ETHICAL ISSUES RELATED TO VACCINATION OF CHILDREN

 

 

 

 

Dr. Sherri Tenpenny, DO
July 18, 2006
NewsWithViews.com

A Conference Report

Parents across the country have reported that their pediatricians have discharged them for refusing vaccines for their children. The individual reports seem to confirm the results of two studies published in 2005 that investigated this recent phenomenon. The first, published in Archives of Pediatrics and Adolescent Medicine, tabulated the results from a survey of 1004 pediatricians. Of the 302 respondents, 39% percent said they would dismiss a family for refusing all vaccinations and 28% said they would dismiss a family for refusing select vaccines.[1] In another study, 4.8% of pediatricians reported that they �always� dismiss families for refusing vaccines and 18.1% discharged patients �at least some of the time� for refusing vaccines.[2]

Having heard personal stories directly from patients, I was prompted to attend a conference in Seattle, held on July 14 and 15, 2006 called, �Ethical Issues Related to Vaccination of Children.� Even though I was only able to attend the second day of the conference, the agenda for the day, �Vaccine Hesitancy and Parents Who Refuse to Vaccinate Their Children,� was of great interest. I wanted to hear first hand what national experts were recommending to pediatricians and local health officials.

The morning started with the Senior Advisor of the Global Immunization Division at the CDC, Dr. Stephen Cochi, reinforcing the golden rule of public health officials: �Vaccines are one of the most important tools we have to protect the health of our nation�s most vulnerable citizens, our children.� He went on to discuss the lofty goals within the CDC�s Healthy People 2010 Project, a comprehensive, national health agenda which contains plans to achieve at least a 90% vaccination rate of all children by the year 2010.[3] Cochi detailed his largest concern: The lack of adequate funding in both the private and public sectors to ensure vaccination of all children. He expressed his opinion that a lack of funding has also contributed to repeated vaccine shortages over the last few years. He further lamented the need for more money to support the �fantastic job� being done by the FDA.

The next discussion was lead by professor of pediatrics and adjunct professor of epidemiology at the University of Washington Schools of Medicine and Public Health, Dr. Edgar Marcuse. His presentation, �The Origins of Immunization Hesitancy,� asserted that the primary reason for refusal is that �parents simply do not understand the importance of vaccination.� He argued that the media and the internet distort science and the scientific process in a way that is unbalanced, diminishing the authority of researchers and physicians. One slide in his presentation stated, �The media value news over scientific truth, controversy over education, regard balance as evidence of journalistic integrity and equate one expert with another.�

With this assessment, he dismissed a parent�s ability to read medical studies and have the intelligence and skills to decipher the information correctly. He went so far as to say, �Most parents have no clear idea how to evaluate the credibility of their source of immunization information.� In an unprofessional moment, Marcuse listed Dr. Andrew Wakefield[4] and Barbara Loe-Fisher[5] as non-credible resources when compared with Dr. David Salisbury[6] and Dr. Julie Gerberding.[7] He quipped that even though both Wakefield and Salisbury have �delightful British accents,� certainly there was a �huge difference� in their credibility. His comment drew snickers from the approximately 125 health care professionals and public health workers in the audience.

His chief concern was that science, physicians and governments have lost legitimacy as sources of authority by the many versions of the �truth� presented in the media and on the internet. He gave an example of the difference between perceived risk and real risk by stating, �A damaged child is not data; it is an anecdote that leads to outrage.� His contention was that outrage of this �perceived truth� is the reason behind parental refusal of vaccines.

Marcuse presented a solution for convincing wary parents to vaccinate. He asserted that public health professionals need a �sustained, state-of-the-art communication strategy� that uses media-savvy spokespersons to convincingly deliver the message of the importance of vaccination to the wary public. Called �social marketing,� he called for the creation of focus groups to interview concerned parents and then develop a marketing campaign to counter their fears.

The next speaker, Dr. Joel Frader, was the co-author of the aforementioned study published Archives of Pediatrics and Adolescent Medicine. His presentation, �How Physicians View the Issue: Physician Response to the Parent Who Refuses to Vaccinate a Child� was one that I had traveled to hear. His conclusions were strikingly different than what I had expected.

The pediatrician�s rationale for dismissing parents for refusing to vaccinate their children, as explained by Frader, is that �vaccination is the core of a pediatric practice.� Physicians point to this �lack of shared values� as the primary reason to ask a family to seek care elsewhere. Surprisingly, he strongly opposed this option. �It is not the role of the medical doctor (MD or DO) to demand respect due to his credentials nor should doctors demand that patients do what they are told.� His position was that the basis for the doctor-patient relationship was just that: A relationship. �Preaching and condescending to parents is not a way to foster trust,� he asserted, �but it is certainly a way to lose the respect of a parent.� He strongly advocated setting aside time to answer questions, discuss misunderstandings and correct misconceptions. Using a heavy-handed approach, saying, �If you don�t see things from my perspective, please go away,� invites a backlash that undermines trust in the entire medical profession and does not advance the health and welfare of children.

Frader�s suggestion was to educate families about the health implications of not vaccinating by taking opportunities to educate the community at large. He strongly discouraged �legalizing� the relationship by forcing parents to sign a hold-harmless waiver. It was refreshing to hear him say in closing, �If you have had multiple conversations with a parent who staunchly refuses to vaccinate, you should conclude that you have different views. Be willing to accommodate those views to avoid driving families away, even if parents will not vaccinate their children.� His voice of reason was a breath of fresh air.

An even more striking discussion was lead by Dr. Lainie Friedman Ross. An associate professor in the Department of Pediatrics and an associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, Dr. Ross admitted that she had never dismissed a parent from her practice for refusing to vaccinate. She went on to say, �Even though I have never discharged a patient from my practice, I am sure that many patients have discharged me. People no longer have blind faith in the healthcare system and their doctors. Patients are not dumb and discussions should be engaged with mutual respect.� She stated that pediatricians should avoid terminating patients at all costs, unless there is global distrust and unresolvable anger between the doctor and the parent.

After her presentation, Ross participated in a panel discussion to suggest policy for the promotion of vaccination. Contrary to the positions of the other panelists, Dr. Ross introduced a bold proposal: Remove all vaccines from school entry requirements and have no mandatory vaccination policies. She stated that mandatory vaccination was �convenient but causes harm� by removing the discussion about vaccines from the doctor-patient relationship.

Her ideas were met with solid resistance from the other panelists, including the moderator, Dr. Maxine Hayes, the State Health Officer for the Washington State Department of Health. Hayes argued that studies have proven school vaccination requirements have kept national vaccination rates high. A significant question should have been raised: Why should parents be forced to vaccinate their children against their better judgment in exchange for a public education funded by their tax dollars?

At one time, public health focused on sanitation and access to clean water; control and prevention of infectious diseases were a distant third. Now that sanitation and clean water are community standards, the priority of public health has become to eliminate infectious diseases through the use of increasingly more vaccines. Because the conference attendees were wholehearted proponents of vaccination, there was no mention of injuries that can result from vaccines. Neither was information given on what to say to parents who endure the heartbreak of a vaccine-injured child. Nonetheless, it was encouraging to hear published physicians from large academic centers strongly disagreeing with the current trend among many pediatricians, discharging parents for refusing to vaccinate their children.

Footnotes:

1. Flanagan-Klygis EA, Sharp L, Frader JE. Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med. 2005 Oct;159(10):929-34. PMID: 16203937
2. Diekema & the Committee on Bioethics: Responding to Parental Refusals of Immunization of Children. Ped 2005; 115:1428-1431.
3. Healthy People 2010 contains 467 objectives designed to serve as a road map for improving the health of all people in the United States during the first decade of the 21st century. Focus Area 14 is Immunization and Infectious Diseases Progress Review.
4. Dr. Andrew Wakefield is a British pediatric gastroenterologist who first reported the possible link between the MMR vaccine and autism.
5. Barbara Loe-Fisher is the co-founder of the National Vaccine Information Center.
6. Dr. David Salisbury is the Principle Medical Officer and Director of Immunization at the British Department of Health.
7. Dr. Julie Gerberding is the Director of the Centers for Disease Control and Prevention.

� 2006 Sherri Tenpenny - All Rights Reserved