Vaccination Guest Post: Ethics and Parental Rights

In the vaccine debate, like so many other debates, proponents from each side seem to have overwhelming evidence for their cause.  It becomes very difficult for parents, patients, and the average person to know which choice is best.  Before we jump into answering some of the questions posed on evidence, effectiveness, and safety of vaccinations lets first talk about how to make the decision.  Not necessarily an argument to make a certain choice but rather how to make a decision and how we might respond to those who disagree.

What is a a parent’s ‘due diligence’ when it comes to vaccination?  Should they do their own research or only rely on their pediatrician? How can parents judge the quality of information they receive?

As a father I believe I have a moral and spiritual obligation to aggressively plan and pursue the welfare of my family.  I am shirking my responsibilities if I do not try to anticipate the needs of my family and attempt to provide for them.  I feel that is part of my role in life.  Interestingly, as a pediatrician this is the exact same obligation I have towards my patients and their health needs.

So as a parent I think we all ought to be researching and learning about the different choices with which we are faced for our families.  A parent’s due diligence for vaccinations is to look into understanding what the risk of injury, death, and disability is for each of the infections for which we have a vaccine.  We should try to understand the ‘why’ of the recommended vaccinations.  This sounds impressively hard at first but really isn’t if you think about it.  We do this all the time already for other things.

I had the chance to go to Haiti a couple years ago after the earthquake on a medical relief team.  In that process I took some time to read online about the cultural framework of the country including some of the local political happenings and some of the recommendations from other US citizens already there.  I wanted to understand better the environment in which I was going to be working.  I talked with people able to give first hand accounts of earthquake recovery.  I looked at expert opinions from the State Department website on the political changes underway and then consulted some of the gold standard textbooks on tropical medicine to help prepare me for their health care needs.  In this process I weeded out information that didn’t seem applicable and trusted other information that had good evidence behind it.  By and large, peoples opinions carry less weight in this process than do published studies citing research evidence.

I think parents should be thorough when looking for vaccine information.  They most certainly look on the internet already and there are lots of good resources available.  I have found that many parents discount good sources of information for the perceived biases they believe the sources have.  For instance, the CDC has a great website dealing with common infections of childhood and travel.  They have good recommendations on how to prevent them through hygiene practices and vaccinations as well as how to treat the disease should it occur.  Even so, many discount this wellspring of information due solely to the ‘.gov’ domain.  Family members are another good source of information, especially the older generations.  Spend an afternoon with your grandmother and ask her what she remembers of polio.  Was she ever recruited to run the hand crank on an iron lung when the hospital power went out? And of course, your pediatrician should be a resource for you.  They should be willing to have a conversation about vaccinations.  Just like a good surgeon should be able to tell you why you need your thingy-ma-jig taken out, a good pediatrician should be able to tell you clearly why the chosen vaccinations are right for your child.

What do you feel are the ethical implications of choosing not to vaccinate?

The ethical implications of not vaccinating are pretty big.  There are at least two implications one should be prepared to handle.  The first is the the most obvious.  By not vaccinating against a certain disease you are increasing the chance of your child contracting that disease and becoming disabled or dying from it.

(Now I hear someone saying “But I’m limiting their chance of injury from the vaccine too!”  We’ll get to that in a future post, but that doesn’t really apply here.  What I mean is that the implications for not vaccinating rest solely on what ill effects happen from not vaccinating.  Potential benefits from not vaccinating are not ethical implications.  So we are going to put those off for now.)

The second implication for vaccine refusal concerns the manner in which we have increased the risk of someone else contracting the vaccine preventable disease and becoming injured, disabled, or dying.  The most likely source from which a child will contract whooping cough or influenza is their parents or caregivers.  Studies have shown that when otherwise healthy adults are vaccinated against seasonal influenza their children as well as their elderly parents contract the illness less often.  I think of this like a parent driving intoxicated.  Their decision to drink too much beer may seem like a personal choice but when they load little Johnny in the backseat they have made a choice for him too.  We need to consider this implication as well.

How does our faith inform our medical decisions in this area?

When I first started writing my answer to this question I realized it was becoming rather long winded and wordy.  I tend to be that way especially when talking about theology or medicine so I erased it.  To put my answer simply, Scripture commands Christians to do whatever they do to the glory of God (1 Cor 10:31).  If you can’t honestly say that you choose to vaccinate or not vaccinate your child for the glory of God then we first need to fix that prior to talking about the details of vaccinations.

How do you respond to a parent that decides against vaccinating? Do you feel a parent should have the “right” to refuse?

With a typical family the first vaccinations we do come at about two months of age.  By that time I’ve had several visits and we are beginning to establish a level of trust and communication necessary to a healthy doctor-patient relationship.  If the family expresses a commitment to not vaccinate I really want to explore that topic to find out more.  What are the factors that have gone into their decision?  Is there a known medical condition that limits vaccination?  Is there family history that is concerning?  Do they have concerns for certain vaccines or is it all of them?

If their decision is based on the scientific evidence as they see it then we usually have an engaging and thought provoking conversation.  There is a lot of give and take and there may be much to think about after the visit.  If families persist in vaccine refusal after several attempts to discuss the scientific merits of vaccinations then we usually need to accept that we have different fundamental viewpoints that will only further interfere with the trust relationship in the years to come.  I think an argument for the usefulness, safety, and effectiveness of vaccines is an easy one from the scientific literature.  If I present this information well, and parents cannot see that viewpoint as valid, then when harder questions come up (like evaluations for cancers or heart defects) and they have even less evidence to go on why would they trust me to make a sound decision?  If they truly do not trust me to make a clearly reasonable choice from the literature then they should not trust me to make a judgment call based on experience and wisdom.  At that point I recommend they would be better served by another pediatrician.

As far as the ‘right’ of parents to refuse vaccinations, almost all states already provide for this.  For most states it only requires the expressly stated choice and perhaps a letter from the parents to exempt their children from vaccination requirements for school.  We also need to understand that organizations, schools, and hospitals might state their ‘rights’ too.  There is more than one well documented case of influenza being spread throughout a hospital by a healthcare worker who had refused the vaccine.  Should an unvaccinated physician or nurse be allowed to care for my elderly mother or attend to NICU babies during the worst part of the seasonal influenza cycle?

All the recent outbreaks of measles in the United States have been directly related to an unvaccinated individual traveling from Europe and spreading the contagion.   In the San Diego outbreak which occurred in 2008 the index case spread the disease to five of his classmates and four of the other children in the pediatrician’s waiting room.  Three of the children in the waiting room were under a year of age and did not qualify for measles vaccination.  Do children in my waiting room have a ‘right’ to be protected from a disease that is preventable?  Who’s job is it enforce that protection?  You can be sure that if someone fired up a cigarette in my waiting room there would be 15 people jumping up to take care of it.