Mandatory Vaccination Programs and Medical Ethics
The issue of mandatory vaccination programs for infants and children is coming to a head. Battle lines are being drawn.
On one side, we find concerned parents, increasingly being supported by dissenting physicians and scientists troubled by the side effects of vaccines, including serious neurological deficits and even death. Physicians on this side of the line have asked for more open data and information to the public; have questioned oft-cited risk versus benefit figures; and call for a return to the individual-based ethics of Hippocrates: particularly, first do no harm.
On the other side of the debate are government officials, representatives of the public health community, and much of the organized medical establishment. They want government to take a more active role in “developing immunization strategies,” developing databases to track vaccination records, increasing medical surveillance, and accelerating the pace of vaccine development. They also favor enlarging the scope of mandatory vaccine programs already in place, particularly for infants and pre-school children.
The Tucson, Arizona-based Association of American Physicians and Surgeons (AAPS) is among the voices calling for vaccine caution. The group supports increased parental involvement and freedom of choice in the vaccination decision. Parents, according to AAPS, should have the right to make fully informed decisions about vaccines, which would require complete disclosure to parents of all information relating to vaccine safety and efficacy. Parents should have the right to refuse to subject their children to certain vaccines.
Medical Ethics and Public Health
The past achievements of scientific medicine, including vaccination policies, largely developed within the scope of the traditional, individual-based ethics of Hippocrates. Even Louis Pasteur, who was not a physician, upheld the tradition and ethics of Hippocrates: first do no harm. Pasteur consulted with several physicians to ascertain there were no other treatments available before rendering experimental treatment against rabies to his young patient, Joseph Meister.
Physicians who follow the Oath and ethics of Hippocrates must always be careful to satisfy two conditions:
- that they place their patient’s interest above the cost considerations important to third-party payers, and even above the physician's own personal or monetary interest; and
- that they uphold the interest of the individual patient above that of the collective, be that the health care networks or some “greater good” of society or the state.
Unfortunately, in the last decade mandatory vaccination programs have allowed these two ethical conditions to be violated. Some physicians have expressed concern that such “public health” policies overtly and deliberately subordinate the patient-doctor relationship to the interest of the state.
In this situation, the physician ceases to be his patient's advocate and merely becomes an agent for the state. Rather than placing the interest of his patients first, he is placed under intense pressure to abdicate his responsibility to his patients for the purported “greater good.”
This collectivist, utilitarian ethic contrasts dramatically with the individual-based ethics that has guided medicine for centuries. The new ethic has caused the development of a new, “population”-based medicine, seen most clearly in the movement toward managed care and national health care (socialized medicine).
The new ethics confronts the physician with a great dilemma, raising hard, tough questions that go to the heart of the profession. Am I recommending vaccination to my patients because it’s in their best interest, or simply because I must comply with the state’s mandate for universal vaccination? Am I a healer, a conscientious physician duly exercising my best medical judgment for my patient? Or am I an agent of the government, enforcing public policy?
Physicians and Patients Should Decide
In most cases, a physician would recommend vaccination for most of his patients. But each patient is different, and the ethical physician evaluates the special situation of his patient, based on an individualized risk-benefit assessment, before determining whether to proceed. “I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous,” explains the Hippocratic Oath.
There is no question of the great benefit of general vaccination for such scourges as poliomyelitis, diphtheria, smallpox, etc. But can we say the same for greatly self-limited rotavirus diarrhea in infants, chickenpox for children, or for the sexually transmitted hepatitis B for both? In the case of rabies, we institute aggressive vaccination treatment only after exposure.
Public health should aim at protecting at-risk populations from afflicted or exposed individuals. Healthy children who pose no threat to their classmates or teachers should not be turned out of their schools because they haven’t complied with vaccination protocols. Parents should not be accused of child abuse merely because, out of genuine concern for their children’s health, they have refused to subject them to certain vaccinations.
Does a newborn infant benefit from being vaccinated at birth against hepatitis B, for example, or would vaccination be safer and more effective when the youngster is older and stronger, and when the risk of contracting hepatitis B may be greater? The medical community does not even know how long the vaccine provides immunity against hepatitis B.
Should adults who choose to abstain from risky sexual behaviors be forced to accept vaccination against sexual herpes, hepatitis B, or HIV infection—diseases they simply will not contract because of the method of transmission?
Historically, exposed or infected persons were quarantined to prevent spreading of a disease. By today’s “ethical” standards, the public health threat is posed by healthy but un-vaccinated persons: adults who practice safe sex, well children excluded from public schools, soldiers court-martialed for refusing to be vaccinated against anthrax.
Directions for Public Policy
Recognizing the increasingly coercive nature of vaccination policies, medical professionals attending the AAPS’s annual meeting in October 2000 unanimously passed a resolution against mandatory government vaccination programs.
"This is not a vote against vaccines," explained Dr. Jane M. Orient, executive director of AAPS. "This resolution only attempts to halt blanket vaccine mandates by government agencies and school districts that give no consideration for the rights of the parents or the individual medical condition of the child."
Forty-two states have mandatory vaccination policies. Many children are required to have as many as 22 shots before they enter first grade. In addition, many school districts require, as a condition for school attendance, vaccination for diseases such as hepatitis B—primarily an adult disease, usually spread by multiple sex partners, drug abuse, or in the occupational hazard of exposure to blood. Children under the age of 14 are three times more likely to suffer adverse effects from the hepatitis B vaccine than they are to contract the disease.
"AAPS believes that parents, with the advice of their doctors, should make decisions about their children's medical care — not government bureaucrats,” said Orient. “This resolution affirms that position."
The pages of medical history are replete with indisputable evidence, including the history of vaccination itself, that physicians, upholding the Oath and individual-based ethics of Hippocrates, actually benefit not only their individual patients but also society . . . secondarily.
In other words, physicians working in the enlightened best interest of their individual patients produce tangible benefits for humanity as a whole.
By contrast, the historic record also reveals that when physicians become agents of the state rather than advocates of their patients, everyone suffers. Physicians become preoccupied with preventive health measures and the "rational allocation of scarce resources," rather than the health of their individual patients.
Miguel A. Faria Jr. is editor-in-chief of the Medical Sentinel, published by the Association of American Physicians and Surgeons, and author of Vandals at the Gates of Medicine (1995) and Medical Warrior: Fighting Corporate Socialized Medicine (1997). His email address is email@example.com.
A longer version of this article appears in the March/April 2000 issue Medical Sentinel, which focuses on the vaccination issue.
For more information . . .
about the Association of American Physicians and Surgeons, visit its Web site at www.aapsonline.org. The Medical Sentinel is available online at http://www.aapsonline.org/aaps/. Books by Dr. Faria are available for purchase on the Web site of Hacienda Publishing Inc., http://www.haciendapub.com.