sentence of Article 31, the Constitutional Court held (constitutional judgment of 10 July 1996, published in the Collection of Laws under no. 206/1996) that its content is limited to what is covered by public insurance, which in turn depends on the amount of the insurance premiums collected. All of the relevant Chapter of the Charter depends on the economic and social level achieved by the State and the attendant standard of living. 71. Under Article 33 § 1: “Everybody shall have the right to education. School attendance shall be mandatory for the period specified by law.” 72. Pursuant to the relevant part of Article 41 § 1; “[The right to education under Article 33] can be relied on only within the scope of the laws adopted for the implementation of that provision.” Public Health Protection Act (Law no. 258/2000 Coll., as amended) 73. This legislation sets out the general framework for vaccination, defining its purpose, personal scope, vaccine types, the conditions for administering vaccination as well as for assessing immunity, and other matters. Section 46(1) and (6) provides for the adoption by the Ministry of Health of implementing measures, regulating in greater detail matters such as the classification of vaccines, the timing of injections and other conditions for the administration of vaccinations, and methods for checking immunity (see below). Moreover, it provides that day-care facilities for children up to the age of three and other types of preschool facilities (i.e. those that receive children until the school year following the date on which they reach the age of six) may only accept children who have received the required vaccinations, or who have been certified as having acquired immunity by other means or as being unable to undergo vaccination due to a permanent contraindication (section 50). Decree on Vaccination against Infectious Diseases 74. As provided for in the PHP Act, the Ministry adopted the Decree on Vaccination against Infectious Diseases. In the period under consideration in the present case, there were two successive Decrees in force: Decree no. 439/2000 Coll., as amended, until 31 December 2006, replaced by Decree no. 537/2006 Coll., as amended, from 1 January 2007 onwards. Since the provisions that are relevant to the present case are essentially identical in both instruments, further references to the Decree in this judgment mean the 2006 Decree, unless otherwise indicated. 75. The Decree determines the classification of vaccinations, the conditions for the administration of vaccines and the methods for examining immunity (section 1 (a)). 76. It defines the scope of compulsory vaccination as comprising vaccination against diphtheria, tetanus, whooping cough (pertussis), Haemophilus influenzae type b infections, poliomyelitis, hepatitis B, measles, mumps, rubella and – for children with specified health indications – pneumococcal infections (sections 4, 5 and 6). 77. The Decree also defines the sequence in which the vaccinations are to be administered, normally starting from the ninth week after birth, with at least two months between the first two rounds of vaccination and the third round being administered between the ages of eleven and thirteen months (sections 4 and 5). In the case of some illnesses, initial vaccination (section 2(2)(a)) is to be followed by booster vaccination (section 2(2)(b)). Pharmaceutical Drugs and Medications Act (Law no. 378/2007 Coll.) 78. Sections 25 to 50 regulate the registration of pharmaceutical drugs, including vaccines, by the State Agency for Drug Control. 79. Under section 93b(1), all doctors, dentists and other health care workers have to report to the above Agency any suspected serious or unexpected side-effects of pharmaceutical drugs, on pain of a fine of up to CZK 300,000 pursuant to section 108(7) (currently equivalent to some EUR 11,350). Education Act (Law no. 561/2004 Coll., as amended) 80. Section 33 defines the aim of preschool education as being to support the development of the personality of the child of preschool age. Such education plays a role in the healthy emotional, intellectual and physical development of children, in their acquisition of basic rules of conduct and fundamental life values, and in their developing of interpersonal relations. Preschool education provides the basic preconditions for continuing with education. It assists in equalising differences in the development of children before entering basic education and provides adapted pedagogical care to children with special educational needs. 81. Section 34(1) provides that preschool education is organised for children who are generally aged from three to six, but not younger than two. A child younger than two is not entitled to admission to nursery school. This provision was amended with effect from 1 September 2017, making preschool education mandatory from the beginning of the school year following the child’s fifth birthday until the beginning of mandatory school attendance. Paragraph 5 of this section includes among the conditions for school admission the vaccination requirement under section 50 of the PHP Act (see paragraph 73 above). 82. Under section 36(3), mandatory school attendance commences at the beginning of the school year following the date on which the child reaches the age of six, unless the child is granted a postponement. Minor Offences Act (Law no. 200/1990 Coll., as amended) 83. At the relevant time, section 29(1)(f), dealing with minor offences in the area of health care, made it a minor offence punishable by a fine of up to the equivalent of some EUR 400 (subsection 2) to fail to discharge a duty imposed in order to prevent the occurrence or spread of infectious diseases. Compensation for Health Damage due to Compulsory Vaccination Act (Law no. 116/2020 Coll.) 84. The Act entered into force on 8 April 2020. It provides for strict liability on the part of the State for damage to health due to compulsory vaccination (section 1). Such compensation is provided for in the event of a particularly grave injury to the health ( zvlášť závažné ublížení na zdraví ) of the vaccinated person and in respect of suffering, loss of income, impairment of one’s ability to be useful in society ( ztížení společenského uplatnění ), expenses in respect of the medical care of the vaccinated person, and care for his or her person and his or her household (section 2). The Act provides for an irreversible presumption of a causal connection between the vaccination and the symptoms appearing after the vaccination, in so far as such symptoms are recognised – in secondary legislation yet to be adopted – as likely consequences of the given vaccine (sections 3 and 8). Domestic practiceSAC case-law SAC case-law SAC case-law 85. In judgment no. 3 Ads 42/2010 of 21 July 2010, an ordinary chamber of the SAC held that the 2000 Ministerial Decree exceeded the permissible limits in that it regulated matters that were reserved to the legislature. It held that, as a result of the very general wording of section 46(1) of the PHP Act, the 2000 Ministerial Decree provided for primary rights and duties beyond the limits fixed by the law. Accordingly, the court quashed an administrative decision imposing a fine on parents for failure to comply with their vaccination duty in relation to their children. 86. This opinion was, however, overruled by an extended chamber of that court in a decision of 3 April 2012 (no. 8 As 6/2011) in the case of the applicant Novotná. In particular, the extended chamber found as follows: “The framework regulation in section 46 of the [PHP] Act on the duty for individuals to undergo vaccination and the precisions added to it by the [2006 Ministerial] Decree satisfy the constitutional requirements to the effect that duties may only be imposed on the basis and within the bounds of the law (Article 4 § 1 of the Charter) and that limitations on fundamental rights and freedoms may only be imposed by the law (Article 4 § 2 of the Charter).” 87. A situation in which primary duties were provided for by law (i.e. by an Act of Parliament) and clarified by secondary legislation within the limits set by that law was compatible with Article 4 § 2 of the Charter. With regard to Article 26 § 1 of the Oviedo Convention, it was similar to Articles 8-11 of the European Convention on Human Rights. In the European Court’s case-law, the term “prescribed by law” used in those provisions was interpreted in the substantive sense, so as to include not only a legislative act by a Parliament, but also any accessible and foreseeable legal rule. None of those provisions thus prevented the finer points of the vaccination duty from being regulated by an implementing instrument, provided that this was done on the basis of the law and within its limits. In the present case, the PHP Act provided for a sufficiently clear and precise framework, placing a duty, in a valid and specific manner, on certain groups of individuals to undergo vaccination after having undergone an immunity test. Although it did not define them, section 46 nonetheless brought out the fundamental meaning of the words “valid and specific vaccination”. The 2000 Ministerial Decree then specified the types of illnesses, the timetable and other details of the vaccination process. Such a legislative approach made it possible to react with flexibility to a given epidemiological situation and to developments in medical science and pharmacology. However, it did not prevent the limitations on fundamental rights provided for in the Ministerial Decree from being subjected, in specific cases, to an assessment of proportionality by the courts. 88. In judgment no. 4 As 2/2011 of 25 April 2012, the SAC pointed out, inter alia, that unlike for the MMR vaccination, the 2006 Ministerial Decree set out legally binding deadlines and age limits for compliance with the vaccination duty in respect of initiation of the primary immunisation series and/or booster doses for diphtheria, tetanus, whooping cough, poliomyelitis, hepatitis B and Haemophilus influenzae type b vaccination (under section 4(1) the last dose of the hexavalent vaccine was to be administered before the age of 18 months). It was therefore an error-free and complete legal norm ( perfektní právní norma ), i.e. non-compliance with it could entail a penalty under the MO Act. 89. In judgment no. 8 As 20/2012 of 29 March 2013, the SAC noted, with regard to the exceptional circumstances capable of outweighing the need for protection of public health within the meaning of the Vavřička jurisprudence (see paragraph 28 above), that the appellant was not alleging, for example, that submitting to the vaccination would compromise his status, or that of his parents, were they to be members of a religious community, or that it would otherwise prevent them from manifesting their beliefs. A different opinion on the part of the appellant’s parents was not sufficient. The vaccination duty pursued a legitimate aim, that of the protection of public health, which outweighed the different views of the parents of the children concerned. While everyone had the right to hold an opinion and to express it freely (Articles 15 and 16 of the Charter), this did not authorise, in a democratic State governed by the rule of law, non ‑ compliance with the regulations in force. A failure to comply entailed the consequences provided for by law. Case-law of the Constitutional Court (a) Judgment no. Pl. ÚS 19/14 of 27 January 2015 90. In the context of proceedings on constitutional appeal no. I. ÚS 1253/14 (see paragraph 93 below), in which the parents of an underage child complained that they had each been fined CZK 4,000 for having refused the routine vaccination of their child, the relevant chamber referred to the plenary formation the appellants’ free-standing request ( akcesorický návrh ) to have section 46 of the PHP Act and section 29(1)(f) of the MO Act set aside. The parents relied on the SAC’s judgment no. 3 Ads 42/2010 (see paragraph 85 above) and argued that the said provisions were contrary to Article 4 of the Charter. They further argued that the regulations on compulsory vaccination were contrary to Articles 5, 6 and 26 of the Oviedo Convention, since it was not a necessary measure for the protection of public health, in the absence of an objective basis in the form of a complex and independent analysis. Relying on their rights to dignity and respect for their physical integrity, as well as their freedom of thought and conscience, they claimed to have refused vaccination in the child’s interests, in order to protect his health. They were thus eligible for an exception within the meaning of the Vavřička jurisprudence (see paragraph 28 above). They noted in this respect that each individual’s attitude towards vaccination was based on his or her personal position, not on objective data. It was thus unthinkable that an administrative authority could re-examine the “correct” or “justified” nature of the parents’ conviction in this respect. Referring to Article 24 of the Oviedo Convention, the appellants noted that the State did not assume any liability for the side effects or damage to health caused by vaccination. There was accordingly no fair balance between the demands of the public interest and the individual’s rights. 91. By judgment no. Pl. ÚS 19/14 of 27 January 2015, the plenary formation of the Constitutional Court dismissed the above-mentioned free ‑ standing request. It noted that the regulations on compulsory vaccination fell fully within the competence of the national legislature. As to the rule that certain matters could only be regulated by an Act of Parliament (Article 4 of the Charter), the Constitutional Court endorsed the conclusions of the extended chamber of the SAC in its judgment no. 8 As 6/2011 (see paragraph 86 above). The wording of section 46 of the PHP Act was sufficiently clear and understandable and it duly defined all necessary parameters for the regulation of details by secondary legislation. This arrangement made it possible to react promptly to the epidemiological situation and to the current state of medical and pharmacological knowledge. Compulsory vaccination amounted to an interference with the individual’s physical integrity and, accordingly, with his or her right to respect for private or family life. As a restriction on this fundamental right, the vaccination duty was accompanied by safeguards to minimise any potential abuse and to prevent this medical intervention from being carried out where the conditions were not met (section 46(2) and (3)). The compatibility of this restriction with the right to respect for private life was to be established on the basis of the following five-step test. Firstly, the issue in question had to fall within the material scope of the rights that were limited, which in the present case it manifestly did. Secondly, there had to be an interference with the right in question, which in the case at hand there was, by virtue of an intrusion into the personal integrity of the vaccinated individual and, in the case of children under fifteen, an interference with the right of their parents to decide on matters concerning their care and education, or even, where applicable, with the right to manifest one’s religion or beliefs freely. Thirdly, the restriction had to be in accordance with the law, which it was, the term “law” being understood in the substantive sense, including texts of secondary legislation. Fourthly, the restriction had to pursue a legitimate aim, in this instance the protection of health. Fifthly, the restriction had to be necessary, and it was, as it was clear from data provided by national and international experts – the assessment of which was a matter for the legislature and the executive, not for the Constitutional Court – that the approach of general vaccination against the specified infectious diseases was to be recommended and that the interest in protecting public health outweighed the arguments of appellants who were opposed to vaccination. In an obiter dictum, referring to Article 24 of the Oviedo Convention, the Constitutional Court considered that if the State imposed penalties for non ‑ compliance with the vaccination duty, it ought also to envisage the situation where vaccination damaged the health of the individual concerned. Thus, it was incumbent on the legislature to give consideration to regulations governing State liability for such consequences, which was not uncommon in other States. (b) Decision no. III. ÚS 3311/12 of 17 August 2015 92. By this decision, the Constitutional Court dismissed a constitutional appeal of parents fined in minor-offence proceedings for having refused the routine vaccination of their child. The court noted, inter alia : “29 ... [T]he present case is not ... an exceptional case in which compulsory vaccination cannot be enforced due to specific circumstances. In the appellants’ case ... the Constitutional Court did not find any exceptional reasons for them not to be penalised for having refused compulsory vaccination of their [child], on the grounds that the penalty would amount to an interference with their freedom of thought and conscience. The Constitutional Court did not find any exceptional or convincingly and consistently claimed reasons for which the appellants had refused to have their [child] vaccinated and which would fundamentally call for respecting their autonomy despite the undisputed and significant public interest in vaccination. 30. The appellants’ arguments ... remained at a completely general level; the appellants ... acted on a general conviction regarding the child’s best interest. They refused vaccination on the basis of an opinion that they had reached (only) by studying literature and other resources. A general opinion so presented cannot be understood as unique and constitutionally relevant reasons for refusing vaccination. The appellants’ assertions are not sufficiently convincing. Over the course of time they were even inconsistent, because in the proceedings before the administrative authorities the appellants cited their reasons ... in a much more urgent manner than in the proceedings before the administrative courts in which, instead of their personal reasons for refusing compulsory vaccination, the mainstay of their arguments was a general analysis of the ... compliance of compulsory vaccination legislation with the constitutional order. Before the Constitutional Court, they once again focused on the reasons for refusing vaccination in their specific case. However, the appellants did not state any relevant circumstances (they noted that their [child] was a healthy child who only suffered from occasional common illnesses) to support [the existence of] any interference with the constitutionally guaranteed rights and freedoms.” (c) Judgment no. I. ÚS 1253/14 of 22 December 2015 93. The case was brought by parents fined for having refused several of the compulsory vaccinations of their child. In its judgment on their constitutional appeal, the Constitutional Court developed and clarified its conclusions reached in Vavřička (see paragraph 28 above). As to the right to a “secular objection of conscience”, it held: “42. The existence of the constitutional judgment [in the Vavřička case] leads to the following postulates regarding the justifiability of the secular objection of conscience, which must be satisfied cumulatively. These are (1) the constitutional relevance of the claims contained in the objection of conscience, (2) the urgency of the reasons that the holder of the fundamental freedom cites in support of his objection, (3) the consistency and persuasiveness of that person’s claims, and (4) the social impact that the acceptance of a secular objection of conscience may have in the specific case. 43. [In the Vavřička judgment] the Constitutional Court held that if all of the above requirements were satisfied then compulsory vaccination of the particular person was not to be insisted upon, i.e. non ‑ compliance with the vaccination duty was not to be penalised, nor was the duty in that case to be enforced by other means. ... 44. The claims underlying the secular conscientious objection to compulsory vaccination acquire a constitutional dimension due to the collision between the protection of public health and the health of the person in whose favour the objection of conscience is applied ... Nor can the parents’ claim of an interference with their right of parental care be ignored ... Article 15 § 1 [of the Charter] on freedom of conscience or conviction of holders of a fundamental right remains immanent to the case. Nor can a very frequent argument that vaccination is an interference with bodily integrity be ignored ... Moreover, all these cases involve fundamental rights that can be weighed against each other (with a view to finding an optimal balance). 45. The urgency of the reasons underlying the conscientious objection to compulsory vaccination remains, undoubtedly, subjective in its nature. It is the proverbial aspect of “here and now” which impedes compliance with a lawful order without any exception. It is difficult to define the variety of the content of the objection; undoubtedly, it potentially includes the conviction that irreversible damage can be caused to the health of a close person. If this is a minor who is represented by a statutory representative, the specific aspects of his or her interest in avoiding the vaccination must be taken into consideration. 46. The convincing and consistent character of the claims underlying a secular conscientious objection must be assessed ad personam and cannot be subjected to the test of objective truthfulness; the content of those claims must not lack an element based on values or strongly contradict the social environment, but it must pass muster above all with the person making such claims and those who are the closest to him. The Constitutional Court has previously required [in the Vavřička case] the author of the objection to communicate with the competent public authority, i.e. to refrain from justifying his conviction only at the later stages of the proceedings. This still applies, and unambiguity and appropriate (reasonable) clarity of the manifestation of that person’s conscience must be a matter of course. 47. Finally, with all due respect for the autonomy of manifestations of will, the social impact of the secular objection of conscience, if it is to be accepted, must not exceed the sphere of the legitimate aims relevant for the given field of law to an excessive degree. In this specific case this means, inter alia, that the desirable level of vaccination coverage ... must be taken into account. The exception granted must not be associated with conclusions that would allow such exceptions to become the rule. ... 49. As regards the relation between the two types of conscientious objections, both religious and secular, the Constitutional Court concludes that in a secular State (Article 2 § 1 of the Charter) there is no reason to treat them differently. ... 50. ... [R]efusal of compulsory vaccination on the grounds of religion and belief, which cannot be completely ruled out depending on the specific circumstances, must remain a restrictively perceived exception, for which the Constitutional Court has already opened some space on account of strong reasons, but not a dispensation granted automatically to a specific religion or a group of persons professing a specific belief. 51. All of the above applies with equal force also in cases where a certain person is to undergo compulsory vaccination and a secular objection of conscience is raised ... [A]n exception from the statutory duty may be considered only in exceptional cases closely linked to the person subject to the vaccination duty, or to persons closely related to such person (a highly adverse reaction to previous vaccination in the case of that person, that person’s child, etc.). The opposite finding would contradict the fact that compulsory vaccination serves the protection of public health, such protection being the preferred option in the law as approved by the Constitutional Court in its judgments nos. Pl. ÚS 19/14 and Pl. ÚS 16/14.” COMPARATIVE MATERIALConstitutional jurisprudence Constitutional jurisprudence Constitutional jurisprudence 94. The following relevant constitutional judgments are included in the CODICES database of the Venice Commission. France 95. In case no. 2015-458 QPC, the Constitutional Council considered a request from the Court of Cassation for a preliminary ruling on the constitutionality of certain provisions of the Public Health Code. Those provisions related to compulsory vaccination against diphtheria, tetanus and poliomyelitis for minor children under the responsibility of their parents. The applicants in the original proceedings claimed that the compulsory vaccinations could entail a health risk, in breach of the constitutional requirement of health protection. 96. In a decision of 20 March 2015, the Constitutional Council ruled that the provisions in question were in conformity with the Constitution. It observed that, by making the given vaccinations compulsory, the legislature had intended to combat three diseases that were very serious and contagious or could not be eradicated. In doing so, it had made each of these vaccinations compulsory only on condition of there being no known medical contraindication. 97. The Constitutional Council ruled that the legislature was free to shape a vaccination policy to protect individual and public health. It was not for the Constitutional Council, which did not enjoy the same general power of assessment and decision-making as Parliament, to call into question the provisions enacted by the legislator, having regard to the state of scientific knowledge, or to seek to establish whether the objective of health protection set by the legislature might have been attained by other means, since the arrangements provided for by the law were not manifestly inappropriate to the objective pursued. Hungary 98. In a constitutional judgment of 20 June 2007 in case no. 39/2007, the Constitutional Court examined a petition lodged by a married couple who were refusing to have their child vaccinated, and who had challenged the constitutionality of the 1997 Health Act providing for compulsory vaccination. A failure to comply warranted an administrative order for the given vaccine to be carried out, the order being directly enforceable, regardless of any appeal. 99. The court found, inter alia, that the protection of children’s health justified compulsory vaccination at certain ages and accepted the legislature’s position, based on scientific knowledge, that the benefits of vaccination for both the individual and society outweighed any possible harm due to side ‑ effects. The system of compulsory vaccination thus did not contravene children’s right to physical integrity. At the same time, the court acknowledged that the system of compulsory vaccination might result in more significant harm for parents who, for reasons of religious conviction or conscience, did not agree with vaccination. The regulation was however in accordance with the requirements of the neutrality of the State. The legal norms in question, being binding on everybody and protecting the health of the children concerned, all other children, and in fact society as a whole, were based on postulates of the natural sciences, rather than the acceptance of the truth content of different ideologies. 100. However, there had been an unconstitutional omission to legislate, as the legislature had failed to provide an effective legal remedy against the refusal of exemptions from compulsory vaccination. In particular, the statutory provision permitting the immediate enforcement of an order for vaccination, with no recourse to any legal remedy, was unconstitutional and accordingly repealed. North Macedonia 101. In case no. U.Br. 30/2014 the Constitutional Court reviewed the constitutionality of certain statutory provisions pertaining to the compulsory vaccination of children and the consequences of non-compliance with it. The legislation in question provided for the compulsory vaccination of all persons of a certain age against tuberculosis, diphtheria, tetanus, whooping cough, polio, measles, mumps, rubella, Haemophilus influenzae type b infections and hepatitis B. In its judgment of 8 October 2014, the court held, inter alia, as follows. 102. Mandatory vaccination could not be called into question with regard to the constitutional provisions on the rights and duties of citizens in relation to the protection and promotion of their own health and that of others. Neither could it be questioned with regard to the provisions on the right and duty of parents to take care of and raise their children. A refusal of a vaccination by the parents not only endangered the health of their children, but also the health of other persons who had not been vaccinated on account of medical contraindications, and it thus denied them the right to a healthy life. 103. In order to safeguard the health of the child and the child’s right to health, which was subject to a special level of protection, it was justified to deny the parents’ freedom to refuse vaccination, since the right of the child to health prevailed over the parents’ right to choose. 104. Moreover, the legislature was not prevented from regulating penal policy in respect of a breach of the vaccination duty by making it punishable by a fine. 105. Similarly, there was no obstacle for the legislature to make enrolment in primary school dependant on the parents’ submitting proof of vaccination of the child. In that regard, the court noted specifically that since all children of the given age were eligible for enrolment in the first grade, a large number of students would enrol from different areas and backgrounds, which carried an inherent risk of the spread of certain diseases. Moreover, parents who refused to vaccinate their children were to be reminded that other parents also had the right to protection from serious illness in respect of their children, and that unvaccinated children posed a greater risk of spreading the disease, especially in child-care facilities, schools and other educational establishments. Italy (a) Constitutional judgment no. 5/2018 106. In this judgment, delivered on 22 November 2017, the Constitutional Court considered the constitutional validity of a decree-law introduced as a matter of urgency to increase the number of compulsory vaccinations from four to ten. The decree-law made access to early childhood educational services conditional on the receipt of all ten vaccines. The sanction for failure to comply was an administrative fine. This was challenged on a number of grounds, including as an unjustifiable interference with the constitutional guarantee of individual autonomy. This argument was dismissed with the following reasoning. 107. The court noted the preventive nature of vaccination, the critically unsatisfactory level of vaccination in Italy at the given time, and the existing trends suggesting that the rate of vaccination was deteriorating. It found that the legislation was within the scope of the discretion and political responsibility of the authorities, who were expected to assess the overriding need to intervene urgently and prior to the emergence of crisis scenarios, and to do so in the light of new data and new epidemiological phenomena. Furthermore, they were expected to act consistently with the principle of precaution, which was inherent in the approach to preventive medication, and was of fundamental importance where public health was concerned. 108. Pointing out that there was no scientific basis for the existing trends in popular opinion which considered vaccination to be futile or dangerous, the court noted that, in medical practice, recommendation and obligation were conjoined concepts and, therefore, moving six vaccinations from being simply recommended to being compulsory did not represent a significant change in their status. It also held that requiring a certificate for school enrolment and imposing fines were both reasonable measures for the legislature to take, not least where it had provided for initial steps to be taken before the imposition of such sanctions, i.e. one-to-one meetings with parents and guardians to inform them about the efficacy of vaccinations. 109. The court drew attention to its established case-law to the effect that, in the area of vaccinations, there was a requirement for balance between the individual right to health (including freedom concerning treatment) and the coexistent and reciprocal rights of others and the interests of the community, as well as, in the case of compulsory vaccinations, the interests of children, who required protection even vis-à-vis parents who did not fulfil their duties of care. 110. As to the interests of minor children, they were to be pursued first of all through their parents’ exercise of their joint right and duty to take action that was well-suited to protecting the health of their children. That freedom did not however extend to making choices that were potentially detrimental to the health of minor children. 111. A law imposing a health-related treatment was not incompatible with the Constitution if: the treatment was intended not only to improve or maintain the health of the recipient, but also to preserve the health of others; the treatment was not expected to have a negative impact on the health of the recipient, with the exclusive exception of those consequences that normally arose and, as such, were tolerable; and, in the event of further injury, the payment of just compensation to the injured party was provided for, separate and apart from any damages to which they might be entitled. 112. The court also noted that the issue of vaccination involved many constitutional values, the coexistence of which left room for legislative discretion in choosing the means by which to ensure the effective prevention of infectious diseases. That discretion had to be exercised in the light of the various health and epidemiological conditions, as ascertained by the responsible authorities and of the constantly evolving discoveries of medical research, to which the legislature had to turn for guidance when making its choices in that area. (b) Constitutional judgments nos. 307/1990 and 118/1996 113. In its earlier judgment no. 307/1990, given on 14 June 1990, the Constitutional Court declared unconstitutional a law making provision for compulsory anti-poliomyelitis vaccination, due to its failure to provide for compensation for those suffering damage to their health caused by the vaccine, in the absence of liability for negligence. 114. The legislation subsequently enacted (Law no. 210 of 25 February 1992) was examined by the Constitutional Court in judgment no. 118/1996, of 18 April 1996. The court noted the two aspects of health in constitutional law: the individual and subjective aspect concerning a fundamental right of the individual; and the societal and objective aspect concerning health as a public interest. The risk of damage to an individual’s health could not be completely avoided. The legislature had therefore struck a balance, giving precedence to the collective aspect of health. Yet nobody could be asked to sacrifice their health to preserve that of others without being granted just compensation for damage caused by medical treatment. The court found the law to be contrary to the Constitution, in that it failed to make provision for compensating those whose health was injured by compulsory vaccination before the law entered into force. It observed that such damage gave rise to a claim for compensation under the Constitution itself without any liability for negligence being taken into consideration. (c) Constitutional judgment no. 268/2018 115. This judgment, which was delivered on 22 November 2017 as judgment no. 5/2018 (see paragraph 106 above), concerned a legislative situation in which no compensation was available for damage to health caused by a vaccination which was recommended rather than compulsory. The court observed that there was no qualitative difference between compulsory and recommended vaccinations, the key issue being the essential objective of preventing infectious diseases that was pursued by both types. Accordingly, the exclusion of compensation was contrary to the Constitution. Republic of Moldova 116. In its judgment no. 26 of 30 October 2018, the Constitutional Court examined a challenge to certain legislative provisions making the admission of children to community groups and educational and recreational institutions contingent upon their systematic prophylactic vaccination, the complaint being that this restricted the access of children to education. 117. Among other things, the court noted that the legitimate aims pursued by the challenged provisions were the protection of children’s health and public health from severe illnesses which spread more when vaccination rates were lower. A restriction on access by unvaccinated children, who had no contraindications, for a limited time pending their vaccination, was a less intrusive measure in terms of the right to respect for private life and to education and would efficiently achieve the aims pursued. 118. The court balanced the principle of health protection with the principles of access to education and respect for private life. Refusing to vaccinate children with no contraindications might not only entail their possible exclusion, pending their vaccination, but also exposed them to the risk of contracting an illness. The damage to their health also had negative effects on other rights they were entitled to enjoy. 119. Children with contraindications, while eligible for admission, were also exposed to the risk of contracting a communicable illness from unvaccinated children who had no contraindications. The consequences of an individual’s action on their innocent peers could not be ignored. In the given context, the rights of the individual were not exercised in an existential vacuum, but within an organised society. 120. The children of parents who did not wish them to be vaccinated in the absence of any contraindications had alternative means of learning. Also, from the perspective of leisure opportunities for children in this category, the exercise of social private life was not a central aspect of their right to respect for private life. 121. The differential treatment of vaccinated children compared to those who could be vaccinated but were not was objectively justified and reasonable. Serbia 122. In case no. IUz-48/2016, the Constitutional Court examined several challenges to the constitutionality of certain legislative provisions concerning compulsory vaccination and their conformity with international agreements ratified by Serbia. 123. As regards the necessity in a democratic society of the measures mandated by the contested provisions, the court noted that the available 2015 immunisation records for the vaccines in the immunisation schedule showed the lowest vaccination rate in ten years. This increased the risk of epidemics of communicable diseases which had been prevented for decades by vaccination, because a high level of collective immunity was needed to prevent an outbreak of an epidemic. In view of all the circumstances, including the duty of everyone to respect the public interest and not jeopardise the health of others, the court found that the criterion of necessity was fulfilled. 124. Concerning the argument that, compared to children who had been vaccinated, those who remained unvaccinated were discriminated against because they were deprived of their constitutionally guaranteed right to education, the court found that the fact that children’s attendance at educational institutions was conditional on their having been vaccinated could not be construed as being relevant in constitutional terms to any form of discrimination in respect of the right to education. This was so because all children in certain age groups were subject to vaccination, unless this was contraindicated on health-related grounds. As that duty pertained equally to all persons belonging to the given group, those who did not comply with it could not be considered discriminated against vis-à-vis those who did, because they were not in the same or a similar situation. Slovakia 125. The relevant jurisprudence is referred to in paragraph 229 below. Slovenia 126. In a judgment of 12 February 2004 in case no. U-I-127/01, the Constitutional Court upheld the constitutionality of a system of compulsory vaccination against tuberculosis, diphtheria, tetanus, whooping cough, infantile paralysis, measles, mumps, rubella and hepatitis B. However, it found deficiencies in the existing rules and their operation as regards the mechanism for individuals to claim exemption from the vaccination duty on the grounds of health contraindication. 127. Moreover, the court found a further deficiency in that the legislation did not regulate the right to compensation for damage to health resulting from vaccination side-effects. In particular, under the principle of solidarity, which itself was the basis for making vaccination compulsory, the State ordering such a measure for the benefit of everyone must be required to pay compensation to those who experienced harmful side ‑ effects. United Kingdom 128. In a case concerning the vaccination of a baby placed in the care of the local authorities, notwithstanding the objections of the parents ( Re H (A Child)(Parental Responsibility: Vaccination ), [2020] EWCA Civ 664), the judgment of the Court of Appeal of 22 May 2020 concluded as follows: “(i) Although vaccinations are not compulsory, the scientific evidence now clearly establishes that it is in the best medical interests of children to be vaccinated in accordance with Public Health England’s guidance unless there is a specific contra ‑ indication in an individual case. (ii) Under [the applicable statutory provision] a local authority with a care order can arrange and consent to a child in its care being vaccinated where it is satisfied that it is in the best interests of that individual child, notwithstanding the objections of parents. (iii) The administration of standard or routine vaccinations cannot be regarded as being a ‘serious’ or ‘grave’ matter. Except where there are significant features which suggest that, unusually, it may not be in the best interests of a child to be vaccinated, it is neither necessary nor appropriate for a local authority to refer the matter to the High Court in every case where a parent opposes the proposed vaccination of their child. To do so involves the expenditure of scarce time and resources by the local authority, the unnecessary instruction of expert medical evidence and the use of High Court time which could be better spent dealing with one of the urgent and serious matters which are always awaiting determination in the Family Division. (iv) Parental views regarding immunisation must always be taken into account but the matter is not to be determined by the strength of the parental view unless the view has a real bearing on the child’s welfare.” INTERNATIONAL AND EUROPEAN LAW AND PRACTICEInternational Covenant on Economic, Social and Cultural Rights International Covenant on Economic, Social and Cultural Rights International Covenant on Economic, Social and Cultural Rights 129. The Covenant, which is a part of the legal order of the Czech Republic (Decree of the Minister of Foreign Affairs no. 120/1976 Coll., in conjunction with Article 1 of Constitutional Law no. 4/1993 Coll.), reads in its relevant part as follows: Article 12 “1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2. The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for: ... (c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; ...” 130. In General comment No. 14 on the right to the highest attainable standard of health, published on 11 August 2000 (E/C.12/2000/4), the UN Committee on Economic, Social and Cultural Rights noted, inter alia : “[Article 12.2 (c). The right to prevention, treatment and control of diseases] 16. ... The control of diseases refers to ... the implementation or enhancement of immunization programmes and other strategies of infectious disease control. ... [Specific legal obligations] 36. The obligation to fulfil requires States parties, inter alia, to give sufficient recognition to the right to health in the national political and legal systems, preferably by way of legislative implementation, and to adopt a national health policy with a detailed plan for realizing the right to health. States must ensure provision of health care, including immunization programmes against the major infectious diseases .... ... [Core obligations] 44. The Committee also confirms that the following are obligations of comparable priority: ... (b) To provide immunization against the major infectious diseases occurring in the community; (c) To take measures to prevent, treat and control epidemic and endemic diseases.” 131. In its Concluding observations as part of the periodic review of individual States, the UN Committee on Economic, Social and Cultural Rights has repeatedly emphasised the duty of preventive vaccination of the highest possible percentage of the population (see, for example, observations of 7 June 2010 on Kazakhstan (E/C.12/KAZ/CO/1), § 4). It has also criticised a decreased rate of vaccination (see, for example, observations of 13 December 2013 on Egypt (E/C.12/EGY/CO/2-4), § 21) and called for a reversal of that negative trend (see, for example, observations of 13 June 2014 on Ukraine (E/C.12/UKR/CO/6), § 19). United Nations Convention on the Rights of the Child 132. This Convention is likewise a part of the legal order of the Czech Republic (Notice of the Federal Ministry of Foreign Affairs no. 104/1991 Coll., in conjunction with Article 1 of Constitutional Law no. 4/1993 Coll.). Article 3 § 1 provides: “In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.” Article 24 provides as relevant: “1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health ... States Parties shall strive to ensure that no child is deprived of his or her right of access to ... health care services. 2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures: (a) To diminish infant and child mortality; (b) To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care; (c) To combat disease ..., including within the framework of primary health care ...; ... (e) To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health ...; (f) To develop preventive health care ...” 133. According to General comment No. 15 by the United Nations Committee on the Rights of the Child in relation to the right of the child to the enjoyment of the highest attainable standard of health, published on 17 April 2013 (CRC/C/GC/15), the realisation of this right entails the universal availability of immunisation against the common childhood diseases. 134. In its Concluding observations as part of the periodic review of individual States, the UN Committee on the Rights of the Child often emphasises the need to strengthen the system of vaccination of children, including increased vaccination coverage, and recommends the full vaccination of all children. As regards the Czech Republic, in observations of 18 March 2003 the Committee noted that the vaccination uptake was excellent (CRC/C/15/Add.201, § 3). Documents of the World Health Organisation (WHO) 135. In its “Global Vaccine Action Plan” published in 2013 the WHO recommended attaining a national coverage rate of at least 90% in relation to all vaccines that form part of national immunisation programmes. As regards vaccination in general, it made the following observations: “Overwhelming evidence demonstrates the benefits of immunisation as one of the most successful and cost-effective health interventions known. Over the past several decades, immunization has achieved many things, including the eradication of smallpox, an accomplishment that has been called one of humanity’s greatest triumphs. Vaccines have saved countless lives, lowered the global incidence of polio by 99 percent and reduced illness, disability and death from diphtheria, tetanus, whooping cough, measles, Haemophilus influenzae type b disease, and epidemic meningococcal A meningitis. ... Immunization is, and should be recognized as, a core component of the human right to health and an individual, community and governmental responsibility. Vaccination prevents an estimated 2.5 million deaths each year. Protected from the threat of vaccine-preventable diseases, immunized children have the opportunity to thrive and a better chance of realizing their full potential. These advantages are further increased by vaccination in adolescence and adulthood. As part of a comprehensive package of interventions for disease prevention and control, vaccines and immunization are an essential investment in a country’s – indeed, in the world’s – future. ... The last century was, in many respects, the century of treatment, resulting in dramatic reductions in morbidity and mortality, with the discovery and use of antibiotics as one of the biggest agents of change in health. This century promises to be the century of vaccines, with the potential to eradicate, eliminate or control a number of serious, life-threatening or debilitating infectious diseases, and with immunization at the core of preventive strategies.” 136. One of the main aims of the WHO’s Global Immunisation Vision and Strategy is to immunise “more people against more diseases”. European Social Charter 137. The Social Charter entered into force in respect of the Czech Republic on 3 December 1999 (Notice of the Ministry of Foreign Affairs no. 14/2000 Collection of international treaties). It forms part of the legal order of the Czech Republic and in case of conflict has precedence over statute (Article 10 of the Constitution). The relevant provision reads as follows: Article 11 – The right to protection of health “With a view to ensuring the effective exercise of the right to protection of health, the Contracting Parties undertake, either directly or in co-operation with public or private organisations, to take appropriate measures designed inter alia : ... 3. to prevent as far as possible epidemic, endemic and other diseases.” 138. In the case of Médecins du Monde – International v. France (collective complaint no. 67/2011, decision on the merits of 11 September 2012) the European Committee of Social Rights explained, inter alia : “160. Article 11 § 3 requires states to ensure high immunisation levels, in order to not merely reduce the incidence of these diseases, but also to neutralise the reserves of viruses and thus to reach the objectives set by the [WHO]. The Committee underlines that vaccinations on a large scale are recognised as the most efficient and most economical means of combating infectious and epidemic diseases (see Conclusions XV-2, Belgium, Article 11 § 3). This concerns the population in general ...” 139. If the vaccination coverage in a Council of Europe Member State is too low, the Committee will find that the situation is not in conformity with Article 11 § 3 of the Charter (see e.g. Conclusions XV-2, Belgium, 31 December 2001), or it can warn the State concerned. The Committee considers the WHO targets to be the reference criteria. 140. In the conclusions of 2 January 2010 (XIX-2/def/CZE/11/3/EN) on review of the Czech Republic, the Committee found, pending receipt of the information requested, that the situation in the Czech Republic, including that in matters of immunisation, was in conformity with Article 11 § 3 of the Charter. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (Oviedo Convention) 141. The Oviedo Convention was opened for signature on 4 April 1997 and entered into force in respect of the Czech Republic on 1 October 2001 (Notice of the Ministry of Foreign Affairs no. 96/2001 Collection of international treaties). It forms part of the legal order of the Czech Republic and has precedence over statute in case of conflict (Article 10 of the Constitution). The relevant parts read as follows: Article 5 – General Rule “An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. The person concerned may freely withdraw consent at any time.” Article 6 – Protection of persons not able to consent “... 2. Where, according to law, a minor does not have the capacity to consent to an intervention, the intervention may only be carried out with the authorisation of his or her representative or an authority or a person or body provided for by law. The opinion of the minor shall be taken into consideration as an increasingly determining factor in proportion to his or her age and degree of maturity. ...” Article 24 – Compensation for undue damage “The person who has suffered undue damage resulting from an intervention is entitled to fair compensation according to the conditions and procedures prescribed by law.” Article 26 – Restrictions on the exercise of the rights “1. No restrictions shall be placed on the exercise of the rights and protective provisions contained in this Convention other than such as are prescribed by law and are necessary in a democratic society in the interest of public safety, for the prevention of crime, for the protection of public health or for the protection of the rights and freedoms of others. ...” Recommendation 1317 (1997) of the Parliamentary Assembly of the Council of Europe (PACE), entitled “Vaccination in Europe” 142. The relevant passages of the Recommendation, which was adopted on 19 March 1997, read as follows: “5. The Assembly considers that efforts to improve the immunisation level should not be concentrated solely on the plight of the countries undergoing transition. The immunisation level of populations in western Europe has been steadily declining in recent years. The low percentage of fully vaccinated people, coupled with outbreaks of infectious diseases in the same geographic area, raises fears of major epidemics in Western Europe too. 6. The Assembly therefore recommends that the Committee of Ministers invite member states: 6.1. to devise or reactivate comprehensive public vaccination programmes as the most effective and economical means of preventing infectious diseases, and to arrange for efficient epidemiological surveillance; ... 7. The Assembly furthermore invites the Committee of Ministers: 7.1. to define a concerted pan-European policy on population immunisation, in association with all partners concerned, for example the WHO, Unicef and the European Union, aimed at the formulation and observance of common quality standards for vaccines, and to ensure an adequate supply of vaccines at a reasonable cost; 7.2. to call upon member states to ratify the European Social Charter of the Council of Europe, in particular Article 11, securing ‘The right to protection of health’, and to instruct the Charter’s supervisory bodies to pay due attention to the fulfilment of this undertaking.” Resolution 1845 (2011) of the PACE, entitled “Fundamental rights and responsibilities” 143. The relevant passages of the Resolution, which was adopted on 25 November 2011, read as follows: “1. Rights, duties and responsibilities cannot be dissociated from each other. Living as members of society inevitably entails duties and responsibilities as well as rights. ... 4. Some duties are already established in international human rights instruments and national legal orders. These duties are indicative of the existence of unwritten fundamental responsibilities. 5. Duties imposed by law are subject to the proportionality principle. When a burden is placed on an individual, in the name of the general interest, a fair balance has to be struck between the various interests at stake. 6. Likewise, responsibilities can never be so heavy that assuming them would bring the individual’s rights, particularly his or her fundamental rights, into jeopardy. Responsibilities should remain reasonable at all times. ... 8. The Assembly: 8.1. hereby identifies the following set of fundamental responsibilities: 8.1.1. all individuals have the general fundamental responsibility ... to respect the rights of others whilst exercising their own rights; 8.1.2. furthermore, all individuals have specific fundamental responsibilities to respect and protect human life, ... to show solidarity, to act responsibly towards children, ...; 8.2. emphasises that these fundamental responsibilities can never be construed as impairing, restricting or derogating from the rights and freedoms contained in the [Convention], the revised European Social Charter ... and other international and regional human rights instruments; 8.3. calls on the member states of the Council of Europe to take these general and specific fundamental responsibilities into account in a proportional way when dealing with individuals.” Law of the European Union 144. Title XIV of Part Three of the Treaty on the Functioning of the European Union, in its consolidated version, deals with public health. Its relevant part reads: Article 168 “1. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities. Union action, which shall complement national policies, shall be directed towards improving public health, preventing physical ... illness and diseases, and obviating sources of danger to physical ... health. Such action shall cover the fight against the major health scourges, ..., their transmission and their prevention, as well as health information and education, and monitoring, early warning of and combating serious cross-border threats to health. ... 2. The Union shall encourage cooperation between the Member States in the areas referred to in this Article ...It shall in particular encourage cooperation between the Member States to improve the complementarity of their health services in cross-border areas. ... 3. The Union and the Member States shall foster cooperation with third countries and the competent international organisations in the sphere of public health. ... 5. The European Parliament and the Council ... may also adopt incentive measures designed to ... combat the major cross-border health scourges, measures concerning ... combating serious cross-border threats to health...” 145. Article 35 of the Charter of Fundamental Rights of the European Union, dealing with health care, and appearing under Title IV, “Solidarity”, provides: “Everyone has the right of access to preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices. A high level of human health protection shall be ensured in the definition and implementation of all the Union’s policies and activities.” 146. In response to a reference for a preliminary ruling submitted by the Supreme Court of Slovakia, originating in proceedings concerning parents’ duty to have their underage children vaccinated against certain diseases, the Court of Justice of the European Union issued an Order of 17 July 2014 in Milica Široká v Úrad verejného zdravotníctva Slovenskej republiky (Case C ‑ 459/13, EU:C:2014:2120, paragraph 25) to the effect that: “… there is no evidence in the order for reference to indicate that the objective of the main proceedings, relating to the vaccination of underage children against certain diseases, concerns the interpretation or application of a rule of Union law other than those set out in the Charter. It follows that the main proceedings do not correspond to a situation in which Union law is being implemented within the meaning of Article 51, paragraph 1, of the Charter.” 147. In 2005 the European Centre for Disease Prevention and Control was established. Its mission is to identify, assess and communicate current and emerging threats to human health posed by infectious diseases. 148. On 1 December 2014 the Council of the European Union adopted conclusions concerning vaccination as an effective tool in public health, noting, inter alia, that: “… communicable diseases, including some re-emerging ones, such as Tuberculosis, measles, pertussis and rubella, still present a public health challenge and can cause a high number of infections and deaths, and that the recent emergence and outbreaks of communicable diseases, such as polio, avian influenza H5N1 and H7N9 ... and Ebola virus disease have confirmed that vigilance must remain high also with respect to diseases that are not currently present in the territory of the Union. ... [V]accination programmes are the responsibility of individual Member States and ... various vaccination schemes exist in the EU ... [M]any vaccines used in community vaccination programmes have been able to prevent disease in individuals and at the same time interrupt the circulation of pathogens through the so-called ‘herd immunity’ phenomenon, contributing to a healthier global society. Community immunity could thus be considered an objective in national vaccination plans.” 149. The resolution of the European Parliament adopted 19 April 2018 on vaccine hesitancy and the drop in vaccination rates in Europe calls on Member States to ensure sufficient vaccination of healthcare workers, take effective steps against misinformation, and implement measures for improving access to medicines. It also calls on the Commission to facilitate a more harmonised schedule for vaccination across the European Union. 150. On 7 December 2018 the Council of the European Union adopted its recommendation on strengthened cooperation against vaccine ‑ preventable diseases. The recommendation recognises that vaccination is one of the most powerful and cost-effective public health measures developed in the twentieth century and remains the main tool for primary prevention of communicable diseases. Moreover, among the recommendations for Member States it includes the following: “1. Develop and implement vaccination plans, at national and/or regional level, as appropriate, aimed at increasing vaccination coverage with a view to reaching the goals and targets of the WHO’s European Vaccine Action Plan by 2020. These plans could include, for example, provisions for sustainable funding and vaccine supply, a life-course approach to vaccination, capacity to respond to emergency situations, and communication and advocacy activities. 2. Aim to achieve by 2020, for measles in particular, a 95 % vaccination coverage rate, with two doses of the vaccine for the targeted child population, and work towards closing the immunity gaps across all other age groups, with a view to eliminating measles in the EU. 3. Introduce routine checks of vaccination status and regular opportunities to vaccinate across different stages of life, through routine visits to the primary healthcare system and through additional measures taken, for example when beginning (pre-)school, in the workplace or in care facilities, according to national capacities.” 151. The 2018 report by the European Commission on the state of vaccine confidence in the EU includes the following observations: “High confidence in vaccination programmes is crucial for maintaining high coverage rates, especially at levels that exceed those required for herd immunity. Across the European Union (EU), however, vaccine delays and refusals are contributing to declining immunisation rates in a number of countries and are leading to increases in disease outbreaks. Recent measles outbreaks – the highest in the EU for seven years – illustrate the immediate impact of declining coverage on disease outbreaks.” EXPERT material relied on by the Government 152. On 6 November 2015 the Czech Vaccinology Society ( Česká vakcinologická společnost ), the key advisory body in the field of State vaccination policy in the Czech Republic, and the Czech Paediatric Society ( Česká pediatrická společnost ) issued a joint statement for the purposes of these proceedings before the Court. They, as well as the Association of General Practitioners for Children and Youth ( Sdružení praktických lékařů pro děti a dorost ) and the Czech Medical Chamber ( Česká lékařská komora ), resolutely supported maintaining the compulsory vaccination system as it exists in the Czech Republic. It was noted, inter alia, that vaccination was undoubtedly one of the most efficient preventive public health measures and that, since the introduction of compulsory vaccination, the occurrence of and deaths caused by vaccine-preventable diseases had radically dropped. Aiming mainly to protect children suffering from severe chronic diseases, for whom vaccination was ineffective or contraindicated, it secured high global vaccination coverage and averted human deaths and economic losses. Any failure to follow the immunisation schedule was dangerous both for the unvaccinated individual, since it increased the risk of health damage and even death caused by a preventable infectious disease in extreme cases, and for the entire population, if a higher percentage of children were not properly vaccinated. Should vaccination coverage even slightly decline and the non-immune population percentage rise, disease outbreaks could reappear even for diseases that are no longer common nowadays. 153. The Chief Medical Officer of the Czech Republic ( Hlavní hygienik České republiky ) issued an opinion for the purposes of the present proceedings before the Court. He referred to the concept of “herd immunity” as a special immunity phenomenon occurring when a significant proportion of the population was vaccinated against a specific disease, thereby providing a measure of indirect protection for individuals who had not been vaccinated or in whom immunity gained by vaccination had not developed. A dramatic drop in that coverage, for example to less than 95% in relation to measles, would mean that the herd immunity threshold would not be achieved, transmission of infections within the population could increase and the incidence of new cases of the disease could rise. 154. In 2010 the National Immunisation Commission ( Národní imunizační komise ) (“the NIC”) was set up as an advisory body of the Ministry with the principal mission to identify infectious diseases in respect of which the outbreak rate could be influenced by vaccination, to determine the optimum strategy for vaccination policy in the Czech Republic, to determine the State’s priorities in vaccination and to discuss proposals to amend the vaccination strategy. The NIC is composed of representatives of the Ministry and of a number of learned societies with relevant expertise. It has the power to request cooperation from other external experts. The minutes of its meetings are published on the Ministry’s website. 155. In 2015, in a special issue of its information bulletin, the State Agency for Drug Control (see paragraph 78 above) addressed the issue of adverse side-effects of vaccines, as reported in 2014. The vast majority of those effects had in fact been expected reactions, already described in the summary of product characteristics for the medicinal product concerned. 156. In June 2015 the Ministry set up the Working Commission for Vaccination ( Pracovní komise pro problematiku očkování ) to provide a broad platform for discussions between experts and the public about vaccination strategy in the Czech Republic, and included in its membership the Czech Human Rights League and ROZALIO, a third-party intervener before the Court in the present case. 157. In 2012 the Vaccine European New Integrated Collaboration Effort (VENICE), a network of national experts from all Member States of the European Union and Iceland and Norway working in the field of immunisation, published a study entitled “Mandatory and recommended vaccination in the EU, Iceland and Norway: results of the VENICE 2010 survey on the ways of implementing national vaccination programmes”. This study provides, inter alia, an overview of the compulsory vaccination situation in the countries concerned. Another overview of this situation was carried out by the Czech Parliamentary Institute in a report of June 2014. According to these sources, fifteen countries did not impose any compulsory vaccinations and fourteen countries required one or more vaccinations. In eight of the latter, vaccination was compulsory against the same or a higher number of diseases as in the Czech Republic. Although in some States vaccination of children was not compulsory in general, it could be ordered in specific cases, either collectively in response to an emergency or in other circumstances. As regards legislation on strict liability for health damage caused by vaccination, according to a WHO study published in 2011, only nineteen countries in the world had special compensation schemes, of which thirteen were Council of Europe member States. THE LAW PRELIMINARY OBSERVATION 158. At the outset, the Court points out that the present case relates to the standard and routine vaccination of children against diseases that are well known to medical science. These six applications, as indicated above, were introduced between 2013 and 2015 and concern the policy of the respondent State to make the set of relevant vaccines compulsory. JOINDER OF THE APPLICATIONS 159. Having regard to their similar subject matter, the Court finds it appropriate to examine the applications jointly in a single judgment (Rule 42 § 1 of the Rules of Court). ALLEGED VIOLATION OF ARTICLE 8 OF THE CONVENTION 160. The applicants complained that it had been arbitrary to impose a fine on Mr Vavřička and to refuse the child applicants admission to nursery school on account of the failure of the parents to comply with their statutory duty to have their children vaccinated according to the prescribed vaccination schedule. They relied on Article 8 of the Convention, the relevant part of which reads as follows: “1. Everyone has the right to respect for his private ... life ... 2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.” AdmissibilityApplication of Mr Vavřička Application of Mr Vavřička Application of Mr Vavřička 161. In relation to the amount of the fine imposed on the applicant, the Government pointed out that it was rather negligible (equivalent to EUR 110 at the relevant time). The applicant had not therefore suffered any significant disadvantage within the meaning of Article 35 § 3 (b) of the Convention. Moreover, in their view the remaining conditions for the application of this provision were also fulfilled, as a result of which the application was inadmissible as a whole. 162. The applicant argued that, at the relevant time, he had been unemployed, had no income and was going through divorce proceedings. The amount of the fine represented more than half of the statutory minimum monthly wage at the time. In addition to the financial burden it had placed on him, he had been distressed by uncertainty as to what other measures the authorities would take in response to his failure to respect the vaccination schedule concerning his children. 163. The Court will here examine the Government’s objection in so far as it concerns the applicant’s complaint under Article 8. It considers that this objection cannot be accepted. This application, along with the others, is now before the Court’s Grand Chamber because it was indeed considered to raise serious questions affecting the interpretation of the Convention or the Protocols thereto and therefore relinquished in accordance with Article 30 of the Convention, neither of the parties having availed themselves of their power to object to this. Moreover, the application of Mr Vavřička raises a distinct aspect, as he alone was subject to a fine for non-compliance with the vaccination duty. The Court is thus of the view that the conditions set down in Article 35 § 3 (b) are not met, since in any event respect for human rights as defined in the Convention and the Protocols thereto requires an examination of this part of Mr Vavřička’s application on the merits. 164. The Government’s objection under Article 35 § 3 (b) of the Convention, in so far as it relates to this applicant’s complaint under Article 8, must accordingly be dismissed. Applications of Mr Brožík and Mr Dubský 165. In relation to their applications as a whole, the Government pleaded non-exhaustion of domestic remedies, pointing out that the merits of the case had been decided by the judgment of the Hradec Králové Regional Court of 10 May 2016 (see paragraph 55 above) and that the applicants could and should have pursued their case further by way of a cassation appeal and a constitutional appeal. 166. In reply, the applicants pointed out that their applications concerned their request to the Regional Court of 18 July 2014 for an interim measure and the outcome of those proceedings. In that regard, the final domestic decision was that of the Constitutional Court of 23 October 2014 (see paragraph 54 above). As that decision was final and not subject to any further appeal, the requirement of exhaustion of domestic remedies had undoubtedly been satisfied. 167. The Court will start by examining the Government’s objection in so far as it concerns the applicants’ complaints under Article 8. To put both the objection and the applicants’ reply in perspective, the Court notes that, in their application forms, the applicants relied on Article 6 § 1 of the Convention and directed their complaints against the dismissal of their application for an interim measure in the course of the proceedings on the merits. Anticipating that the latter proceedings would last beyond their preschool age and that their outcome could by then no longer bring about any change in the fact that they had been prevented from attending nursery school, the applicants argued that by not granting them the interim measure the domestic courts had in fact denied them an effective remedy under Article 13 in respect of what they considered to be a violation of their rights under Articles 8 and 14 of the Convention and Article 2 of Protocol No. 1. 168. The Court has already characterised these complaints as falling, inter alia, under Article 8 of the Convention and it was on that basis that the two applications were communicated, to which there was no objection from the parties. 169. The Court reiterates that it is the master of the characterisation to be given in law to the facts of a case, and is not bound by the characterisation given by an applicant or a Government (see, for example, Molla Sali v. Greece [GC], no. 20452/14, § 85, 19 December 2018, and also Radomilja and Others v. Croatia [GC], nos. 37685/10 and 22768/12, §§ 123-26, 20 March 2018). In view of the Court’s interpretation of the object of all the applicants’ Article 8 complaints, as addressed in more detail below, it considers that the Government’s non-exhaustion plea in relation to the cases of Brožík and Dubský raises issues that are closely linked to the merits of their Article 8 complaint. 170. Accordingly, in so far as it relates to that aspect of these two applications, the Government’s objection should be joined to the examination of the merits of the complaint raised under Article 8. Conclusion in relation to all the applications 171. The Court notes that the applicants’ Article 8 complaints are not manifestly ill-founded within the meaning of Article 35 § 3 (a) of the Convention. It further notes that they are not inadmissible on any other grounds. They must therefore be declared admissible. MeritsThe parties’ submissions The parties’ submissions The parties’ submissions (a) The applicants 172. The applicant Vavřička complained that it had been arbitrary to impose a fine on him for his failure to have his children vaccinated in accordance with the applicable schedule. The child applicants argued that it had been arbitrary to refuse them admission to nursery school for the same failure on the part of their respective parents. 173. As regards the applicability of Article 8, the applicants invoked their right to personal autonomy in making decisions concerning their health and, in the case of Mr Vavřička, the health of his children. The child applicants also relied on their right to personal development in the context of attending nursery school. The applicants further referred to a right of parents to care for their children in accordance with their opinions, convictions and conscience and in keeping with the children’s best interests. In that regard, they submitted that the best interests of a child were to be primarily assessed and protected by his or her parents, any State intervention being permitted only as a last resort in the most extreme circumstances. 174. They further submitted that since the detailed arrangements for the vaccination duty had been laid down only in secondary legislation (the Ministerial Decree), it could not be considered as being “prescribed by law” within the meaning of Article 8. 175. Moreover, in their view the process of defining the vaccination schedule was not transparent, lacked proper analysis and any public debate and suffered from a conflict of interest on the part of some members of the official bodies involved. In particular, relying on a reply of the Ministry dated 7 February 2020 to their enquiry, the applicants argued that the authorities had failed to provide them with sufficient information showing that the existing compulsory vaccinations were in fact necessary and justified. Furthermore, in defining the vaccination policy, the Ministry had wielded unlimited discretion. 176. In addition, the applicants contended that in a system with compulsory vaccination there was an incentive for fraudulent reporting of vaccination status. This problem did not arise in systems based on voluntary vaccination, which for this reason produced more reliable statistical data on vaccination uptake. In turn, these data could serve to shape the system in a more adapted and efficient way. 177. In so far as the Government relied on the authority of the learned societies specialised in the area of vaccinology in the Czech Republic or of the WHO (see paragraphs 152 et seq. above), the applicants submitted that these were broadly sponsored by pharmaceutical corporations. In particular, the applicants disagreed on matters such as the impact of vaccination on reducing mortality, the susceptibility of infants to infections, the negative impact of non ‑ vaccination and the effectiveness of some of the prescribed vaccines. Moreover, they addressed various aspects of the functioning and development of the vaccination system, for example the interpretation in the Czech Republic of the criterion of permanent contraindication to vaccination. Furthermore, the applicants submitted that in so far as potential side-effects of compulsory vaccines played a role in the assessment of their necessity and justification, these should include not only the immediate side-effects but also long-term side-effects consisting of a general weakening of the vaccinated persons’ immunity to various illnesses. 178. It was not justified to refuse access to nursery schools as a form of punishment for the fact that the children were not vaccinated. The refusal of admission to preschool had meant that the families of the child applicants had had to provide care for them by their own means, which had impacted on the family as a whole, both financially and socially. Depriving the child applicants of preschool education had put them at a significant disadvantage in their subsequent education. This was particularly important for the applicant Novotná, who was interested in pursuing a particular educational model. 179. The applicants argued that the Vavřička jurisprudential exception to the vaccination duty (see paragraphs 28 and 93 above) was almost never granted in relation to admission to nursery school. Moreover, the applicant Vavřička argued that in his case it had been defined by the Constitutional Court in a retroactive manner. On that ground, he claimed that the law at the relevant time had been lacking in quality and that he could not have made proper use of it. 180. As regards the consistency of the attitude of the applicant Vavřička towards the issue of vaccination, given that he had had his children vaccinated against all of the illnesses except for poliomyelitis, hepatitis B and tetanus, he submitted through his lawyer that he was entitled to change his convictions over the course of time. As recognised by the Constitutional Court, what counted was whether or not the conviction remained constant throughout the respective proceedings, and this had been so in his case. 181. In addition, the applicants argued that any judicial review available was merely formal and did not involve any real substantive review of the rationality and proportionality of the vaccination duty. 182. Furthermore, at the relevant time the law did not provide for any means of claiming compensation in respect of non-culpable vaccine injury to health. Under the compensation mechanism that was subsequently introduced, compensation was available only in the event of a “particularly grave injury to health”, which was a prohibitively high threshold (see paragraph 84 above). 183. In contrast to the child applicants, for whom having been vaccinated was a prerequisite for admission to nursery school, there was no such condition for the employment of nursery school staff. Some of the statutorily prescribed vaccines concerned illnesses that were not transmissible, or not transmissible in a nursery school setting. 184. In the view of the applicants, the aim of protecting the health of other children could be achieved by less intrusive means, such as the exclusion of unvaccinated children from educational establishments only in the event of a threatened or actual outbreak of one of the diseases. 185. The applicants acknowledged that vaccination involved issues of general interest, social solidarity and shared responsibility. The problem was that of proportionality. A voluntary vaccination model was based on positive motivation and was therefore both more efficient overall and more proportionate than the mandatory model based on compulsion that was in place in the Czech Republic, which they considered unacceptable. 186. The interference with the applicants’ Article 8 rights had accordingly not been necessary in a democratic society. (b) The Government 187. The Government emphasised that it was important to clarify who was the applicant in each case – child or parent – so as to determine whether and to what extent the matters complained of fell within the Court’s jurisdiction ratione personae. 188. Regarding the issue of the best interests of the child, which was at stake in cases such as the present ones, the Government considered that it was reflected in the right of the child to the enjoyment of the highest attainable standard of health within the meaning of Article 24 of the Convention on the Rights of the Child. In individual cases, the child’s best interests were to be assessed in the light of any objections of the parents, which were to be examined in the appropriate proceedings, ultimately with an element of judicial control. 189. It was accordingly not possible a priori to presume that the interests of the parents were identical to those of the children. There was at least a potential for conflict between the respective interests. 190. Responding to the argument of the applicant Roleček that in consequence of his non-admission to nursery school his mother had been obliged to stay at home with him and that, as a result, their family life had been impacted, the Government noted that the fact that family members were required to enjoy each other’s company in this way could not constitute an interference with the right to respect for family life. 191. Moreover, the Government pointed out that the parameters of the present applications were limited to the facts that directly concerned the applicants and did not include other aspects of the Czech vaccination scheme as it had evolved over time. 192. Nevertheless, the Government did not contest that the facts of the six applications fell within the scope of the right to respect for private life and acknowledged that, regarding the applicant Vavřička, the fine imposed on him constituted an interference with that right. 193. As to the child applicants, irrespective of slight distinctions in how their Article 8 complaints before the Court had been formulated, in view of the actual consequences for them, consisting of their non-admission to nursery school, they were all in fact in the same position. The existence as such of the applicable legal framework did not amount to an interference with their Article 8 rights. To that end, the Government sought to distinguish the child applicants’ cases from those such as, for example, Dudgeon v. the United Kingdom (22 October 1981, § 41, Series A no. 45), Norris v. Ireland (26 October 1988, § 38, Series A no. 142) and Modinos v. Cyprus (22 April 1993, § 29, Series A no. 259), in that the legislative restrictions imposed on the child applicants were not absolute but subject to exceptions and applied only for a limited time (until the mandatory school attendance age – see paragraph 82 above). 194. Moreover, the non-admission of the child applicants to nursery school was due to their parents’ failure to comply with a statutory duty, on subjective grounds put forward by the parents. It was questionable whether it had been in the best interests of the applicants to have been prevented by their parents from attending nursery school and spending time with children of a similar age. The Government pointed out that, unlike in Boffa and Others v. San Marino (no. 26536/95, Commission decision of 15 January 1998, Decisions and Reports (DR) no. 92-B, p. 27), these applicants were the children and what was at stake in their case was their non ‑ admission to a childcare establishment rather than a fine or any other type of penalty. Furthermore, attending nursery school was a public activity and it accordingly fell outside the scope of Article 8 of the Convention. In addition, there were alternative ways of developing one’s personality and the child applicants’ inability to attend nursery school had not fundamentally interfered with their right to development and education. Accordingly, in the Government’s submission, there had been no interference with the child applicants’ Article 8 rights. 195. Should the Court nevertheless find that there had been an interference, the Government maintained that it had been duly “prescribed by law”. The domestic legal framework consisted of the rules on the duty to vaccinate in conjunction with the rules on liability for a minor offence where the duty was not complied with, and also the rules governing admission to childcare establishments. Those rules had the quality of “law” in terms of the Court’s case-law; in so far as they originated in secondary legislation, they were subject to judicial review. Moreover, the constitutionality of the given legislative arrangement had been repeatedly examined and upheld by both the SAC and the Constitutional Court. 196. There was no real dispute about the legitimacy of the aim served by the impugned interference, which was the general interest of society in protecting public health as well as the protection of the rights and freedoms of others. In more concrete terms, vaccination protected those vaccinated as well as others, in particular vulnerable persons who could not themselves be vaccinated or in respect of whom immunisation had been ineffective. While vaccinations were voluntary in some countries and compulsory in others, the underlying aim was the same and vaccination was the safest and the most cost-effective way of achieving it. 197. In relation to the necessity of any interference in abstracto, the Government relied on their positive obligations under the Convention to take measures in the sphere of protection of life and referred to their similar obligations under other international legal instruments. More specifically, States were under a positive obligation to put in place effective public health policies for combating serious and contagious diseases and to protect the life and physical integrity of those within their jurisdiction. In that regard, it was relevant that the diseases in respect of which vaccination was compulsory were all very serious and mostly highly contagious. The risk of these diseases spreading was amplified by the current high level of migration. As these diseases had now effectively been controlled, public and media attention had shifted away from disease prevention to vaccine safety. This had the potential to distort the perception of reality and to generate vaccine misinformation, which in turn could result in decreasing vaccination rates and the possible return of previously controlled vaccine ‑ preventable diseases. Vaccine hesitancy was recognised as a serious global problem. Making vaccination compulsory was a natural response, in that it was demonstrated that it led to an improvement of the vaccination coverage. Other European States were resorting to this approach. 198. In the Czech Republic, vaccines were provided free of charge by the State. The vaccination duty was primarily aimed at children because they were the most vulnerable. In a preschool setting they were inevitably exposed to a higher risk of infection. Therefore, carrying out vaccination at a young age was conducive to achieving the overall aims of the vaccination policy. In that regard, the Government acknowledged that not all of the vaccines that were mandatory in the Czech Republic were aimed at achieving herd immunity and submitted that the herd immunity thresholds varied according to the specific illness in question. 199. The vaccination duty was not directly enforceable and any sanctions for a failure to respect it were merely administrative, with a fine only being imposable as a last resort and only once. 200. The scope of the vaccination duty was determined by the Ministry on the recommendation of its advisory board of epidemiologists and, since 2010, the NIC (see paragraph 154 above). In compliance with the requirements of the Disclosure Code of the European Federation of Pharmaceutical Industries and Associations and those of the WHO, at the beginning of every meeting of the NIC each of its members had to make a declaration as to any conflict of interests he or she might have in relation to any item on the meeting’s agenda. As for the NIC’s membership, the fact that it was limited to officials and experts reflected the prevailing practice among European States. 201. The Government rejected the applicants’ criticism that the Czech vaccination scheme was not based on proper scientific analysis. In particular, publicly available serological surveys had been performed since 1960. Both the scope and the parameters of the scheme were under constant review and there was a comprehensive mechanism in place for monitoring any adverse effects of pharmaceuticals, including vaccines. 202. A vaccination could only take place after a check-up for fitness and there were statutory as well as case-law exceptions. The latter had been defined by the Constitutional Court in the Vavřička case (see paragraph 28 above) and required no legislative implementation. Although it was true that there were no concrete examples that could be cited of application of the case ‑ law objection of conscience in relation to nursery-school admission, the exception was applicable in that context, in particular if there had been any adverse health effects of vaccination in the family of the child concerned. 203. In addition, the legislation left a certain leeway to the parents in selecting the vaccines to be used and the relevant dates, within a defined period for vaccination. Moreover, experience showed that the vaccination policy in place was in fact successful and all relevant Czech expert societies were clearly in favour of preserving it (see paragraphs 152 et seq. above). Any fines or non ‑ admissions to nursery school in connection with a failure to comply with the vaccination duty had to be based on a reasoned decision that was subject to judicial review at several levels of jurisdiction. As there was clearly no European consensus on the matter of compulsory vaccination, the margin of appreciation left to the Member States was wide. An additional reason for allowing a wide margin was that the issue involved the assessment of expert and scientific data by the national authorities. 204. As regards the six applications in concreto, the Government emphasised that as no vaccination had actually taken place against any parent’s wishes, there had been no interference with anyone’s physical integrity. None of the applicants had shown at the national level that any of the criteria for an exemption from the vaccination duty on the basis of religion, conscience or otherwise, had been met. The applicants had rather relied on no more than a generally dismissive attitude towards vaccination. In particular, in the proceedings brought by the applicants Novotná, Hornych and Roleček, the SAC had specifically noted that they had neither invoked any fundamental rights or freedoms nor relied on any exceptional circumstances at all. 205. While it was true that no specific vaccination requirement applied to the hiring of nursery school personnel, such persons were subject to the general vaccination duty applicable to anyone residing on the territory of the Czech Republic. It was thus highly unlikely that such personnel would not have previously received the relevant primary or booster vaccinations, in line with that duty. 206. As regards the possibility to claim compensation in respect of damage to health due to vaccination performed in accordance with the applicable rules and standards, the Government confirmed that there was no provision for granting compensation in respect of any such damage occurring after 31 December 2013. However, any damage caused prior to that date would be covered by the previous legislative regime, which had provided for compensation. New legislation adopted in 2020 made provision for this once again (see paragraph 84 above). This legislative development was due to the fact that, under the original regime, it was the healthcare provider administering the vaccine who could be held strictly liable for damage to the patient’s health. However, as that liability essentially had to do with the public interest, it should rest with the State. 207. Moreover, the costs of the treatment of any harmful side-effect of vaccination would be covered by public health insurance. Nevertheless, serious side ‑ effects, i.e. with life-long health consequences, were rare, with no more than six such incidents per year for 100,000 vaccinated newborns. 208. Although the jurisprudential exception to the vaccination duty on the basis of the right to freedom of religion or belief had been recognised for the first time by the Constitutional Court in the Vavřička case, this did not render the domestic courts’ interpretation and application of the existing legislation arbitrary. Regarding the applicant Novotná, the fact that the decision not to admit her to nursery school was taken in reopened proceedings after she had initially been admitted and had in fact been attending the school for two years had to be considered in the light of the fact that the original admission had been granted on the basis of incorrect information, provided by her. In providing that information she had assumed the risk that the admission decision might be reviewed once this came to light. Regarding the applicant Hornych, there was a similar anomaly in the information provided by his parents in the context of his application to nursery school. Finally, in relation to the applicant Novotná, the Government argued that attendance at a particular type of nursery school was not in fact a precondition for enrolment in an elementary school using the same teaching methodology. In any event, the non-admission of the child applicants to nursery school had not prevented them from developing social relations in other settings and contexts. 209. Relying on the Constitutional Court’s case-law, the Government concluded by submitting that, as an immunisation tool preventing selected diseases, vaccination in general constituted a social benefit calling for shared responsibility on the part of the members of society and for social solidarity from each individual, who assumed a minimum risk in order to protect public health. Submissions of the third-party interveners (a) The Government of France 210. The French Government emphasised the importance for States to be able to adopt effective public health policies to combat serious and contagious diseases, as clearly illustrated by the COVID-19 pandemic. 211. In France, the law of 30 December 2017 provides for the compulsory vaccination of children aged up to 24 months against eleven diseases. Previously, vaccination was compulsory in relation to three of these diseases; regarding the other eight, it was simply recommended. With one exception, the list of illnesses is identical to that in the Czech Republic. Under French law, persons with a medical contraindication are exempted from the duty. The law of 30 December 2017 increased the potential penalty for a breach by a parent of the child vaccination duty, from a term of imprisonment of up to six months and a fine of up to EUR 3,750 to a term of imprisonment of up to two years and a fine of up to EUR 30,000. Compliance with the vaccination duty is a prerequisite for admission to childcare structures and services as well as to the education system ( collectivité ). In the absence of a required vaccination, a child may be admitted provisionally on condition that they are fully vaccinated within three months. Continued attendance is subject to proving each year that the vaccination duty has been complied with. 212. Accepting that compulsory vaccination is an interference with the right to respect for private life, the French Government underlined that it served the legitimate aim of protecting health. The necessity of the interference should be assessed in the light of the States’ positive obligations to protect the life and physical integrity of those within their jurisdiction. The importance of those obligations had recently been emphasised by the Secretary General of the Council of Europe in a document entitled “A toolkit for member states – Respecting democracy, rule of law and human rights in the framework of the COVID-19 sanitary crisis”. As there were competing Convention rights at stake and no European consensus over compulsory vaccination, the French Government invited the Court to recognise that, in matters of public health policy and the prevention of the spreading of very serious diseases, the States enjoy a wide margin of appreciation, since they were in the best position to assess, in the light of the health situation on their territory and the means at their disposal, the measures necessary to protect public health. 213. Compulsory vaccination was justified by the serious adverse public health effects of low vaccination coverage. It was important to protect children from an early age and before the onset of a period of risk. In order to protect the community effectively, a vaccination policy had to apply to the greatest possible number of people. A high rate of vaccination was particularly important to protect those who could not be vaccinated. 214. If vaccination were merely voluntary, it was clear that some would seek to benefit from the effect of herd immunity without exposure to the residual risk associated with vaccination. If such behaviour were to become widespread, it would inevitably cause a decrease in vaccination coverage and ultimately the reappearance of pathologies that were thought to be in decline. 215. The French Government referred to Recommendation No. 1317 (1997) of the Parliamentary Assembly of the Council of Europe entitled “Vaccination in Europe”, to Article 11 of the European Social Charter (Revised), and to the Recommendation of the Council of the European Union on strengthened cooperation against vaccine-preventable diseases (2018/C 466/01) (see paragraphs 137, 142 and 150 above). The diseases in question were all very serious, and most of them highly contagious. The effectiveness of the compulsory vaccines was recognised, their negative side effects were limited and medical contraindications were taken into account. The interference represented by such a compulsory vaccination scheme with the right to respect for private life was accordingly proportionate to the objective of promoting the degree of vaccination coverage needed to reach the herd immunity threshold for the benefit of the entire population. (b) The Government of Germany 216. The German Government clarified that compulsory vaccination referred to a duty to receive vaccination in defined situations, not to the coercive administration of a vaccine. They described the context in which domestic legislation had been adopted after an extensive societal and parliamentary debate, with effect from 1 March 2020, providing for compulsory vaccination against measles. Certain categories of persons are required to provide proof of vaccination, immunity or medical contraindication to vaccination before receiving care or being employed in specified types of facilities, including schools and other educational establishments. The vaccination duty is enforced indirectly by the threat of a penalty of up to EUR 2,500, which may be repeated under certain circumstances, and exclusion from educational institutions. The latter are under a duty to report unvaccinated children to the public health authorities. It is not possible to coerce a person into vaccination; consent is always required. Children under the age of one year are exempted. Other exemptions are based either on purely medical grounds or on the non ‑ availability of a vaccine. There are no exceptions permitted on the basis of religion or belief. Compensation is available for any adverse effects even where the vaccine has been administered in conformity with the applicable rules. 217. The German Government observed that compulsory vaccination aimed to protect not only those vaccinated but also society as a whole and, in particular, vulnerable persons who cannot be vaccinated themselves on account of their age or state of health. If the vaccination rate is sufficiently high, the threshold for measles being 95% of the population, a given disease can be eliminated. Despite efforts to raise awareness, the rate of voluntary vaccinations achieved in Germany never reached more than 93%. This was the challenge faced by the legislature when adopting the legislation. 218. In the interest of achieving the 95% threshold, compulsory vaccination starts at a young age. Moreover, young children are particularly vulnerable to measles, given their immature immune systems. In that context, the German Government referred to the recommendation by the respective body of the Robert Koch Institute, the country’s central scientific institution in the field of biomedicine, to the effect that children should be vaccinated twice against measles before they reach the age of two. Moreover, the German Government considered that the compulsory vaccination scheme was best managed in the context of long ‑ term care such as preschools and nurseries, all the more so in view of the increasing number of children attending such facilities. 219. As already established in the relevant Convention case-law, compulsory vaccination constituted an interference with the right to respect for private life, its compatibility with the provisions of Article 8 depending mainly on respect for the principle of proportionality. 220. A penalty for disrespecting the vaccination duty and exclusion from educational institutions as a consequence of it constituted a real but merely indirect interference with personal integrity. The interest in protecting public health and above all the health of those who cannot be vaccinated was of fundamental significance. The State had positive obligations under Article 2 of the Convention in that regard. The vaccinated person not only carried the burden of vaccination but also benefited from the protection it procured. The above-mentioned 93% vaccination rate had been achieved voluntarily, showing that vaccination was widely accepted by the population. The reasons for parents not to have their children vaccinated had mostly to do with convenience and carelessness. Such cases were easily addressed by a legal duty of vaccination. This constituted no major interference with individual rights but merely a small individual sacrifice. Only a small proportion of the population opposed vaccination as a matter of principle. Once the 95% threshold was reached, the disease would be eliminated, further vaccination would no longer be necessary and the vaccination duty would become dispensable. 221. In any event, the Contracting Parties enjoyed a wide margin of appreciation with regard to their health care systems and policies. (c) The Government of Poland 222. The Polish Government submitted that compulsory vaccination schemes did not constitute a violation of the Convention and the sanctions applicable in this context were compatible with the second paragraphs of Articles 8 and 9. 223. Consent to medical treatment was vital to the principles of self ‑ determination and personal autonomy. An involuntary medical treatment constituted an interference with physical and moral integrity. Epidemics of infectious diseases might lead to sanitary, social and economic crises. The Contracting Parties were obliged to combat such diseases in humans. Vaccinations were an optimal preventive measure in that they not only reduced the number of those infected but also could lead to a complete elimination of a given illness. By promoting “herd immunity”, they protected not only those vaccinated but also others who could not be vaccinated. The more people were vaccinated, the better the community’s resilience. Vaccinations were therefore primarily addressed to the youngest generation. According to the current state of medical knowledge, there were no better preventive measures. Widespread vaccination was also recommended by the European Centre for Disease Prevention and Control (see paragraph 147 above). 224. Vaccinations played an important role in shaping public health. They reduced the social consequences of health complications in connection with infectious diseases, including those related to the costs of the necessary treatment. The compulsory vaccination system thus enabled effective prevention of the spreading of dangerous infectious diseases, striking a balance between the fulfilment of the State’s obligations towards citizens to provide the highest level of public health to as many persons as possible and those of citizens towards the State to comply with the vaccination duty. The cost-effectiveness of vaccinations was also a relevant factor. 225. In Poland, a vaccination duty had existed for nearly 60 years as a duty of an administrative nature. It was currently provided for by a statute of 2008, accompanied by a 2011 ordinance of the Minister of Health, adopted on the basis of that statute. In addition, every year the Chief Sanitary Inspector issued Protective Vaccination Programmes addressed to healthcare professionals implementing the compulsory vaccination scheme. Vaccination against eleven diseases currently found on the territory of Europe was compulsory for anyone residing in the Polish Republic. The State Sanitary Inspection was required to enforce compliance with the vaccination duty in relation to children by using administrative powers, the respective regulation and its enforcement never having been challenged. The State was responsible for the safety of the vaccination procedures and it bore the cost of vaccination as well as of the treatment of any possible side ‑ effects. There was also the possibility of opting for commercially obtainable vaccines, the cost of which was not borne by the State. 226. As there was a diversity of legal and healthcare systems, it was inevitable that the Contracting Parties resorted to varying solutions to ensure a sufficient level of vaccination, reflecting the social, economic and cultural differences between them and the local conditions, habits and expectations as well as each country’s economic possibilities. In the absence of a pan ‑ European consensus, the Contracting Parties had a wide margin of appreciation to make arrangements to the best of their knowledge and possibilities. The assessment of the specific system of sanctions in each Contracting Party should not lead to the undermining of the compulsory vaccination system in general. The proportionality of the solutions adopted was rather to be assessed on a case-by-case basis. (d) The Government of Slovakia 227. The Government of Slovakia noted that the present cases were not about the vaccination duty as such but rather about the consequences of non ‑ compliance with that duty, a distinction that was relevant for the assessment under Article 8 of the Convention. 228. Observing that there was no uniform approach among Council of Europe member States, the Government referred to the arrangement in place in Slovakia. There the vaccination duty was laid down in legislation, consisting of an Act of Parliament and an implementing executive decree. The duty applied to everyone, except if there were health contraindications. There was no mechanism for physically enforcing compliance. However, the attending doctor was duty bound to explain to the patient, or to his or her statutory representatives, all relevant aspects and effects of the vaccination to be given. If still not accepted, the doctor had to report the case to the relevant public health authorities, who would summon the person in question for an interview. A persistent refusal to comply could then be seen as a minor offence punishable by a fine of up to EUR 331. The legislation in force did not provide for the exclusion of unvaccinated children from preschool establishments. 229. The Government referred to a judgment of 10 December 2014 (case no. PL. US 10/2013), in which the Constitutional Court of Slovakia found the vaccination duty to be constitutional. It considered that the State was under a positive obligation to ensure the protection of public health. The legislature’s decision to comply with that obligation by means of compulsory vaccination was primarily of a political and expert nature falling within a broad margin of appreciation. It could contravene the individual right to protection of health if it were to be administered despite medical contraindications or if any general adverse effects of vaccination were demonstrated. However, such was not the case. Mandatory vaccination set two constitutional principles in opposition with one another: the protection of public health and respect for private life. It was not possible to reconcile both principles without fundamentally limiting one of them. The specific contraindication exemption was accompanied by a duty on the attending doctors to enquire into the existence of any contraindications prior to administering any vaccine. As with regard to any medication, the quality and safety of vaccines were supervised by the State Agency for Drug Control. In addition to healthcare providers, who were under a duty to report any suspicion of serious or unexpected side-effects of vaccines, any patient, or – in the case of child patients – their parents, could do so. Moreover, the legislative framework provided for compensation in respect of damage to health resulting from a vaccination performed contrary to the applicable rules. There were, to the existing level of medical knowledge, no other effective means to reduce or eradicate infectious diseases. The interference represented by compulsory vaccination with an individual’s right to respect for private life was accordingly justified by the interest in the protection of public health that it served. While it was true that some countries provided for compensation also in respect of health damage resulting from a vaccination performed in accordance with the applicable rules, the absence of such a scheme in Slovakia had no impact on the above conclusion. 230. The Government added that, specifically with regard to children, the crucial criterion was that of their best interests. This was to be determined by whether or not there was any health contraindication to vaccination. A refusal to vaccinate a child without contraindications could be seen as being contrary to his or her best interests. It was accordingly necessary to ensure compliance with the applicable rules by way of sanctions. It was important to protect children from a young age and especially those who could not be vaccinated on account of contraindications. (e) Společnost pacientů s následky po očkování, z.s. (Association of Patients Injured by Vaccines) 231. The intervening association represents patients who suffer from health problems as a result of having been vaccinated. On that basis it described the situations of children who had not been vaccinated at all or were not in full compliance with the applicable vaccination schedule. Those situations mostly involved the children not being admitted to nursery schools, the mother losing her job as she was left with no alternative but to stay at home with her child and the family losing a source of income. Nonetheless, those families would rather change their lifestyle than expose their children to the risks inherent in vaccination. 232. The existing system in fact ignored individual needs stemming, for example, from previous adverse effects on the child in question or its relatives. This was partly the result of an insufficient level of independent knowledge of the risks and negative effects of vaccination among paediatricians, whose continuing education was often sponsored by the pharmaceutical industry. Moreover, there was a lack of transparency as to the criteria for and the method of defining the compulsory vaccination schedule at the expert level. This created room for arbitrariness on the part of the executive and gave rise to mistrust and resistance on the part of the public. This in turn called for counter-measures by the proponents of vaccination, with the overall effect of polarising society and stigmatising those opposed to vaccination. Such counter-measures consisted of: (i) enforcing the duty on paediatricians to perform vaccination; (ii) massive media campaigns promoting vaccination, funded by the pharmaceutical industry; (iii) the exercise of judicial power in a manner sympathetic to the vaccination duty, in particular by the Constitutional Court; and (iv) a disinformation campaign by official bodies promoting vaccination. 233. The number of compulsory vaccinations and the tight schedule for administering them did not allow in practice for the assessment of any individual needs. For similar reasons, vaccination was also performed in situations in which the patient was not sufficiently healthy to receive it. In addition, in view of the interpretation given in practice to the term “permanent contraindication”, it was not feasible to satisfy this ground for an exemption from the vaccination duty. 234. These features of the existing system had an extensive impact on the children concerned and their families. There was a variety of other and strikingly different arrangements at the European level, including in neighbouring countries with an epidemiological situation similar to that in the Czech Republic, where the vaccination system was the strictest. Were the Court to find that the Czech approach was not at odds with Convention requirements, the situation could even worsen and this trend could spread to other jurisdictions. Should the Court find the opposite, the respondent State would be required to limit the power of the executive to define and apply the criteria for and the method for establishing the vaccination schedule and to open this matter to a wider public and political debate. (f) European Centre for Law and Justice (ECLJ) 235. In so far as the intervention of the ECLJ concerned Article 8, this third-party intervener pointed to the importance of the present case in that it concerns respect for the physical and moral welfare of the human being, as guaranteed by the principles that such welfare must prevail over the sole interest of society or science and that an intervention in the health field may be carried out only with the free and informed consent of those concerned, as established in Articles 2 and 5 of the Oviedo Convention. It emphasised the need for regulating these matters, in particular in view of the experience of several countries in the 20th century with regard to various policies in the fields of health and eugenics, and considered that in so doing use could be made of the case-law principles stemming from the cases decided by the Court concerning forced sterilisation. The present cases involved a situation of strongly encouraging individuals to submit to the vaccination duty by means of the threat of a sanction. As no forced vaccination had taken place, the principal question was not so much the legitimacy of the vaccination duty but rather of the sanction imposed on the applicants for failing to comply with it. 236. The intervener submitted that the physical integrity of a person was covered by the concept of “private life” protected by Article 8 of the Convention and that compulsory vaccination – as an involuntary medical intervention – amounted to an interference with that right. The main problem was the question of the necessity of the measures taken by the authorities in relation to the applicants in support of the vaccination policy. 237. In that respect, an adequate approach was to seek to reconcile the competing rights and interests rather than merely to set them against each other. The conciliatory approach involved seeking compromise and applying principles of pluralism and tolerance. 238. The intervener noted that in countries such as Austria, Cyprus, Denmark, Estonia, Finland, Germany, Ireland, Lithuania, Luxembourg, the Netherlands, Norway, Portugal, Spain, Sweden and the United Kingdom, vaccination was not compulsory. Other countries imposed vaccination in respect of between one (Belgium) and twelve (Latvia) diseases. The usefulness and necessity of compulsory vaccination had not been established. 239. Placing emphasis on information and recommendations, combined with more flexible procedures, was an alternative to coercion, and was more respectful of the moral and physical integrity of individuals guaranteed, inter alia, under Article 8 of the Convention. (g) ROZALIO – Rodiče za lepší informovanost a svobodnou volbu v očkování, z.s. 240. This third-party intervener submitted the following information, based on its experience. There was an increasing number of parents in the Czech Republic who wished to be informed on matters concerning vaccination, who questioned its necessity and timing and who were conscious of their inalienable right to take informed decisions on all matters concerning their children. The majority of such parents did not oppose vaccination of their children en bloc but rather desired an individual approach. They did not know how to communicate on these matters with doctors and authorities and the State failed to provide adequate sources of relevant information. 241. Repressive tools for promoting the vaccination rate were inappropriate because they gave rise to mistrust. Verifiable data showed that an increasing repression level corresponded to a decreasing vaccination rate. A better approach was to promote dialogue with parents on an equal footing. 242. The core of the problem was that the PHP Act provided for sanctions on parents who failed to ensure vaccination of their children and excluded such children from public and private preschool facilities, and from further activities such as school trips and retreats. 243. As regards the sanctions on the parents, the intervener referred to the secular objection of conscience as defined by the Constitutional Court in the case of Vavřička and developed in its judgment of 22 December 2015 in another case (see paragraphs 28 and 93 above). In that connection, it pointed out that after 2011 minor-offence proceedings were no longer instituted in the event of parents’ failure to have their children vaccinated but that since 2018 such proceedings were again being instituted. However, the administrative bodies involved in such proceedings did not grant the exception provided for by the constitutional case-law in any individual case and no such exceptions were applied with regard to the admission of children lacking any prescribed vaccination to preschool establishments. Furthermore, the statutory exception from the duty on health grounds required a permanent contraindication and doctors generally interpreted that category restrictively. 244. The threat of a sanction also applied to preschool establishments if they admitted an unvaccinated child, and the inability to have one’s children admitted to such an establishment resulted in the parents either having to stay and provide for their children at home or to bear the costs of alternative care. The affected parents sometimes organised themselves to provide day-care for their children in informal groups. However, all of this had financial and career implications. 245. The intervener then described the legal regime applicable to vaccinations and its functioning in a wider context, its reform, and the consequences of the vaccination duty for various groups of stakeholders. In 2017/18 preschool attendance became mandatory for children aged five (see paragraph 81 above). Those children were no longer obliged to be vaccinated. Nevertheless, there had been no dramatic effects on public health although such children would usually be kept together with younger children whose vaccination remained compulsory. Any consultative processes at the level of the Ministry in connection with the definition of the vaccination schedule were inadequate: a specialised working commission established in 2015 (see paragraph 156 above) had only met five times, had reached no conclusions and had been dormant since 2018. (h) European Forum for Vaccine Vigilance 246. This intervener submitted that, in contrast to other areas of societal importance in a democratic society, where opposing views were institutionally represented, there were no trade unions of any specific profession in the area of public health to defend an individual’s health ‑ related choices. While in the area of justice there were rules adopted by the lawmaker and adjusted by the judiciary, there was no equivalent to this in the area of health. Whilst there had traditionally been a doctors’ professional body and an administrative body in charge of matters of health, there was generally no institution representing the patient. The need for representation of the patient in relation to the health authorities was, in France, reflected in the creation of a specific university doctorate for patient ‑ experts. 247. However, sworn experts in the area of health in France were appointed by a tribunal and operated in a regime that was open to criticism, inter alia, in view of the scope of their specialisation and expertise. For various reasons, basic, pre-clinical and clinical research in relation to vaccines had a limited potential. 248. Moreover, the intervener criticised the use of aluminium-based compounds in the production of vaccines and attributed it to economic considerations on the part of the pharmaceutical industry. 249. In addition, the intervener described in detail various physiological aspects of immunity and commented on an individual clinical case of adverse health effects arising from vaccination. 250. Public pronouncements by health authorities on the side-effects of vaccines were generally prejudiced and official studies in the area of vaccination would commonly not cite their authors and sources. Yet issues such as the efficiency of booster-vaccination of adults and vaccines administered subcutaneously in general were open to debate. 251. Just as there was the premise in dubio pro reo in matters of liability, doubts in the area of vaccination should be interpreted in favour of a free choice by an individual under the principles of primum non nocere and in dubiis abstinere. 252. It was common in the healthcare world to confuse the categories of “informed consent” and a “permission to proceed with a specific procedure granted by the patient”. This might be because despite long studies doctors were not trained to transmit scientific and medical information to patients in a language that the latter understood. It was unclear whether the state of the science regarding therapeutic approaches adequately took into account individual’s physiological responses. 253. Although the vaccination procedure was intrusive in terms of the law and thus normally subject to the requirement of informed consent, in France it was imposed administratively and not subject to free and informed individual consent. 254. There were many reports of serious pathologies which had emerged as a result of a vaccination, such as autism, multiple sclerosis, Guillain-Barré syndrome, macrophage myofasciitis, etc. Some had been demonstrated before the courts in individual cases against pharmaceutical corporations. It was necessary and a matter of scientific and medical responsibility in a democratic society to rule out potential risks by demonstrating that there was no causal link between the pathologies observed after the vaccination and the administration of the vaccine. Failure to do so could not be justified by economic considerations. 255. The current understanding of physiology was still in its infancy and vaccination as practiced presently was an archaic procedure which was provided by the laboratories and the institutions above them. 256. Many of the illnesses against which vaccination was compulsory did not produce serious consequences and the effect of vaccinating against them was that they would mutate and become more pernicious. 257. Lastly, broad immunisation coverage was currently promoted by many governments through an aggressive vaccination policy, although no scientific studies had proven the effectiveness of this approach. On the other hand, some other European countries provided for a free individual choice in the matter. The first imperative step was to ensure that those concerned were amply informed on all relevant aspects of vaccination and it was questionable whether doctors were able to do so. Secondly, there should be a free choice between informed consent and refusal. The Court’s assessment (a) Subject matter of the applications 258. The Court notes that the applicants formulated their Article 8 complaints principally with reference to the fine imposed on Mr Vavřička and to the non-admission of the child applicants to nursery school. In other words, it was the consequences of non-compliance with the vaccination duty that was complained of. 259. However, in the Court’s opinion, the consequences borne by the applicants cannot be meaningfully dissociated from the underlying duty. On the contrary, they flow immediately and directly from the applicants’ attitude towards it and are therefore intrinsically connected to it. 260. In these circumstances, the Court finds that the subject matter of the applicants’ complaints is the vaccination duty and the consequences for them of non-compliance with it. (b) Scope 261. It is common ground among the parties that the complaint raised under Article 8 of the Convention relates to the right to respect for the applicants’ private life. The Court agrees, it being well established that a person’s physical integrity forms part of their “private life” within the meaning of this provision of the Convention, which also encompasses, to a certain degree, the right to establish and develop relationships with other human beings (see Paradiso and Campanelli v. Italy [GC], no. 25358/12, § 159, 24 January 2017, with further references; and also, in relation to vaccination specifically, Boffa and Others, cited above, and Baytüre and Others v. Turkey (dec.), no. 3270/09, 12 March 2013 ). 262. While some of the applicants also referred to the right to respect for family life, the Court does not consider it necessary to examine their Article 8 complaints from this additional perspective. (c) Interference 263. The Court has established in its case-law that compulsory vaccination, as an involuntary medical intervention, represents an interference with the right to respect for private life within the meaning of Article 8 of the Convention (see Solomakhin v. Ukraine (no. 24429/03, § 33, 15 March 2012, with further references). With regard to the present applicants, it is true that, as the Government underlined, none of the contested vaccinations were performed. However, having regard to the subject matter of this case as established above (see paragraph 260), and also to the fact that the child applicants bore the direct consequences of non ‑ compliance with the vaccination duty in that they were not admitted to preschool, the Court is satisfied that, in their regard, there has been an interference with their right to respect for private life. 264. As regards Mr Vavřička, while it is the vaccination of his children that is at issue, the Court considers that this does not lead to a different conclusion. It notes that under domestic law he was personally subject to the duty to have his children vaccinated, and that the consequences of non ‑ compliance with it, i.e. the fine, were borne by him directly as the person legally responsible for their well-being. As noted above, in opposing their vaccination, he explained that he was principally motivated by concern for their physical integrity, fearing that vaccination could cause serious damage to their health. In these circumstances, the Court considers that the facts of the case of Mr Vavřička also may be regarded as disclosing an interference with the right to respect for private life, as indeed was accepted by the Government (see Boffa and Others, cited above, p. 34). (d) Justification for the interference 265. To determine whether this interference entailed a violation of Article 8 of the Convention, the Court must examine whether it was justified under the second paragraph of that Article, that is, whether the interference was “in accordance with the law”, pursued one or more of the legitimate aims specified therein, and to that end was “necessary in a democratic society”. (i) In accordance with the law 266. The Court reiterates that an impugned interference must have some basis in domestic law, which law must be adequately accessible and be formulated with sufficient precision to enable those to whom it applies to regulate their conduct and, if need be with appropriate advice, to foresee, to a degree that is reasonable in the circumstances, the consequences which a given action may entail (see, for example, Dubská and Krejzová v. the Czech Republic [GC], nos. 28859/11 and 28473/12, § 167, 15 November 2016, with a further reference). 267. The Court notes that the vaccination duty has its specific basis in section 46(1) and (4) of the PHP Act, applied in conjunction with the Ministerial Decree issued by the Ministry in the exercise of the power conferred on it to this end by sections 46(6) and 80(1) of the PHP Act (see paragraphs 11, 13 and 74 above). The consequences of non-compliance with the duty stem, for Mr Vavřička, from the application of section 29(1)(f) and (2) of the MO Act (see paragraphs 17 and 83 above) and, for the child applicants, from the application of section 34(5) of the Education Act, in conjunction with section 50 of the PHP Act (see paragraphs 15, 73 and 81 above). The accessibility and foreseeability of those provisions have not been disputed by the applicants. 268. Rather, the applicants’ specific challenge to the lawfulness of the impugned interference rests primarily on their contention, made in reliance on the provisions of Article 4 of the Charter of Fundamental Rights and Freedoms (see paragraph 65 above), that in the given context the term “law” should be understood as referring exclusively to an Act of Parliament, this being how the notion of “law” ( zákon ) is commonly understood at the national level. They take issue with the fact that the Czech vaccination scheme is based on a combination of primary and secondary legislation. 269. The Court reiterates that the term “law” as it appears in the phrases “in accordance with the law” and “prescribed by law” in Articles 8 to 11 of the Convention, is to be understood in its “substantive” sense, not its “formal” one. It thus includes, inter alia, “written law”, not limited to primary legislation but including also legal acts and instruments of lesser rank. In sum, the “law” is the provision in force as the competent courts have interpreted it (see, for example, Sanoma Uitgevers B.V. v. the Netherlands [GC], no. 38224/03, § 83, 14 September 2010, with a further reference). 270. Moreover, the Court observes that the constitutionality of the legislative arrangement in question was examined in extenso and upheld by both the SAC and the Constitutional Court (see paragraphs 36, 60, 86 and 91 above). 271. The Court is therefore satisfied that the interference in question was in accordance with the law within the meaning of the second paragraph of Article 8 of the Convention. (ii) Legitimate aim 272. With regard to the aims pursued by the vaccination duty, as argued by the Government and as recognised by the domestic courts, the objective of the relevant legislation is to protect against diseases which may pose a serious risk to health. This refers both to those who receive the vaccinations concerned as well as those who cannot be vaccinated and are thus in a state of vulnerability, relying on the attainment of a high level of vaccination within society at large for protection against the contagious diseases in question. This objective corresponds to the aims of the protection of health and the protection of the rights of others, recognised by Article 8. In view of the above, there is no need to decide whether other aims recognised as legitimate under Article 8 § 2 may be of relevance where a State takes measures to guard against major disruptions to society caused by serious disease, namely the interests of public safety, the economic well ‑ being of the country, or the prevention of disorder. (iii) Necessity in a democratic society (α) General principles and margin of appreciation 273. The applicable principles may be summarised as follows (see, in particular, Dubská and Krejzová, cited above, §§ 174-8, with further references): - An interference will be considered “necessary in a democratic society” for the achievement of a legitimate aim if it answers a “pressing social need” and, in particular, if the reasons adduced by the national authorities to justify it are “relevant and sufficient” and if it is proportionate to the legitimate aim pursued. - The Convention system has a fundamentally subsidiary role. The national authorities have direct democratic legitimation in so far as the protection of human rights is concerned and, by reason of their direct and continuous contact with the vital forces of their countries, they are in principle better placed than an international court to evaluate local needs and conditions. - It is therefore primarily the responsibility of the national authorities to make the initial assessment as to where the fair balance lies in assessing the need for an interference in the public interest with individuals’ rights under Article 8 of the Convention. Accordingly, in adopting legislation intended to strike a balance between competing interests, States must in principle be allowed to determine the means which they consider to be best suited to achieving the aim of reconciling those interests. - That assessment by the national authorities remains subject to review by the Court, which makes the final evaluation as to whether an interference in a particular case is “necessary”, as that term is to be understood within the meaning of Article 8 of the Convention. - A certain margin of appreciation is, in principle, afforded to domestic authorities as regards that assessment; its breadth depends on a number of factors dictated by the particular case. The margin will tend to be relatively narrow where the right at stake is crucial to the individual’s effective enjoyment of intimate or key rights. Where a particularly important facet of an individual’s existence or identity is at stake, the margin allowed to the State will also be restricted. Where there is no consensus within the Contracting Parties to the Convention, either as to the relative importance of the interest at stake or as to the best means of protecting it, particularly where the case raises sensitive moral or ethical issues, the margin will be wider. 274. The Court has held that matters of healthcare policy are in principle within the margin of appreciation of the domestic authorities, who are best placed to assess priorities, use of resources and social needs (see Hristozov and Others v. Bulgaria (nos. 47039/11 and 358/12, § 119, ECHR 2012 (extracts), with further references). 275. Lastly, the Court reiterates that the respondent State’s margin of appreciation will usually be wide if it is required to strike a balance between competing private and public interests or Convention rights (see, for example, Evans v. the United Kingdom [GC], no. 6339/05, § 77, ECHR 2007 ‑ I, with further references). (β) The margin of appreciation in the present case 276. As the case in hand concerns a compulsory medical intervention, the vaccination duty may be regarded as relating to the individual’s effective enjoyment of intimate rights (see Solomakhin, cited above, § 33). However, the weight of this consideration is lessened by the fact that no vaccinations were administered against the will of the applicants, nor could they have been, as the relevant domestic law does not permit compliance with the duty to be forcibly imposed. 277. On the existence of a consensus, the Court discerns two aspects. Firstly, there is a general consensus among the Contracting Parties, strongly supported by the specialised international bodies, that vaccination is one of the most successful and cost-effective health interventions and that each State should aim to achieve the highest possible level of vaccination among its population (see paragraph 135 above). Accordingly, there is no doubt about the relative importance of the interest at stake. 278. Secondly, when it comes to the best means of protecting the interest at stake, the Court notes that there is no consensus over a single model. Rather, there exists, among the Contracting Parties to the Convention, a spectrum of policies on the vaccination of children, ranging from one based wholly on recommendation, through those that make one or more vaccinations compulsory, to those that make it a matter of legal duty to ensure the complete vaccination of children. The Czech Republic has positioned itself at the more prescriptive end of that spectrum, a position supported and shared by three of the intervening Governments (see the submissions of the French, Polish and Slovak authorities at paragraphs 211, 225 and 228 above). The Court notes, moreover, a recent change of policy in several other Contracting Parties, towards a more prescriptive approach due to a decrease in voluntary vaccination and a resulting decrease in herd immunity (see the submissions of the French and German Governments above at paragraphs 211 and 216 above, and also the 2018 judgment of the Italian Constitutional Court, summarised at paragraphs 106-112 above). 279. While childhood vaccination, being a fundamental aspect of contemporary public health policy, does not in itself raise sensitive moral or ethical issues, the Court accepts that making vaccination a matter of legal duty can be regarded as so doing, as attested by the examples of constitutional case ‑ law set out above (at paragraphs 95-127). It notes in this regard that the recent change of policy in Germany was preceded by an extensive societal and parliamentary debate on the issue. The Court considers, however, that this acknowledged sensitivity is not limited to the perspective of those disagreeing with the vaccination duty. As submitted by the respondent Government, it should also be seen as encompassing the value of social solidarity, the purpose of the duty being to protect the health of all members of society, particularly those who are especially vulnerable with respect to certain diseases and on whose behalf the remainder of the population is asked to assume a minimum risk in the form of vaccination (see in this respect Resolution 1845(2011) of the Parliamentary Assembly of the Council of Europe, set out at paragraph 143 above). The Court will return to this question below. 280. As reiterated above (see paragraph 274), the Court has previously held that healthcare policy matters come within the margin of appreciation of the national authorities. Having regard to the above considerations and applying its well ‑ established case-law principles, the Court takes the view that in the present case, which specifically concerns the compulsory nature of child vaccination, that margin should be a wide one. (γ) Pressing social need 281. Having recognised the importance, generally, of childhood vaccination as a key measure of public health policy, it must next be considered whether the choice of the Czech legislature to make the vaccination of children compulsory can be said to answer to a pressing social need. 282. In this respect it is relevant to reiterate that the Contracting States are under a positive obligation, by virtue of the relevant provisions of the Convention, notably Articles 2 and 8, to take appropriate measures to protect the life and health of those within their jurisdiction (see L.C.B. v. the United Kingdom, 9 June 1998, § 36, Reports of Judgments and Decisions 1998 III; Budayeva and Others v. Russia, nos. 15339/02 and 4 others, §§ 128-130, ECHR 2008 (extracts); Furdík v. Slovakia (dec.), no. 42994/05, 2 December 2008, with further references; Hristozov and Others, cited above, §§ 106 and 116; İbrahim Keskin v. Turkey, no. 10491/12, § 62, 27 March 2018; and Kotilainen and Others v. Finland, no. 62439/12, §§ 78 et seq., 17 September 2020). Similar obligations arise under other widely accepted international human rights instruments, further developed in the practice of the competent monitoring bodies (see, regarding the International Covenant on Economic, Social and Cultural Rights, paragraphs 129-131 above; regarding the Convention on the Rights of the Child, paragraphs 132-134 above; and regarding the European Social Charter, paragraphs 137-140 above). 283. The Court refers to the expert material submitted by the respondent Government, conveying the firm view of the relevant medical authorities of the Czech Republic that the vaccination of children should remain a matter of legal duty in that country, and underlining the risk to individual and public health to which a possible decline in the rate of vaccination would give rise were it to become a merely recommended procedure (see paragraphs 152-153 above). Concerns at the risk associated with a decrease in vaccine coverage were also expressed by the intervening Governments, with emphasis placed on the importance of ensuring that children are immunised against the diseases in question from an early age (see also the decision of the Italian Constitutional Court at paragraph 107 above). Similar concerns have also been raised at European and international levels (see paragraphs 131, 134, 142, 149 and 151). 284. In view of these submissions, and of the clear stance adopted by the expert bodies in this matter, it can be said that in the Czech Republic the vaccination duty represents the answer of the domestic authorities to the pressing social need to protect individual and public health against the diseases in question and to guard against any downward trend in the rate of vaccination among children. (δ) Relevant and sufficient reasons 285. As regards the reasons put forward for the mandatory nature of vaccination in the Czech Republic, the Court has already acknowledged the weighty public health rationale underlying this policy choice, notably in terms of the efficacy and safety of childhood vaccination. It has likewise acknowledged a general consensus supporting the objective, for every State, to attain the highest possible degree of vaccine coverage. Although the applicants argued that the authorities failed to establish that the duty to accept the prescribed vaccinations was necessary and justified (see paragraph 175 above), the Court considers that the Government have clearly set out the reasons behind this choice. It further notes the conclusion of the Czech Constitutional Court that the relevant data from national and international experts in the matter justified pursuing this policy (see paragraph 91 above). While a system of compulsory vaccinations is not the only, or the most widespread, model adopted by European States, the Court reiterates that, in matters of health-care policy, it is the domestic authorities who are best placed to assess priorities, the use of resources and social needs. All of these aspects are relevant in the present context, and they come within the wide margin of appreciation that the Court should accord to the respondent State. 286. Furthermore, the subject matter of the case necessarily raises the question of the best interests of children. In this respect the applicants maintained that it must be primarily for the parents to determine how the best interests of the child are to be served and protected, and that State intervention can be accepted only as a last resort in extreme circumstances. The Government submitted that, in the context of health care, the best interest of the child was served by enjoying the highest attainable standard of health. 287. It is well established in the Court’s case-law that in all decisions concerning children their best interests are of paramount importance. This reflects the broad consensus on this matter, expressed notably in Article 3 of the UN Convention on the Rights of the Child (see, for example, Advisory opinion concerning the recognition in domestic law of a legal parent-child relationship between a child born through a gestational surrogacy arrangement abroad and the intended mother [GC], request no. P16 ‑ 2018 ‑ 001, French Court of Cassation, § 38, 10 April 2019, with further references; and Neulinger and Shuruk v. Switzerland [GC], no. 41615/07, § 135, ECHR 2010). 288. It follows that there is an obligation on States to place the best interests of the child, and also those of children as a group, at the centre of all decisions affecting their health and development. When it comes to immunisation, the objective should be that every child is protected against serious diseases (see paragraph 133 above). In the great majority of cases, this is achieved by children receiving the full schedule of vaccinations during their early years. Those to whom such treatment cannot be administered are indirectly protected against contagious diseases as long as the requisite level of vaccination coverage is maintained in their community, i.e. their protection comes from herd immunity. Thus, where the view is taken that a policy of voluntary vaccination is not sufficient to achieve and maintain herd immunity, or herd immunity is not relevant due to the nature of the disease (e.g. tetanus), domestic authorities may reasonably introduce a compulsory vaccination policy in order to achieve an appropriate level of protection against serious diseases. The Court understands the health policy of the respondent State to be based on such considerations, in the light of which it can be said to be consistent with the best interests of the children who are its focus (see General comment No. 15 of the United Nations Committee on the Rights of the Child at paragraph 133 above; see also the findings of the Italian Constitutional Court and the judgment of the Court of Appeal of England and Wales in this regard, set out at paragraphs 109 and 128 above). 289. The Court therefore accepts that the choice of the Czech legislature to apply a mandatory approach to vaccination is supported by relevant and sufficient reasons. This finding extends to the specific interferences complained of by the applicants, as the administrative sanction imposed on Mr Vavřička and the non-admission of the child applicants to preschool stemmed directly from the application of the statutory framework. (ε) Proportionality 290. Finally, the Court must assess the proportionality of the interferences complained of, in light of the aim pursued. 291. It will first examine the relevant features of the national system. The vaccination duty concerns nine diseases against which vaccination is considered effective and safe by the scientific community, as is the tenth vaccination, which is given to children with particular health indications (see paragraph 76 above). While the Czech model espouses compulsory vaccination, this is not an absolute duty. An exemption from the duty is permitted notably in respect of children with a permanent contraindication to vaccination. The applicants and two of the intervening third parties were critical of the manner in which this ground is interpreted and applied by the medical profession in the Czech Republic. The Court notes, however, that none of the applicants, either in the domestic proceedings or before this Court, relied on an actual contraindication in relation to any of the vaccinations concerned by their objections. The question of how the exemption is applied in practice is therefore not specifically relevant to their complaints. The Court reiterates that its task is not to review the relevant legislation or practice in the abstract. While it should not overlook the general context, it must as far as possible confine itself to examining the issues raised by the case before it (see, among many other authorities, Paradiso and Campanelli, cited above, § 180). It therefore cannot attach weight to the criticism now levelled at the statutory exemption to the vaccination duty. 292. In the respondent State, an exemption may also be permitted on the basis of the Vavřička case-law of the Constitutional Court (see paragraph 28 above), subsequently developed into the right to a “secular objection of conscience” (see paragraph 93 above). Pursuant to domestic law, this exemption relates to both forms of interference at issue in the present case, and, as confirmed by the Government, it may be relied on directly to challenge a fine or a refusal to admit a child to nursery school. The applicants argued that this exemption would almost never be granted in practice, in particular as regards admission to preschool. Here too the Court can only note that the child applicants did not seek to rely on this exemption during the domestic proceedings. As for the applicant Vavřička’s criticism in this respect, the Court will address it in its examination of his complaint under Article 9 (see paragraph 335 below). 293. While vaccination is a legal duty in the respondent State, the Court reiterates that compliance with it cannot be directly imposed, in the sense that there is no provision allowing for vaccination to be forcibly administered. In common with the arrangements made in the intervening States, the duty is enforced indirectly through the application of sanctions. In the Czech Republic, the sanction can be regarded as relatively moderate, consisting of an administrative fine that may only be imposed once. In Mr Vavřička’s case, while he argued that the fine was high for him in the circumstances (see paragraph 162 above), the Court notes that the amount was towards the lower end of the relevant scale, and cannot be considered as unduly harsh or onerous. 294. Regarding the child applicants, the Court has viewed their non ‑ admission to preschool as an “interference” within the meaning of Article 8 § 2 of the Convention. The applicants perceived it as a form of sanction or penalty on them. However, the Court regards the consequence, which was clearly provided for in primary legislation, of non-compliance with a general legal duty intended to safeguard in particular the health of young children as being essentially protective rather than punitive in nature (see also paragraph 61 above). It will consider the significance of their non ‑ admission when it assesses the intensity of the interference with their right to respect for private life (see paragraphs 306 and 307 below). 295. The Court notes the procedural safeguards provided for in domestic law. As shown by the course of the domestic proceedings brought by the applicants, they had at their disposal both administrative appeals as well as judicial remedies before the administrative courts and ultimately the Constitutional Court. It was therefore open to them to contest the consequences of their non-compliance with the vaccination duty. Contrary to the applicants’ criticism of these remedies, the Court observes that the Constitutional Court’s case-law in particular cannot be fairly described as merely formal or as eschewing a substantive review of the vaccination duty from the perspective of fundamental rights. While it was in different and later proceedings that the Constitutional Court directly addressed the compatibility with the Constitution of the vaccination duty (see paragraph 93 above), finding that the public interest at stake outweighed the objections of the plaintiffs in those proceedings, its reasoning in the proceedings brought by Mr Vavřička, recognising a constitutional exception to the general duty, must be regarded as a meaningful safeguard. Likewise, in the proceedings brought by Ms Novotná, the Constitutional Court held that in order to effectively protect fundamental rights which conflicted with the public interest, the circumstances of each individual case were to be rigorously assessed. The fact that neither applicant was ultimately successful in their constitutional action does not diminish the significance of this jurisprudential safeguard of fundamental rights. 296. Turning now to the applicants’ opposition to the policy of the compulsory vaccination of children, the Court observes that at the heart of their complaint lies a twofold objection. In the first place, they criticised the institutional arrangements in place in the Czech Republic in this area, contending that the discretion granted to the health authorities was excessive and that there were conflicts of interest and a deficit of transparency and public debate. The Court is not persuaded by this criticism. Regarding the scope left to the executive to devise and implement health policy, the Court has already found that no issue of quality of law arises (see paragraphs 267 et seq. above). Moreover it finds pertinent the observation of the SAC that the legislative approach employed makes it possible for the authorities to react with flexibility to the epidemiological situation and to developments in medical science and pharmacology (see paragraph 87 above; see also the remarks of the Italian Constitutional Court at paragraph 107 above). In addition, the domestic system is, as noted above, attended by significant procedural safeguards. 297. As for the integrity of the policy-making process, the Court notes that in reply to the applicants’ claim about conflicts of interest the Government have explained the procedure followed by the NIC, in accordance with relevant European and international standards (see paragraph 200 above). In the light of the elements before it, the Court considers that the applicants have not sufficiently substantiated their allegations that the domestic system is tainted by conflicts of interest, or their suggestion that the position on vaccination adopted by the relevant Czech expert bodies, or by the WHO, is compromised by financial support from pharmaceutical corporations. 298. With respect to the transparency of the domestic system and the extent to which the authorities invite public discussion, the Court notes that a degree of transparency is achieved in this respect through the publication of the minutes of the meetings of the NIC on the website of the Ministry of Health (see paragraph 154 above). As for public participation, the Government submitted that the exclusively expert composition of the NIC was in line with the practice of many European States. The Court notes the initiative taken in 2015 to set up a platform for public discussion of vaccination policy, bringing together medical experts and civil society (see paragraph 156 above), although the applicants and the intervenor ROZALIO indicated that its meetings were few and had ceased by 2018. It cannot be said that the arrangements in force, under which policy is entrusted to an expert body operating under the aegis of the Ministry of Health, in accordance with the model chosen by the legislature and ultimately accountable to it, suffer from a serious deficit of transparency such as to call into question the validity of the vaccination policy followed by the Czech Republic. 299. In addition to their submissions regarding the institutional aspects of the domestic system, the applicants also take issue with the effectiveness and safety of vaccinations, expressing strong concern with regard to the potential adverse effects on health, including in the long term. The Court notes first of all the Government’s explanation that under the domestic system a certain leeway is allowed regarding the choice of vaccine, although only the standard vaccines are free of charge, the cost of other products resting with the parents. Some leeway regarding the vaccination timetable is also permitted, as long as the child is fully immunised by the relevant age (see paragraphs 76 and 203 above). 300. As for the effectiveness of vaccination, the Court refers once again to the general consensus over the vital importance of this means of protecting populations against diseases that may have severe effects on individual health, and that, in the case of serious outbreaks, may cause disruption to society (see paragraph 135 above). 301. With regard to safety, it is not disputed that although entirely safe for the great majority of recipients, in rare cases vaccination may prove to be harmful to an individual, causing serious and lasting damage to his or her health. Complaints in relation to such situations have been the subject of previous proceedings under the Convention (see, in particular, Association of Parents v. the United Kingdom, no. 7154/75, Commission decision of 12 July 1978, DR 14, p. 31; and Baytüre and Others, cited above, § 28). At the oral hearing in the present case, the Government indicated that out of approximately 100,000 children vaccinated annually in the Czech Republic (representing 300,000 vaccinations), the number of cases of serious, potentially lifelong, damage to health stood at five or six. In view of this very rare but undoubtedly very serious risk to the health of an individual, the Convention organs have stressed the importance of taking the necessary precautions before vaccination (see Solomakhin, cited above, § 36; Baytüre and Others, cited above, § 29, and Association of Parents, cited above, pp. 33-34). This evidently refers to checking in each individual case for possible contraindications. It also refers to monitoring the safety of the vaccines in use. In each of these respects the Court sees no reason to question the adequacy of the domestic system. Vaccination is performed by medical professionals only if there is no contraindication, which is checked beforehand as a matter of routine protocol. Vaccines are subject to registration by the State Agency for Drug Control, with all healthcare professionals concerned being under a specific duty to report any suspicion of serious or unexpected side-effects (see paragraphs 78 and 79 above). Accordingly, the safety of the vaccines in use remains under continuous monitoring by the competent authorities. 302. Turning to the question of the availability of compensation on a no ‑ fault or strict liability basis for injury to health caused by vaccination, which was also raised by the applicants, the Court recalls that it has previously examined a case in which the issue of compensation for damage to health caused by vaccination arose, although the vaccine in question was one that was recommended rather than compulsory in the country concerned (see Baytüre and Others, cited above, §§ 28-30). The Court observes, as a general proposition, that the availability of compensation in case of injury to health is indeed relevant to the overall assessment of a system of compulsory vaccination, and it refers in this respect to the obiter dictum of the Czech Constitutional Court (see paragraph 90 above). The same issue has been raised by other constitutional courts (see the example of the relevant Italian case-law at paragraphs 111, 113, 114 and 115 above, and the Slovenian case-law at paragraph 127 above). However, in the context of the present applications, the issue cannot be given any decisive significance. As previously observed, no vaccine was administered contrary to the will or wishes of any of the applicants. For most of them, the facts occurred at a time when compensation was available under the 1964 Civil Code (i.e. before 31 December 2013). Moreover, in none of the domestic proceedings brought by the various applicants was the issue of compensation specifically raised. The dictum of the Constitutional Court came in the context of proceedings brought by other parties, who expressly included among the grounds advanced the question of compensation. The Court deduces from this that the issue was not actually relevant to the present applicants’ refusal of the vaccination duty, which stemmed instead from the concerns noted above. 303. The Court must furthermore consider the intensity of the impugned interferences with the applicants’ enjoyment of their right to respect for private life. 304. Regarding the first applicant, the Court has already found that the administrative fine imposed on him was not excessive in the circumstances (see paragraph 293 above). The Court notes that there were no repercussions for the education of this applicant’s children, who were already teenagers when the sanction was applied to him. 305. With respect to the remaining applicants, their enrolment in preschool was either denied or revoked for lack of the required vaccinations. While the applicants and some of the intervening associations complained about the impact of this on the organisation of family life, notably in financial and career terms, the Court reiterates that the personal scope of the case, examined under the private life head of Article 8, is limited to the applicants themselves and the repercussions for them of the contested measures. 306. The Court accepts that the exclusion of the applicants from preschool meant the loss of an important opportunity for these young children to develop their personalities and to begin to acquire important social and learning skills in a formative pedagogical environment. However, that was the direct consequence of the choice made by their respective parents to decline to comply with a legal duty, the purpose of which is to protect health, in particular in that age group. As stated by the respondent Government, and by some of the intervening Governments, who rely on extensive scientific evidence (see paragraphs 213, 218 and 223 above), early childhood is the optimum time for vaccination. Moreover, the possibility of attendance at preschool of children who cannot be vaccinated for medical reasons depends on a very high rate of vaccination among other children against contagious diseases. The Court considers that it cannot be regarded as disproportionate for a State to require those for whom vaccination represents a remote risk to health to accept this universally practised protective measure, as a matter of legal duty and in the name of social solidarity, for the sake of the small number of vulnerable children who are unable to benefit from vaccination. In the view of the Court, it was validly and legitimately open to the Czech legislature to make this choice, which is fully consistent with the rationale of protecting the health of the population. The notional availability of less intrusive means to achieve this purpose, as suggested by the applicants, does not detract from this finding. 307. The Court would further observe that, while not underestimating the educational opportunity foregone by the child applicants, they were not deprived of all possibility of personal, social and intellectual development, even at the cost of additional, and perhaps considerable, effort and expense on the part of their parents. Moreover, the effects on the child applicants were limited in time. Upon reaching the age of mandatory school attendance, their admission to primary school was not affected by their vaccination status (see paragraph 82 above). As for the specific wish of the applicant Novotná to be educated in accordance with a particular pedagogical philosophy, she did not contradict the Government’s statement that she would have remained eligible for such schooling notwithstanding her non-attendance at preschool level. 308. Lastly, the applicants argued that the system was incoherent, in that while small children were required to be vaccinated, this did not apply to those employed in preschools. The Court notes, however, the Government’s reply that the general vaccination duty, which consists of initial vaccinations as well as booster vaccinations, applies to everyone residing in the Czech Republic permanently or on a long-term basis (see paragraphs 11 and 77 above), so that the staff members concerned should normally have received all the prescribed vaccinations at the relevant time, as required by law. 309. For these reasons, the Court considers that the measures complained of by the applicants, assessed in the context of the domestic system, stand in a reasonable relationship of proportionality to the legitimate aims pursued by the respondent State through the vaccination duty. (στ) Conclusion 310. The Court would clarify that, ultimately, the issue to be determined is not whether a different, less prescriptive policy might have been adopted, as has been done in some other European States. Rather, it is whether, in striking the particular balance that they did, the Czech authorities remained within their wide margin of appreciation in this area. It is the Court’s conclusion that they did not exceed their margin of appreciation and so the impugned measures can be regarded as being “necessary in a democratic society”. 311. Accordingly, there has been no violation of Article 8 of the Convention. 312. In view of this conclusion, there is no need to examine the Government’s non-exhaustion objection in relation to the Article 8 complaints of the applicants Brožík and Dubský (see paragraphs 169 and 170 above). ALLEGED VIOLATION OF ARTICLE 9 OF THE CONVENTION 313. The applicants Vavřička, Novotná and Hornych also complained that the fine imposed on Mr Vavřička and the non-admission of Ms Novotná and Mr Hornych to nursery school was contrary to their rights under Article 9 of the Convention, which provides: “1. Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief and freedom, either alone or in community with others and in public or private, to manifest his religion or belief, in worship, teaching, practice and observance. 2. Freedom to manifest one’s religion or beliefs shall be subject only to such limitations as are prescribed by law and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals, or for the protection of the rights and freedoms of others.” The parties’ submissionsThe Government The Government The Government 314. The Government considered that the complaints made in reliance on Article 9 were essentially a restatement of those made under Article 8 and that they should be examined under the latter provision only. As regards Article 9, they argued mainly that the complaints were incompatible ratione materiae with that provision, or in any event manifestly ill-founded on account of a lack of any interference with the applicants’ Article 9 rights. 315. Personal views on compulsory vaccination based on wholly subjective assumptions about its necessity and suitability did not constitute a “belief” within the meaning of Article 9 of the Convention. That provision essentially aimed to protect religions or theories about philosophical or ideological universal values. Lacking sufficient specification and substantiation, the views professed by the applicants did not constitute a coherent view on a fundamental problem and accordingly did not amount to a manifestation of personal beliefs in the sense of Article 9 of the Convention. 316. The Government submitted that there was no clear line in the existing case-law as to what beliefs were or were not regarded as a “religion or beliefs” within the meaning of Article 9 § 2 of the Convention. Even if that provision were in principle to apply to a situation such as that which obtains in the present case, on the specific facts there had been no interference with the applicants’ rights protected by it. This was because, as the domestic courts had established, the applicants had failed to substantiate their objection to the vaccination duty by giving relevant and sufficient reasons. Moreover, the views of the applicants Vavřička and Novotná had not been consistent and so had not been convincing. Mr Vavřička had accepted the vaccination of his children against some diseases. The same was true for Ms Novotná. 317. Furthermore, although Mr Hornych had claimed before the Court that in his case there had been a medical contraindication to vaccination, in the formulation of his complaints he referred to his parents’ philosophical convictions. Yet his argumentation at the national level had been specifically health related. His complaint before the Court was accordingly inadmissible for non-exhaustion of domestic remedies or, as the case may be, as manifestly ill-founded. 318. In addition, to the extent the applicant Novotná relied in her Article 9 complaint on the views and convictions of her parents, such complaint was incompatible ratione personae with that provision. Moreover, in view of their age and maturity at the relevant time, neither she nor the applicant Hornych could have held any views on the subject of sufficient cogency, seriousness, cohesion and importance to come within the ambit of Article 9. 319. The measures complained of had been the result of the application of general and neutrally formulated legislation which applied to all persons regardless of their thought, conscience or religion. Under the Convention case-law, such legislation could not, in principle, interfere with the rights protected under Article 9. 320. Moreover, the Government’s objection under Article 35 § 3 (b) of the Convention in relation to the application of Mr Vavřička (see paragraph 161 above) extended also to his complaint under Article 9. The applicants 321. The applicant Vavřička submitted that his main motivation had been to protect the health of his children. Being convinced that vaccination caused health damage, his conscience would not allow him to have them vaccinated. 322. The applicants Novotná and Hornych relied on a right to parental care in conformity with parental conscience. On the basis of this, it was their parents who had held views protected under Article 9 of the Convention on the applicants’ behalf since at the relevant time, in view of their age, the applicants could not themselves have had any attitude towards vaccination. 323. As regards the consistency of the views asserted under Article 9, the applicants argued that under the Constitutional Court’s jurisprudence what was essential was that the views be constant throughout the proceedings in question. Yet a development of those views prior to or after those proceedings was no impediment to the applicability of the “secular objection of conscience”, as specified by the Constitutional Court. 324. Lastly, the reply of Mr Vavřička to the Government’s objection based on Article 35 § 3 (b) of the Convention extended also to his complaint under Article 9 (see paragraph 162 above). Submissions of the third-party intervenersThe Government of France The Government of France The Government of France 325. The French Government invited the Court to uphold the existing case-law that a neutral statutory duty applicable to everyone regardless of their thought, conscience or religion could not, in principle, interfere with the rights protected by Article 9. However, even if the duty were to be regarded as an interference, for the reasons already set out above it should be accepted as compatible with the requirements of that provision. The Government of Germany 326. The German Government considered it open to doubt whether compulsory vaccination or measures for its enforcement amounted to an interference with the rights protected under Article 9. Not all opinions or convictions constituted beliefs protected by that provision, and the position of the person opposing vaccination would mostly not attain the level of cogency, seriousness, coherence and importance for its applicability. European Centre for Law and Justice 327. This intervener contested the premise adopted by the Commission in Boffa and Others (cited above) as regards the applicability of Article 9 of the Convention to an individual’s reason for opposing a neutral statutory duty applicable to everyone and proposed a different approach. In the ECLJ’s view, the quality of the conviction invoked as well as of the objection based on it should be examined in order to determine which objections warranted respect in a democratic society and which constituted merely a matter of personal convenience that would fall rather within the ambit of Article 8 of the Convention. In determining the quality of the conviction, the questions to be asked were as follows – Is it “sincere” or, depending on the terminology, does it correspond to a “deeply and genuinely held religious or other belief”? Can the content of the conviction be identified and is it substantial? If the conviction is of a religious nature, does it concern a known religion? If the conviction is not of a religious nature, does it warrant respect in a democratic society and does it not offend human dignity? As to the quality of the objection, the intervener argued that it had itself to be a conviction attaining sufficient cogency, seriousness, cohesion and importance to attract the guarantees of Article 9. An objection only on an intermittent or opportunistic basis would not enjoy the protection of that provision. The objector had to be coherent and the objection had to be motivated by a serious and insurmountable conflict between the obligation objected to and the objector’s conscience or convictions and to rest not on reasons of personal benefit or convenience but on genuinely held religious convictions. As regards moral convictions, as distinct from religious convictions, the respect they deserved depended more directly on the nature of the conviction, since objections based on a moral conviction called into question the very justice of the order objected to, whereas objections based on a religious conviction simply tested the tolerance of society. Objections based on moral convictions were to be examined with great care because, if accepted by society, they afforded the objector immunity both from the duty objected to and from sanctions for having disrespected it. Society had acknowledged the legitimacy of such moral objections only in a very few cases, usually in situations where it tolerated an evil because it was considered necessary or inevitable, such as war, abortion or prostitution. 328. In order to determine whether a conscientious objection of a moral nature was genuinely based on moral convictions and rested on a need for justice, four criteria should apply: the objection had to be aimed at respect for the just and the good; the rule objected to had to derogate from a fundamental right or principle; it had to be possible to generalise the objection as being available to everyone; and the objection had to concern an ethically sensitive issue. 329. Where the refusal was motivated by a genuine belief within the meaning of Article 9, and accordingly deserved the respect of society, but without being acknowledged as a requirement of justice, the existence of a sanction was not in itself sufficient to constitute a breach of Article 9. What needed to be examined then was the necessity of the sanction imposed in a given case, which was not different from the examination carried out under Article 8. The difference between the two provisions lay in the fact that Article 9 protected personal conscience, which was linked to the perception of what was just and good, while Article 8 protected only “individual autonomy”, which was independent of it. The Court’s assessment 330. The three applicants have sought to invoke the protection of Article 9 for their critical stance towards vaccination. There is no suggestion on the part of any of them that their stance on this matter is religiously inspired. It is therefore not their religious freedom that is potentially at stake, but their freedom of thought and conscience. 331. The applicability of Article 9 to this particular conviction has not previously been examined by the Court. It was briefly considered by the Commission in Boffa and Others (cited above). In its decision, in so far as relevant, the Commission held that, in protecting the sphere of personal beliefs, Article 9 did not always guarantee the right to behave in the public sphere in a way which was dictated by such beliefs and noted that the term “practice” did not cover each and every act which was motivated or influenced by a belief. It further noted that the obligation to be vaccinated, as laid down in the legislation at issue in that case, applied to everyone, whatever their religion or personal creed. Consequently, it considered that there had been no interference with the freedom protected by Article 9 of the Convention. 332. The Court finds it relevant to refer to its reasoning in the case of Bayatyan v. Armenia ([GC], no. 23459/03, § 110, ECHR 2011, with further references), in which it considered the applicability of Article 9 to the conscientious objection of the applicant, on religious grounds, to military service. It held that “opposition to military service, where it is motivated by a serious and insurmountable conflict between the obligation to serve in the army and a person’s conscience or his deeply and genuinely held religious or other beliefs, constitutes a conviction or belief of sufficient cogency, seriousness, cohesion and importance to attract the guarantees of Article 9.” It further held that whether and to what extent such objection came within the ambit of Article 9 must be assessed in the light of the particular circumstances of the case (ibid.). 333. The Court would also point to its reasoning in the case of Pretty v. the United Kingdom (no. 2346/02, §§ 82-3, ECHR 2002 ‑ III), in which it did not doubt the firmness of that applicant’s views concerning assisted suicide, but observed that not all opinions or convictions constitute beliefs in the sense protected by Article 9. 334. As regards the applicant Vavřička, the Court notes that in its first ruling on his case, the Constitutional Court held that there must be the possibility of an exceptional waiver of the penalty for non-compliance with the vaccination duty where the circumstances call in a fundamental manner for respecting the autonomy of the individual. It underlined the importance of the consistency and credibility of the person’s claims in this regard, and remarked on the lack of consistency on Mr Vavřička’s part in the proceedings until that stage, who had submitted to that court that his objection to vaccination was primarily health-related; philosophical or religious aspects were secondary (see paragraph 29 above). In the subsequent proceedings, it was found by the SAC that the reasons of conscience given by Mr Vavřička had been brought forward only at a late stage and that he had failed to advance any concrete argument concerning his beliefs and the intensity of the interference with them caused by vaccination. 335. The applicant complained that his conscientious stance had been assessed negatively in accordance with a standard that had been developed only at a late stage in the domestic proceedings. The Court considers, on the contrary, that the approach of the domestic courts was reasonable and indeed in keeping with its own interpretation of Article 9, which has been set out above. Having regard to the conclusions reached by the domestic courts in this regard, and considering that the applicant has not further specified or substantiated his complaint under Article 9 in the present proceedings, the Court finds that his critical opinion on vaccination is not such as to constitute a conviction or belief of sufficient cogency, seriousness, cohesion and importance to attract the guarantees of Article 9. 336. The same applies, a fortiori, to the complaints of the applicants Novotná and Hornych, neither of whom even presented such arguments in the domestic proceedings (see paragraphs 37, 45 and 46 above). 337. The Court therefore finds that these complaints are incompatible ratione materiae with the provisions of Article 9 of the Convention within the meaning of Article 35 § 3 (a), and must be rejected in accordance with Article 35 § 4. 338. This finding makes it unnecessary to address the Government’s other inadmissibility objections. ALLEGED VIOLATION OF ARTICLE 2 OF PROTOCOL NO. 1 The parties’ submissions The parties’ submissions The parties’ submissions 339. The child applicants further complained that the refusal of admission to nursery school was contrary to their rights under Article 2 of Protocol No. 1. 340. The Government submitted that the complaints fell to be examined under the first sentence of that Article. In so far as the applicants complained of any repercussions on their parents, such complaints were incompatible ratione personae with this provision. Moreover, and in any event, the complaints were incompatible ratione materiae since Article 2 did not apply to preschool education. In addition, in so far as the complaint was brought by the applicants Brožík and Dubský, it was also subject to the Government’s objection of non ‑ exhaustion of domestic remedies (see paragraph 165 above). 341. The applicants Brožík and Dubský replied to the said objection as indicated above (see paragraph 166 above). Other than that, all of the applicants did no more than reiterate their complaints, referring in particular to the constitutional judgment of 27 January 2015, recognising that the right to education, within the meaning of Article 33 of the Charter of Fundamental Rights and Freedoms, concerned all types and levels of education, including preschool education (see paragraph 62 above). Submissions of the third-party interveners 342. The Government of Germany noted that the exclusion of non ‑ vaccinated children from nursery schools might amount to an interference with their right to education, although it was not clear from the relevant case-law that this level of education was covered by Article 2 of Protocol No. 1. Even if that provision were held to be applicable, the low education level should be taken into account in assessing the proportionality of the restriction. 343. The Government of Slovakia pointed out that the right to education was not absolute and argued that the existing Convention case-law did not specifically acknowledge its applicability to preschool establishments such as kindergartens. 344. The Government of France commented that the non ‑ admission of an unvaccinated child to school was a justified restriction of the right to education. The Court’s assessment 345. In light of the scope of its examination and findings as regards the child applicants’ complaints under Article 8 of the Convention, the Court finds that there is no need to examine their applications separately under Article 2 of Protocol No. 1. OTHER ALLEGED VIOLATIONS OF THE CONVENTION 346. Lastly, some of the applicants also complained of a violation of Articles 2, 6, 13 and 14 of the Convention. 347. However, in the light of all the material in its possession, and in so far as the matters complained of are within its competence, the Court finds that they do not disclose any appearance of a violation of the rights and freedoms set out in the Convention or its Protocols. Accordingly, the remainder of the applications is manifestly ill-founded and must be rejected in accordance with Article 35 §§ 3 (a) and 4 of the Convention.
The Court held that there had been no violation of Article 8 (right to respect for private life) of the Convention in the present case, finding that the measures complained of by the applicants, assessed in the context of the national system, had been in a reasonable relationship of proportionality to the legitimate aims pursued by the respondent State (to protect against diseases which could pose a serious risk to health) through the vaccination duty. The Court clarified that, ultimately, the issue to be determined was not whether a different, less prescriptive policy might have been adopted, as had been done in some other European States. Rather, it was whether, in striking the particular balance that they did, the Czech authorities had exceeded their wide margin of appreciation in this area. The Court concluded that the impugned measures could be regarded as being “necessary in a democratic society”. The Court noted, in particular, that in the Czech Republic the vaccination duty was strongly supported by the relevant medical authorities. It could be said to represent the national authorities’ answer to the pressing social need to protect individual and public health against the diseases in question and to guard against any downward trend in the rate of vaccination among children. The judgment also emphasised that in all decisions concerning children, their best interests must be of paramount importance. With regard to immunisation, the objective had to be that every child was protected against serious diseases, through vaccination or by virtue of herd immunity. The Czech health policy could therefore be said to be consistent with the best interests of the children who were its focus. The Court further noted that the vaccination duty concerned nine diseases against which vaccination was considered effective and safe by the scientific community, as was the tenth vaccination, which was given to children with particular health indications.