Tag: vaccines

A COVID-19 Vaccine Won’t Stop the Pandemic

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This post is a part of our Bioethics in the News series

By Parker Crutchfield, PhD

As the COVID-19 pandemic continues to maim and kill thousands and devastate countless others, many are pinning their hopes of returning to a life resembling normal upon the development of a vaccine. The Centers for Disease Control and Prevention has even advised states and cities to be prepared to allocate up to 800 million doses of a vaccine in late October or early November. But it is highly unlikely that a vaccine will do much to stop the pandemic and related significant harm. For a vaccine to get us out of the pandemic, it needs to be developed, distributed, and received. Regardless of its development and distribution, if people don’t take it, then it won’t do any good. And there isn’t much reason to think that many people will take it, at least initially.

Image description: an illustration of a bottle with a white label that says “COVID-19 Vaccine” in black text. The bottle is different shades of blue with a dark blue background. Image source: Shafin Al Asad Protic/Pixabay.

Allocation Models

Recently, a team of scholars advocated for a scheme to allocate the eventual vaccine, the Fair Priority Model. This model, like most models of allocation, assumes that the vaccine will initially be scarce. On this assumption, the allocation then proceeds in phases, the first preventing the most significant harms such as death, the second preventing other serious harms and concomitant economic devastation, and the third addressing community transmission. Other models may set different priorities by, for example, putting health care workers or racial and ethnic minorities first in line.

Developing allocation models is important. But they all rest on a questionable assumption: that the people to whom the vaccine is allocated actually want it, or are at least willing to take it. Scarcity is just as much a matter of demand as it is a matter of supply.

Demand for a Vaccine

Recent evidence suggests that, generally, people won’t take the vaccine initially, even if offered. Almost 80% of people said they wouldn’t get it, if available, at least until others have done so, according to a recent CBS News poll. A return to something resembling normal life requires around 70-80% of the population to be immune.

Mistrust of the politicization of vaccine development or of the scientific practices involved may be responsible for much of the population’s apparent hesitation. But reasonable people may also simply not want to be first in line for a new immunity enhancer. Thus, whatever criteria are used, the allocation scheme must incorporate consideration of demand, not simply supply.

For example, the first allocation according to the Fair Priority Model should go to those people whose being vaccinated would most likely prevent death and who want the vaccine. If the vaccine is allocated to health care workers, the allocation must be to people who are health care workers and who want the vaccine. That is, demand for a vaccine should be just as much a component of allocation models as any other consideration.

Voluntary or Compulsory?

Allocation models must consider the population’s demand for a vaccine in order for such models to provide useful guidance on distribution. Given the apparent lack of demand, giving people the choice of whether to take the vaccine is unlikely to stop the pandemic any time soon. But demand only matters if people have an option. One way to avoid having to consider the population’s willingness to take the vaccine, and to dramatically decrease the time it takes to boost 70-80% of the population’s immunity, is to take that willingness out of the equation and make it compulsory.

Already some vaccinations are compulsory, depending on a person’s circumstances. Some have argued that the COVID-19 vaccine should be mandatory. One common principle in philosophy is that ought implies can. This means that what one’s moral obligations are hinges on what one can do. Even if one can justify compulsory COVID-19 vaccination, it’s unlikely that this is something that can be achieved. Compulsory vaccination is not something we can do, which means it’s not something we should do.

Consider, for example, the widespread reluctance to wear a mask and the flouting of social distancing guidelines. Wearing masks and social distancing are very minor burdens to bear for others’ well-being. While it is true that mask and social distancing mandates push against unrestrained permission to do what you want when you want to do it, others be damned, these intrusions are arguably minor (though are admittedly disruptive). Requiring 70-80% of the population to go someplace and get poked by a needle on multiple occasions or sprayed in the nose are much greater liberty intrusions. It is a pipe dream to think that a vaccine mandate would be accepted by the very same population who refuses to bear the more minor burdens of mask wearing and social distancing, which amounts to at least 29% of the population, enough to undermine our ability to stop the pandemic.

Different Baskets for Our Eggs

If administration of the COVID-19 vaccine is voluntary, not enough people will volunteer to get it. If administration is mandatory, still not enough people will get it. The vaccine’s allocation can only be either voluntary or mandatory. Either way, not enough people will get it, at least at first. The only conclusion to draw is that a vaccine is not going to stop the pandemic, at least any time soon. If ought implies can, we ought not pin our hopes upon a vaccine, because we cannot hope for it to work to stop the pandemic. There is no light at the end of the tunnel.

Image description: a narrow tunnel between two brick walls that leads to darkness. Image source: Peter H/Pixabay.

However, incentives and disincentives can change a person’s mind. Other than the incentive intrinsic to getting the vaccine—the preservation of human life and well-being—are there others that might make people more willing to get it, such as money or tax breaks? Or are there disincentives to vaccine refusal that might convince someone it is better to get it than it is to refuse? Carrots or sticks?

If neither, then we’re in for the long haul.

Parker Crutchfield photo

Parker Crutchfield, PhD, is Associate Professor in the Program in Medical Ethics, Humanities, and Law at the Western Michigan University Homer Stryker M.D. School of Medicine, where he teaches medical ethics and provides ethics consultation. His research interests in bioethics include the epistemology of bioethics and the ethics of enhancement, gene editing, and research.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 8, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Crutchfield: Trust and Transparency in Quarantine; Public Health Crisis Warrants Liberty Restrictions; We Should Tolerate and Regulate Clinical Use of Human Germline Editing

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COVID-19 vs. Childhood Immunization? A Bioethics Perspective from Nigeria

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This post is a part of our Bioethics in the News series

By Felix Chukwuneke, MD

Avoiding the Impending Calamity: Our Ethical Responsibility

United Nations Children’s Fund (UNICEF) has warned that COVID-19 is disrupting life-saving immunization services around the world, putting millions of children in both rich and poor countries alike at risk of diseases like diphtheria, measles and polio. UNICEF, the Sabin Vaccine Institute and Gavi, the Vaccine Alliance are also worried that thousands of children could die needlessly from the diseases that were hitherto controlled through vaccination but are now being redundant because of the lockdown and compulsory quarantine by the government of the day. UNICEF Executive Director Henrietta Fore stated that there is going to be a real problem as many of these already conquered preventable diseases for children such as measles, diphtheria and cholera are in the increase across the world.

“Immunization is one of the most powerful and fundamental disease prevention tools in the history of public health,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Disruption to immunization programmes from the COVID-19 pandemic threatens to unwind decades of progress against vaccine-preventable diseases like measles.”

[WHO News release, May 22, 2020]

There is no doubt Africa will be the worst hit by this quarantine and lockdown policy. In a place where lack of education and poverty are commonplace, the rebound of these preventable diseases as a result of improper policy and control implementation will be unprecedented in the near future after we are done with the pandemic. Most governments especially in Africa did not take into consideration the sustenance of immunization programs and were more focused on the COVID-19 pandemic – the devastating effect of the disease cannot be equated to some of these childhood preventable diseases.

The quarantine and social lockdown have resulted in a drop in vaccination rates leaving several numbers of children open to diseases that were hitherto prevented. There is a need to step up campaigning once again on the importance of sustaining immunization that has been in place before the COVID-19 pandemic.

A 13-year-old male is receiving an intramuscular vaccination in the deltoid muscle from a nurse. His mother is standing behind him with her hand on his shoulder; they are smiling.
Image description: 2006 Content Provided by Judy Schmidt. This photograph shows a 13-year-old male receiving an intramuscular vaccination in the deltoid muscle, from a nurse. His mother is standing behind him with her hand on his shoulder; they are smiling. Image source: Centers for Disease Control and Prevention.

The Philosophy of Objectivism in Public Health Emergencies Such as the Coronavirus Pandemic

The mandate from a responsible government to ensure and protect the health of the public is an inherently moral pursuit with obligation to care for the well-being of its communities. In doing so the government should refrain from immediately engaging extreme measures. Further, the widespread deployment of uniform measures should first understand the peculiarity of the environments in which they will operate. Africans across many nation states, for example, live in a diversity of settings where communicable diseases are all too common. Many individuals live in poor living conditions necessitating proper advance planning of COVID-19 pandemic management. With that management, such planning should carefully consider the sustainability of the on-going vaccinations of childhood preventable diseases. Vaccinations have had an enormous beneficial impact on population health, and the related prevention of disease has been one of the single greatest public health achievements of the last century.

The questions I pose center on an exploration of which disease should rightly be given priority based on established fact. I question why there has been so much panic and fear about COVID-19. With the introduction of this novel disease, with a mortality rate lower than that of those diseases preventable by vaccination, should we permit gains made in vaccinating children against common childhood diseases to stop? With respect to more preventable diseases, especially those that affect children, why is there such an emphasis on COVID-19? Should mothers and caregivers give precedence to the COVID-19 pandemic, deferring their children’s routine immunization? Again, in an isolation and quarantine situation with strict governmental constraints on movement, how might childhood immunizations continue, especially in rural areas (assuming that accessible immunization centers are even open and operating)?

Currently, keeping to a routine immunization regimen by parents and caregivers is a challenge, especially for those who come from remote areas. The government, through the health ministry, should ideally put procedures in place for the duration of the pandemic to encourage all women to ensure that their children get access to these vaccines. It would be tragic to view this situation as a tradeoff, thus incurring the risk of returning to the horrors of polio, diphtheria, cholera and smallpox, and in doing so, allowing many to die of already controllable diseases.

Government Needs Proper Strategizing, COVID-19 Should Not Stop Normal Existence

There is no doubt that ethical challenges abound in quarantining people compulsorily, potentially against their decisions and will because of the COVID-19 pandemic. But more challenges abound when the government fails to take the precautionary measures necessary to ensure the continuity of the vaccination program for known and preventable childhood diseases. Because some of the latter are transmitted person-to-person there is, therefore, a need to provide both individual and public protection against the disease in addition to focusing on COVID-19. Though the COVID-19 pandemic may pose a health threat to many people across the globe, I suggest that there is even greater threat to personal liberty by compulsory quarantine and economic lockdown.

There is suspicion among some that the COVID-19 pandemic has been exaggerated, and that the measures currently in place across the world are not supported by the data. This doubt is illustrated by the Tanzanian President who had samples collected from goat, pawpaw and sheep for COVID-19, assigning human names to those animal samples. Reportedly, the related test results were positive, thus feeding the concerns on the accuracy of information regarding the incidence and prevalence of the infection, influence of co-morbidities, etc.

Demystifying the COVID-19 Pandemic While Achieving Health for All

Conflicting data notwithstanding, there are those who hold the opinion that measures taken by governments around the world are based on fear and speculations, and ultimately, might prove ineffective. It is argued here, that denying people their right to personal movement has a preventable impact on established vaccination programs, programs with known effectiveness in the reduction of mortality among children. High numbers of people are still being infected by those preventable diseases. It might also be argued that at present the imposition of a uniform isolation strategy is premature, especially with conflicting reports on its mode of transmission and degree of virulence. Perhaps it would be prudent to lay emphasis on practicing safe habits, building and supporting one’s immune system, maintaining proper hygiene, social distancing, and taking care of those most vulnerable ones among us such as the children and the elderly.

Felix Nzube Chukwuneke photo

Felix Nzube Chukwuneke, is a Fogarty Trained Bioethicist and Professor of Oral & Maxillofacial Surgery and Dean of Dentistry in the College of Medicine, University of Nigeria Nsukka (UNN) Enugu Campus. He is Chair of the UNESCO Bioethics Unit at the College of Medicine, University of Nigeria; Chair of the College of Medicine Research Ethics Committee (COMREC) and Chair of the Eastern Nigeria Research Ethics Forum (ENREF).

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, July 9, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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COVID-19 Vaccine: “Not throwing away my shot”

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Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sabrina Ford, PhD

In the advent of the novel coronavirus (COVID-19) pandemic, there is an underlying belief in the United States that a COVID-19 vaccine may be the Holy Grail, the silver bullet to assuage the pandemic and open up the quarantine doors. Yet, there is a divide in the United States regarding vaccination acceptance. The Centers for Disease Control and Prevention (CDC) reports less than 50% of adults receive the vaccine for influenza (flu). In the 2017-2018 flu season, 37.1% received the vaccine, the lowest rate in ten years. The rate increased to 45.3% in 2018-2019. In a recent study reported in The Boston Globe, authors Trujillo and Motta found that 23% of persons surveyed said they would not get the COVID-19 vaccination. The study breaks it down further regarding anti-vaccination attitudes (also known as “anti-vaxxers”) and found that 16% of respondents identified themselves as anti-vaxxers, and of those, 44% said they would not get the COVID-19 vaccine. The researchers contend that anti-vaccine sentiment still exists in spite of the deadliness of COVID-19.

Vaccine debate

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Image description: An illustration of a light green circle with a vaccination syringe in the center that is surrounded by green viruses. Image source: Alexandra_Koch/Pixabay.

As Americans, we want what we want how we want it. For some of us, the vaccine cannot come fast enough, and it better be effective. Others don’t plan to get it even when it is available. I have set up a dichotomous choice, but indulge with me in thinking through the debate. Many philosophical and ethical discussions occur in academic research—and particularly in mainstream and social media—highlighting opposing views of those who choose to vaccinate and those who do not. Often, these two positions fall along partisan lines, but not in the way that we might expect. The anti-vaccine movement began with the political left, but spread to the religious right, conservatives, and libertarians.

Approximately 20 years ago, a flawed but influential study linked the Measles, Mumps, Rubella (MMR) vaccine to autism. It started a hot debate fueled by staunch supporters of anti-vaccination from both sides of the aisle. The anti-vaxxer movement took hold with powerful liberal voices, but in recent years has become convenient for the religious and far-right who aim to keep government out of personal decisons. A 2015 Pew Research Center Study found that 12% of liberals and 10% of conservatives are opposed to vaccination. Herein lies my question: to what can we attribute the strong stance that anti-vaxxers take regardless of political position? Why does this question matter? America is a free country. However, the movement warrants an understanding in the midst of a pandemic of an extremely deadly disease whereby science tells us that a vaccine may mitigate infections and death.

Facts are stubborn things

One commonality between the liberal and conservative anti-vaccine stance is a lack of trust in science and medicine, and belief in “alternative facts.” This is particularly true within the anti-vaxxer movement. Some don’t trust science based on real life experiences or notable past deceptions in public health interventions, such as the Tuskegee Experiments, Havasupai Diabetes Project, Henrietta Lacks, etc. Antithetically, the autism study was deceptive by negating the lifesaving MMR vaccine as harmful. This myth has persisted over time, fueled by the anti-vaxxer movement and the discount of science as faulty, dangerous, driven by big government, and against individual choice. Facts versus feelings further complicates the human cognitive decision-making process. For example, in the case of vulnerable children with autism for whom science has not fully unraveled a cause or treatment, anti-vaxxers feel they can place blame on the MMR vaccination. Feelings contribute to the uptake of faulty information and fake news via social media, in turn drowning out the facts.

Herd immunity

Vaccines have been one of the greatest public health successes in the world due in large part to herd immunity. Herd immunity comes with centuries of science resulting in the reduction of deadly diseases. The cursory explanation for herd immunity is: if a large proportion of a community is vaccinated, the lower the collective risk to the community. The algorithm suggests at least 80-90% of a community needs to have immunity to a disease and/or be vaccinated to protect the proportion of persons with compromised health conditions who cannot be vaccinated. The range in vaccination rates is dependent on the effectiveness of the vaccine. We have seen the eradication of smallpox and polio because of a highly effective vaccine delivered to most of the children in the U.S. This was achieved through mass immunization and extremely effective public health messaging. Most recently, buy-in to herd immunity has devolved from a fear of deadly disease to a fear of the very thing that prevents deadly disease. As a result, we have seen a resurgence in measles, which can be deadly for children with compromised immune systems. The science of herd immunity is powerful but relies on collectivism and social responsibility. The requirement that a large proportion of a community needs to be vaccinated to protect others cuts across American values of individuality and freedom of choice.

Final thoughts

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Image description: Fabric face masks of various colors and patterns are arranged flat on a yellow surface. Image source: antefixus21/Flickr Creative Commons.

Before COVID-19, we lived in a different era with some generations never experiencing or witnessing extremely contagious, deadly diseases, confirming a belief that we can individually control our own disease states. Now, we are faced with a history making, highly infectious, deadly disease. Will we adopt a philosophy of sacrificing a bit of comfort by quarantining, wearing masks, or experiencing the pinch of a vaccination to save the lives of others? The jury is still out on that debate. We have witnessed segments of our society rebel and even retaliate against the idea of vaccination. Yet, scientists are working faster than ever to develop an effective COVID-19 vaccine, and the U.S. government has promised to enable the Food and Drug Administration (FDA) to relax clinical testing protocols to push the vaccine out in order to save lives. No, the vaccine will not be the silver bullet, but it has the potential to augment natural immunity to work as a tool of collective protection. Is the deadliness of COVID-19 enough to override the need for anti-vaxxers to hold onto personal choice?

This is not an indictment on one’s personal choice not to be vaccinated, but an opportunity to ponder individuality versus social responsibility for the greater community benefit. COVID-19 has been a game changer on human behaviors, requiring us to social distance and wear masks for the greater good. Will we embrace social responsibility and be vaccinated to save lives? How do we reconcile our individualism with the adoption of collectivism?

ford-sabrina-2020Sabrina Ford, PhD, is an Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Biology and the Institute for Health Policy in the Michigan State University College of Human Medicine. Dr. Ford is also adjunct faculty with the Center for Ethics and Humanities in the Life Sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Monday, June 1, 2020. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Ford: Contemplating Fentanyl’s Double Duty

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February webinar to address Michigan’s vaccine waiver education policy

bbag-blog-image-logoWhat’s the point of Michigan’s vaccine waiver education requirement?

Event Flyer

Since 2015, Michigan parents have had to attend education sessions at public health offices if they want their unvaccinated or under-vaccinated children to attend school or daycare. This policy seems to have succeeded: the state’s nonmedical exemption rate declined by 35% from 2014 to 2015. But what explains this apparent success? Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions? Also, does vaccine education promote additional public health goals, i.e. other than short-term vaccination compliance? This presentation will attempt to answer these questions by drawing on immunization records, interviews with public health staff, and surveys of health department leaders, with the goal of informing arguments about the value of Michigan’s vaccine waiver education policy.

Feb 15 date iconJoin us for Dr. Navin’s lecture on Wednesday, February 14, 2018 from noon till 1 pm in person or online.

Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University. His recent work is primarily in bioethics and public health ethics. His book, Values and Vaccine Refusal, was published by Routledge in 2015.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lectures. To receive reminders before each webinar, please subscribe to our mailing list.

Announcing the Spring 2018 Bioethics Brownbag & Webinar Series

green brownbag and webinar iconThis year’s Bioethics Brownbag & Webinar Series resumes in February. You are invited to join us in person or watch live online from anywhere in the world. Information about the spring series is listed below. Please visit our website for more details, including the full description and speaker bio for each event.

Spring 2018 Series Flyer

Feb 15 date iconWhat’s the point of Michigan’s vaccine waiver education requirement?
Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions?
Wednesday, February 14, 2018
Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University.

March 14 calendar iconPain But No Gain: Pain as a Problematic and Useless Concept?
Do references to pain help us with anything, or should we perhaps abandon pain as a “useless concept?”
Wednesday, March 14, 2018
Marleen Eijkholt, JD, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine, and Clinical Ethics Consultant at Spectrum Health System.

April 11 calendar iconEthical Issues Related to Fundraising from Grateful Patients
How should the process of philanthropic development be structured in order to demonstrate respect for all persons involved?
Wednesday, April 11, 2018
Reshma Jagsi, MD, DPhil, is Professor and Deputy Chair in the Department of Radiation Oncology, and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan Medical School.

In person: These lectures will take place in C102 (Patenge Room) East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

Pseudoscience and Measles in Minnesota

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Hannah C. Giunta, DO, PhD, MPH

A recent measles outbreak in the Minneapolis-St. Paul, MN metro area is all over the news. More than thirty children have been treated at local hospitals, and at least 50 measles cases have been confirmed. The local Somali immigrant community has been hardest hit in large part due to their low vaccination rates. Commentators have demanded a variety of measures to control the vaccine-preventable disease, including enhanced border security. However, there has been less coverage of the outbreak as evidence of systemic social injustice.

Indeed, no matter what ones views are on compulsory vaccination, Somali parents’ vaccine refusal is not a case of informed, empowered parental choice but one of disadvantage and exploitation. The Somali immigrant community has been targeted by anti-vaccine activists spreading scientifically suspect information. Activists have taken advantage of an as yet unexplained increased rate of severe autism (but not autism in general) in the Somali community, encouraging parents not to vaccinate while spreading long debunked claims about the link between vaccination and autism. Realizing that internet rumors were not effective, activists have taken to personally visiting families and warning them about the dangers of vaccination. Yet, there is a real temptation to place some of the blame for the epidemic on Somali parents. Even commentators who rightly place blame on the anti-vaccine activists and declare the situation quite literally “a natural experiment” do not take the extra step of calling activists what they really are: gamblers and fraudulent pseudo-scientists willing to bet on the lives of disadvantaged children. This is not a case about free speech or poor parental decision-making; rather, it is a case of advocates conducting a so-called “natural” experiment where they stand to possibly gain the benefits (i.e. possible support for their cause) without taking on or acknowledging any of the risks faced by their subject-victims. The activists are guilty not just of being ill-informed and having dubious goals but also of perpetrating a larger social injustice.

While people certainly have the right to free speech and we all have a responsibility to evaluate the information presented to us, anti-vaccine advocates in this case chose to target a vulnerable population and to take advantage of individuals’ lack of empowerment. Of course, they did not set out to conduct a classic scientific experiment, but they are certainly still guilty of participating in a type of experiment. Some might say that the activists were just trying to help Somali families because they sincerely believe in a link between autism and vaccination. Others would argue that these individuals are not qualified scientists and were not performing research. But, the activists’ project was more devious than misinformation. The activists sought to target a minority community, take advantage of a medical puzzle, keep community members in the dark about their true objectives, and to recruit participants into a risky gamble where “benefits” primarily accrue to the activists themselves. After all, if the activists could point to any decline in the autism rate (regardless of causation) or show the public that vaccine-preventable infections are simple childhood illnesses from which children recover without incident, they would have more “data” to support their cause. The very fact that parents believed the activists likely lent more credibility to the anti-vaccine crusade in populist minds. If enough people believe the message, surely there must be something to it?

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Image description: a baby is in the hospital with measles in the Philippines. Image source: CDC Global/Flickr Creative Commons

The social injustice implications of a pseudo-research paradigm come into focus when we consider three major aspects of the case in question. First, the activists exploited their own relative privilege by providing biased information. There is no way that individuals engaged with the anti-vaccine campaign are unaware of vaccine-preventable diseases and the risks they present. They simply choose not to focus on those risks. They so strongly support their own hypothesis that they believe it to be true despite evidence to the contrary, much like a researcher might believe that nothing could possibly go wrong in an experiment. Anti-vaccine activists usually have access to many sources of information and thereby a certain degree of epistemic privilege. They have socioeconomic resources to travel to ethnic enclaves and meet with Somali families. On the other hand, the Somali community in Minnesota continues to struggle with poverty, unemployment, and related social ills. Somali children are already at-risk for poorer health outcomes, but the activists did not consider this relative health disadvantage.

Secondly, the activists maximized their own benefits while placing all of the burdens on the Somali children. The segregation of poor Somali immigrants into certain ethnic enclaves virtually insures that children, including the activists’ children, outside these neighborhoods face much less risk of illness. Should there be a serious outbreak, Somali children would bear the burden, not the activists’ children. The Somali community would also be blamed for not vaccinating their children, absolving the activists’ of responsibility through a leveraging of their privileged social position.

Lastly, even with obvious evidence that the Somali community is suffering a measles outbreak, activists have failed to reach out and attempt to retract their message. Their pseudoscientific project continues unabated. They cloak themselves in the language of science while allowing a natural experiment to run wild and harm innocent children. Clearly, they believe their agenda and hypothesis about autism causation are more important than the lives of innocent children. Measles does kill, and over 30% of children will experience one or more complications, including diarrhea and dehydration, pneumonia, and encephalitis. Perhaps, if anti-vaccine crusaders wish to engage in pseudoscience, we should hold them to the standards and responsibilities of real medical scientists, including the wrongful death of any children who succumb and the continuing expense of measles-related complications. You can’t yell “fire” in a crowded room if there really isn’t a fire, and activists have crossed a line and are doing just that. We, in the name of equitable health outcomes, need to remind activists that words do matter and their experiment has failed.

hannah-giunta-2017-cropHannah C. Giunta is a May 2017 graduate of the Michigan State University DO-PhD program. She received her MPH in May 2015 and her philosophy PhD in May 2016. Dr. Giunta is an incoming Mayo Clinic Pediatrics Resident.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, June 1, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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Bioethics for Breakfast: Boundaries: Do Public Health Interests Trump Individual Parent Prerogatives?

bioethics-for-breakfastDean G. Sienko, MD, MS, and Mark Largent, PhD, presented at last Thursday morning’s Bioethics for Breakfast event, offering opposing views on the topic, “Boundaries: Do Public Health Interests Trump Individual Parent Prerogatives?”

Given the recent measles, pertussis, and ongoing chickenpox outbreaks, there are a number of people who have called for expanded authoritarian responses. At the most aggressive end of the spectrum are people who call for laws forcing people to vaccinate (often referencing using the century-old Jacobson case for justification). The Jacobson case was a 1902 Massachusetts case in which a minister refused to have his children vaccinated. But the Massachusetts Supreme Court ruled that the freedom of individuals must sometimes be subordinated to the common welfare. More moderate views call for the elimination of all non-medical exemptions to mandated vaccines. Which approaches are prudent and which might be unintentionally counterproductive? Could efforts to curtail parents’ ability to opt out of mandated vaccines inadvertently feed further resistance? Are there any reasonable compromises that might be forged? The speakers offered their views on these issues.

Dean G. Sienko, MD, MS
Dean G. Sienko is the MSU College of Human Medicine Associate Dean for Prevention and Public Health and the Division Director of the Division of Public Health.  In addition Dr. Sienko serves as the Acting Director of CHM’s Institute for Health Policy. The mission of the Institute is to improve the health care available to Michigan residents through research, policy analysis, education and outreach, and support of quality improvement activities.

Mark Largent, PhD
Mark Largent is an historian of science, technology and medicine and Associate Dean at Lyman Briggs College at MSU. His research and teaching focuses on the role of scientists and physicians in American public policy. He has written Breeding Contempt: The History of Coerced Sterilization in the United States (2008), Vaccine: The Debate in Modern America (2012), and Keep Out of Reach of Children: Reye’s Syndrome, Aspirin, and the Politics of Public Health (2015).

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

Vaccination, Free Riders, and Family Autonomy

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series. For more information, click here.

By Jamie Lindemann Nelson, PhD

Still rather spent from an intense bioethics workshop in Germany the weekend just past, it was through a bit of a lingering haze that I glanced at the New York Times editorial page for the 21st of April. What attention I could muster was caught by the bottom of the page—“Vaccine Phobia in California.”

I can usually count on the Times Op-Ed writers to be on the side of the angels (as I make it out) and this time seemed no exception. Commenting on legislation pending in the California legislature that would remove exemptions from vaccination on the grounds of a parent’s “personal belief” that vaccines might harm children, the editorial briefly but effectively supported the bill. Considering it obvious that vaccines are safe and effective, the Times writers stress that near-universal vaccination is key to maintaining reliable herd immunity against a range of serious illnesses.

Herd immunity is crucial to those who cannot undergo vaccination for medical reasons, and for whom vaccines are ineffective. Yet it is imperiled particularly in California, where the rate of “philosophical” (i.e., personal belief-based) vaccine exemptions has more than tripled since 2000, and which is, not incidentally, the site of the recent Disneyland measles outbreak.

Perhaps what was left of my jet lag was to blame, but the editorial didn’t prompt the indignation at “anti-vaxxers” I have typically felt when confronting their willingness to put children at risk on such flimsy grounds. I’m inclined to think, though, that a recent lecture by a Harvard pediatrics professor, Dr. Claire McCarthy, may be the cause of my somewhat more conciliatory inclinations (McCarthy 2015).

There should be no confusion about Dr. McCarthy’s pro-vaccine views. However, she is also a thoughtful scholar. During her lecture, she spoke of a healthy child who had a routine inoculation. Very sadly, the child had an extreme reaction; shortly thereafter, he was dead.

The tragedy of a child’s death can hardly be overstated. Yet the odds of any given child dying from a vaccination are miniscule, and parents expose their kids to miniscule mortal risks every day, and sometimes pretty whimsically—think of the last time you buckled your toddler into her car seat for a quick drive through snowy streets to pick up the evening’s wine.

Still, imagine a parent reasoning like this: “I don’t live in California; my community isn’t full of people who won’t vaccinate their kids. And I know there’s no evidence for a link between vaccination and autism. What I’m scared about is Dr. McCarthy’s story. In my town, I can count on robust herd immunity. Why, then, should I expose my own precious child to even a very small risk of death when I don’t need to? She’ll be fine so long as we keep an eye on the vaccination rates wherever we live or visit.”

There’s an obvious reply: this plan is plainly unjust. It allows her family and her child to benefit at the expense of other kids who have undergone the same very small risk this parent rejects, in order to secure the herd immunity on which she relies. Her “justification” seems a textbook example of “free riding.”

Yet families are a curious kind of social institution. Small-scale, and typically intimate associations in which much important work of personal identity formation and maintenance goes on, they make up a centerpiece of the most important part of many people’s lives. To perform their special functions well, they are widely recognized as requiring some degree of insulation from some of the moral norms that people are expected to follow in their dealings with strangers and acquaintances.

Justice is often seen as one of those norms whose full force gets a bit diluted in families. For example, families are routinely allowed to pass along from generation to generation resources, training, and traditions that may well entrench social inequalities; many conceptions of justice see those inequalities as indefensible. In a fairer world, we mightn’t be suffered to favor “our own” to such an extent. Yet many would reply “so much the worse for fairness.”

Utilitarians may sigh and deontologists scold, but people typically don’t think that the moral claims of strangers are as significant as are those of family; that just seems part of what it is to love some people and not others. The “free riding” charge may be simply another departure from general moral norms allowed by what many theorists have called “family autonomy.”

Of course, if you can’t get a philosophical exemption, there’s always the option of homeschooling. Yet I’m coming to think this response is rather draconian, at least absent a more pressing public health emergency. Not all parents can responsibly educate their children through high school, and what the children of such parents might miss could impair them in ways far more serious than a typical case of the measles.

There seems a less confrontational option—gentle persuasion based on clearly presented facts. The Times Op Ed concedes this very point, noting that the rate of unvaccinated kids in California schools declined during this school year, due to a “new requirement that parents speak to a licensed health care professional about vaccines and the risks of not getting vaccinated.” (New York Times, April 21, 2015, p. A 22.)

Yet not all observers have the Times’ confidence in education. Last April, Pediatrics published a study entitled, “Effective Messages in Vaccine Promotion” (Nyhan, et al. 2014). Almost 1800 parents were randomized to either a control group, or to one of four types of pro-vaccine messages: information debunking the vaccine-autism link; messages about the dangers of measles, mumps and rubella; images of children who have those diseases; a dramatic story about a child who almost died of measles.

The study’s take-home lesson? None of the messages increased parents’ inclination to vaccinate. Some of them actually made matters worse. Nor does the study address our imagined parent who fears, not autism, but the tiny chance of vaccination-induced death.

If education won’t work, is there anything short of coercion available? A study by Douglas Opel and colleagues (Opel, et al. 2013) found that presumptive, rather than participatory language and behavior on the part of health care professionals increased compliance. The trick is to treat vaccination as the standard expectation, and if parents demur, to respond along the lines of, “Look, Mary really needs these shots.” If parents object strenuously, they’ll not be overridden, but that is a very different matter from encouraging engagement in decision-making.

While there’s a good deal to argue about here, I think that presumptive approach to vaccination may be on balance defensible—it can help secure herd immunity against damages caused by dissenters, whether they mean to free ride, or simply don’t believe that shots do anyone any good, thus saving some children and parents a good deal of anguish. It doesn’t ride roughshod over the deep convictions of people implacably opposed to vaccination. It simply treats as a routine matter what should be seen as a routine matter, in a way analogous to letting science teachers determine that evolution structures the curriculum.

Admittedly, the presumptive approach hardly seems strictly in keeping with the gospel of informed consent and respect for autonomy, whether of individuals or of families. But strict fundamentalism doesn’t seem to me to be a more attractive policy in bioethics than in religion.

References
  • McCarthy, C.  2015. A Sticky Decision. Lecture, Harvard University Medical School, March 19.
  • New York Times. 2015. Vaccine Phobia in California.  April 21, p. A 22. http://nyti.ms/1Dus1zT
  • Nyhan, B., et al. 2014. “Effective Messages in Vaccine Promotion.” Pediatrics (doi: 10.1542/peds.2013-2365)
  • Opel, D., et al. 2013. “The Architecture of Provider-Parent Vaccine Discussions at Health Supervision Visits.” Pediatrics (doi: 10.1542/peds.2013-2037)

jamie-nelsonJamie Lindemann Nelson, PhD, is a Professor of Philosophy in the College of Arts and Letters at Michigan State University.

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