In the monthly "Ethical Inquiry" series, we examine ethical questions, highlighting a broad array of opinion from journalism, academia, and advocacy organizations. Our intent is to illuminate and explore the complexity of some of the most vexing ethical questions of our time.
Ethical Inquiry: January 2011
Is it ethical for parents to opt out of immunizing their children?
Child immunization is frequently noted as one of the major milestones in the history of public health. It currently prevents about 2 million deaths every year, and has eradicated the deadly disease smallpox, while polio is heading towards elimination.
It is one of the key strategies for achievement of the fourth goal of the United Nations Development Programme’s Millennium Development Goals: “Reduce child mortality.” It is highly effective and costs as low as $1.00 per child.
Child immunization has saved more lives than all of the “miracle drugs” of the latter half of the 20th century – antibiotics (e.g. like penicillin), antivirals (e.g. drugs used to fight AIDS and influenza), and so on – and has even promoted reduction of birth rates, as parents have become more confident that the children they have will survive. A study in the United States released by the Centers for Disease Control and Prevention (CDC) in 2007 demonstrated that immunization had resulted in reduction in deaths and hospitalization by over 90% for 9 of 13 vaccine-preventable diseases, and no child at all was dying of or being hospitalized for smallpox, diphtheria, or polio.
However there are parents who object to immunization recommendations and requirements. This inquiry will explore that choice. Is it ever ethical not to immunize one’s child? If so, under what circumstances?
This question is hardly academic. In just the past few years there have been several cases in which parental resistance to childhood immunization was at least claimed to be a significant factor:
- After immunization coverage rates plummeted, Zimbabwe recently experienced a measles outbreak with over 11,744 cases and more than 570 deaths. The outbreak was initially confined to religious objectors but later spread to everyone else across the nation. About US $8.5m was needed for the consequent immunization campaign, but cases still persist after the campaign. Inconsistent media reports about the government considering invoking provisions of the law to protect children by immunization demonstrate the complexity of a move to compulsory immunization.
- In the United States, human papillomavirus (HPV) is the most common sexually transmitted disease, affecting 6 million every year, and is also linked to cervical cancer. The vaccine against works best if given before one becomes sexually active, thus there have been efforts to make it mandatory for girls around ages 11 and 12. Some have opposed this, arguing that it will undermine education for abstinence behavior. Some bioethicists have also been exclusively skeptical about HPV vaccination requirement, saying since HPV is not casually transmissible, there is less compelling reason to justify the paternalistic laws for it.
- A 1986 federal law limits lawsuits against vaccine manufacturers, as a way of encouraging availability of vaccines. However, WBUR radio in Boston reports (October 2010) the case of a family seeking to sue manufacturers in a regular court following the claim that the DPT vaccine given 18 years ago to their daughter is causing the seizures that she succumbs to up to this day.
- During the 1991 measles epidemic in Philadelphia, public health officials were granted a court order to immunize six children whose families were members of one of the faith-healing congregations identified as the source of the outbreak. (See Virtual Mentor, the American Medical Association Journal of Ethics, and the New York Times.
- In Boulder, Colorado, endemic pertussis (whooping cough) has been linked to vaccination rates of just 50% among children at a local private school. (Noted in Virtual Mentor. See also “Bucking the Herd” (Atlantic Monthly, 2002).
- In 1998 the highly respected British medical journal The Lancet published an article linking the measles, mumps and rubella (“MMR”) vaccine to autism. Although it was later retracted for being based on tenuous research and the author was consequently banned from practice, the damage had been done. Measles immunization coverage in the United Kingdom plummeted from 92%-95% before the announcement to 60%-80% afterwards depending upon the region and groups studied, and the extent of ongoing local press coverage of the story.
Why Opt Out?
It has been estimated that in the US, 1-3% of the children are excused from immunization by their parents, but it varies from state to state with some schools reporting as high as 15 to 20%.
Reasons for resisting immunization in recent years range from philosophical, to political, to scientific and ideological grounds, as James Colgrove notes in a 2006 New England Journal of Medicine article “The Ethics and Politics of Compulsory HPV Vaccination”, [Note: Link may require subscription. Alternative link: http://journal.shouxi.net/qikan/article.php?id=221633], and include “devotion to “natural” or alternative healing, opposition to state power, mistrust of pharmaceutical companies, belief that vaccines are not as safe as experts claim, and conviction that children receive more shots than are good for them.
Community vs. Individual:
Risks, Rights, and Responsibilities
While some maintain that parental autonomy should be invariably respected, others have labeled such individuals “free riders” who benefit without contributing, and place family interest ahead of civic responsibility/moral duty.
Unproven theories alleging connections between vaccines and illnesses including autism, diabetes, and multiple sclerosis concern many parents. The American Academy of Pediatrics, and The Institute of Medicine (IOM) agree that no vaccine or component of any vaccine is responsible for the number of children who are currently being diagnosed with autism. The PBS documentary TV series Frontline has a website with a large volume of information on the various perspectives on this issue, including commentary from experts, parents and the general public. It includes interviews and even videos such as “The Vaccine War.” (See minute 21 for the arguments regarding autism and vaccines.)
The scientific community generally perceives the probability of negative reactions to vaccines to be safely low, with that risk overwhelmingly offset by the risks of not being immunized. For instance, incidence of measles-vaccine-induced acute encephalitis is one in a million, whereas it is one in a thousand following infection with the wild-type.
In “Responding to Parental Refusals of Immunization of Children” from Pediatrics Magazine (2005), the American Academy of Pediatrics’ Committee on Bioethics argues that many commonly held beliefs about the risks of immunization are not supported by available data, and they frequently originate from the unsupported claims of organizations that are critical of immunization. These anti-vaccine information sources not only propagate unproven claims regarding vaccines but also may undermine the physician-family relationship by challenging the parents' trust of the medical profession.
As stated by Dr Nancy Berlinger in an article in Virtual Mentor, the American Medical Association Journal of Ethics, "Parental Resistance to Childhood Immunizations: Clinical, Ethical, and Policy Considerations," there are provisions for exemption from immunization for children whose specific underlying health conditions, such as HIV infection, cancer or immunosuppressive therapies, place them at undue risk from one or more routine childhood immunizations.
In 2009 Dr. Brian Williams, an epidemiologist for the World Health Organization in Geneva, visited Brandeis as an International Center for Ethics, Justice, and Public Life Distinguished Visiting Practitioner, sponsored by Irving Epstein of the Chemistry Department. In a discussion of HIV/AIDS in Africa, he argued “We have to balance the human rights issues with the public health issues,” yet suggested that in the delicate balance between human rights and public health in the battle against AIDS, the pendulum may have swung too far in one direction, commenting that “We've been too concerned about individual human rights.”
Some proponents have argued that parents who choose not to immunize their own children increase the potential for harm to other persons in important ways, including risking passing sickness to those who could not choose to be immunized because of underlying medical conditions, and those who did everything they could to protect themselves by being immunized but unfortunately did not develop the immunity.
As noted above, recent measles outbreak in Zimbabwe was initially confined to communities that objected to conventional medicine, including child immunization, but eventually spread out across the nation.
A community does not however, have to achieve 100% coverage for herd immunity to be achieved, at least for some diseases (e.g. Hib requires at least 85% and measles 95%). The authors of “Should routine childhood immunizations be compulsory?” (Journal of Paediatrics and Child Health, 2004) “conclude that, for both ethical and practical reasons, routine immunization should not be compulsory if adequate levels of immunization can be achieved by other means.”
Yet even with an average high coverage, concentration of unimmunized people in one place has often resulted in “hot spots” that have triggered outbreaks. Isaacs, Kilham, and Marshall, in “Should routine childhood immunizations be compulsory?” (Journal of Paediatrics and Child Health) explain the concept of herd immunity. Yet Saad B. Omer, an assistant scientist at the Johns Hopkins Bloomberg School of Public Health who has extensively studied disease outbreaks and vaccines, is quoted in the New York Times saying that “If you have clusters of exemptions, you increase the risk of exposing everyone in the community.”
The American Medical Association “has long-standing policy that supports this goal [of vaccinating every child born in the U.S.], endorsing the need for adequate resources and programs to ensure that children are vaccinated on schedule – with an eye on reaching the Healthy People target of a 90% coverage rate by 2010.”
The availability of religious or philosophical exemptions mitigates concern about governmental intrusion on individual decision-making. Opinions vary about the permissible scope of exemptions. In the U.S., religious belief is generally the most easily accepted non-medical reason for exemption (with varying standards of proof required). In addition to those who opt out of vaccination for genuine religious belief, it has been reported that some parents have feigned religious faith, joining mail-order or Internet-based churches to bolster their case for a religious exemption. There are a number of states in which religious belief is not necessary to opt out, however.
Does the freedom of religion itself extend to allow objection to a child’s health intervention, when the belief itself may not necessarily be shared by the child? In Prince v Massachusetts (1944), The U.S. Supreme Court asserted that “neither the rights of religion nor the rights of parenthood are beyond limitation….The right to practice religion freely does not include the right to expose the community or the child to communicable disease or the latter to ill health or death.... Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children before they have reached the age of full and legal discretion when they can make that choice for themselves.” This case is referenced by the Massachusetts Department of Public Health (DPH) in a 2003 memo that “explains the legal underpinnings of the DPH power to require immunization and quarantine in the school setting.”In the aforementioned 1991 Philadelphia case, a Family Court judge granted the city the right to immunize for measles six children who are deemed at risk in the congregation of one of two churches that believe in faith healing. Yet the ruling went beyond the immunization requirement to such an extent that the American Civil Liberties Union of Philadelphia criticized it as unconstitutional.
Advocacy and the Legal Debate
Laws making vaccination compulsory raise unique ethical and policy issues and ignite polarizing debates. While controversy is common whenever individual rights are apparently breached in the interest of public health, what makes child immunization resistance even more complicated is the fact that the objector is a third party – the parent – on behalf of a minor.
Medical neglect, defined as a parent’s failure to obtain adequate medical care for a child despite the ability to do so, is regarded as a form of child abuse and neglect can come into conflict with state laws that allow religious exemptions to child protection statutes. Yet “[w]hat is unclear among physicians, legal scholars and bioethicists is how the concept of medical neglect applies to immunization refusal cases.”
In the British Journal of Medical Ethics, Bradley considers the rights of parents to rear their children according to their own standards; of the child to receive health care, and of the community to be protected from vaccine preventable diseases, and concludes “that compulsory vaccination cannot, with very few exceptions, be justified in the UK, in view of the high levels of population immunity which currently exist,” as of the 1999 publication of the article, but may be justified if the coverage falls below a relevant threshold for a specific disease.
Isaacs, Kilham, and Marshall, in “Should routine childhood immunizations be compulsory?” (Journal of Paediatrics and Child Health), consider the arguments for and against compulsory immunization from different ethical perspectives and reaches a somewhat similar conclusion, that coercion is unnecessary as long there are alternatives (outlined) to achieve the desired herd immunity. The authors also suggest that the state should compensate the few children harmed by immunization.
An article by the Committee on Bioethics of the American Academy of Pediatrics suggests a wide range of potentially effective alternatives and factors to consider in response to parental refusal for child immunization. (It is also recommended that parents read the Red Book [Note: Subscription required], a guide to pediatric infectious diseases that specifically addresses the issue of immunization including misconceptions and misinformation.
Activist organizations openly advocate for or against compulsory immunization. (For example, Women in Government advocates use of the Human Papilloma Virus – HPV – vaccine and the GAVI Alliance supports the immunization of “every child”, while the politically conservative Association of American Physicians and Surgeons opposes mandatory government vaccination programs – though mainstream American medical associations support vaccination.
Globally recognized organizations such as the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the United States’ Centers for Disease Control and Prevention (CDC), tend to only go as far as highly recommending and emphasize the need for respecting either rights and being sensitive to context, but can’t enforce their recommendations.
It is left for states/governments to decide on vaccination mandates, and for parents/caregivers to decide how to respond. The passing of such laws, their interpretation, and their enforcement has been clouded with controversy. For more on related legal issues see Kenneth R. Wing’s The Law and the Public’s Health. See also “Conscience Clauses, Health Care Providers, and Parents,” from The Hastings Center, which describes itself as “an independent, nonpartisan, and nonprofit bioethics research institute.”
The question of parental refusal to immunize a child, to some a straightforward issue of public health or of parents’ rights, is a matter of continuing debate. We invite you to continue exploring the ethical issues that arise in this context, and to share your thoughts with us on our Facebook page.
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This installment of "Ethical Inquiry" was written by Alec Mkwamba, MS '11 in International Health Policy and Management, at the Heller School for Social Policy and Management, Brandeis University.