Parental concern regarding recommended vaccinations for the minor child is a very real issue that currently presents itself on a regular basis. Many parents are concerned about the risks of individual vaccination products, and moral and religious convictions also lead some parents to forego vaccination of their children. A generation ago most parents would have readily acknowledged that "the doctor knows best" and thus would have unquestioningly assented to his or her counsel. In today's autonomous society, however, such is not the case. Medical practitioners confronted with this issue must always be concerned with the beneficence, justice, and autonomy of those who seek our care. The following considerations are designed to assist parents and practitioners alike in making decisions regarding vaccination.
First, it is important to recognize that vaccinations have not always been offered. Older doctors may have a vivid recollection of the "Iron Lung" as the only available treatment for patients who had contracted the poliovirus. As a medical student, I took care of a child who was in one of these machines. The only contact that the child's mother had with this patient was to stroke her hair as she lay on her back, her body encased by the iron contraption. Many of the initial vaccination products became available during a time of limited medical care, and the vaccines actually saved thousands of lives. Prominent examples of childhood diseases that became preventable through vaccinations are measles, mumps, diphtheria, and even chickenpox. Due to the availability of vaccinations, it has become quite clear that these "normal childhood diseases" need not be routinely experienced. Such diseases are—to a large extent—preventable, and it is within our medical pervue to employ and encourage standard vaccination of our patients.
Second, it has been well documented that vaccinations work. The Centers for Disease Control and Prevention (CDC) have accumulated much data regarding the efficacy of vaccinations. We know that the frequency of illness decreases with increased success of community immunization programs. Waning immunity—through refusal to vaccinate and through the diminishing efficacy of a vaccination over time—leads to an increased reservoir of potential disease, often in adolescents and adults.[1] In addition, there have been numerous examples (at the international level) where an entire country has suspended vaccination requirements only to observe a notable increase in the frequency of reported cases of disease. It is reasonable to assume that latent viruses persist and may be spread (by close contact) to unprotected individuals.
Third, vaccinations are monitored. The Food and Drug Administration (FDA) and the CDC monitor both the use of and possible problems regarding vaccinations. For example, a vaccine approved for protection against Rotavirus (a viral disease causing severe diarrhea and dehydration, especially in young children) was discontinued after approximately one year of use. An increased frequency of intussusception (a condition where the bowel folds over itself) in patients who had had received the vaccine was the reason for its discontinuation.[2]
While vaccinations are often very beneficial and are subject to strict regulations, can their use nevertheless be problematic? Many people have alleged that certain vaccines may lead to very real harms. For example, links between the measles vaccine and autism, as well as inflammatory bowel disease, have been asserted. The vaccine for pertussis has also been associated with seizures, and a vaccine preservative (Thimerosal) has been said to negatively affect blood mercury levels. In many situations of this type, a relatively rare medical issue (e.g., seizure or autism) coexists with a very common medical practice (routine vaccination). In the quest to explain such rare phenomena, people are often quick to point out that the health problem is secondary to vaccination and, thus, vaccine-induced. Prolonged and detailed investigation has, however, disproved most of these allegations. It is nevertheless true that some vaccinations do carry a limited and specific (and exceedingly rare) complication—for example, the pertussis vaccine and the association with prolonged episodes of inconsolable crying and fussiness. In this situation, as in a few notable others, the risks and benefits of repeated vaccination need to be considered on an individual basis. In the case of Thimerosal, the Public Health Service and other organizations have recommended that the preservative be removed in an effort to decrease the total amount of mercury exposure that a child has—even though there has been no proof of harmful effect.[3]
Many people are also concerned that vaccination of a child may carry with it moral guilt and wrongdoing. The issue of moral guilt (or moral complicity) arises because the initial source of some vaccination materials was a fetus who was electively aborted decades ago.[4] Some individuals therefore feel that the administration of certain vaccines incriminates them in the promulgation of a wrongful act. It must be recognized, however, that medical science is simply extending the original cell line that was established from the aborted fetus, and that there is no ongoing abortive process to continue and maintain the cell line. Apart from concern about the method by which certain vaccines are derived, some communities of faith refuse vaccinations on the basis of their religious convictions. While we respect such positions, we must also take into account the evidence that clearly suggests an increased rate of disease in unvaccinated individuals. Because large pockets of unvaccinated individuals may contribute to the seriousness and prolongation of a community-wide outbreak, the decision not to vaccinate must be grappled with as well.[5]
Finally, some parents express reluctance to vaccinate their child because they know that the risk of getting a particular disease is less than the admittedly minimal risk of the vaccination. They believe that it is their parental duty to protect their child from the minimal risk posed by the vaccine. This laudable desire must be balanced, however, against the societal obligation to maintain so-called "herd immunity" as a means of preventing epidemics. While it may be argued that parents' willingness to "ride on the coattails" of the rest of society is unjust, such a perspective may not trump their understanding of parental duty. Thus, it should also be pointed out that choices have consequences. A parent who refuses vaccination must be prepared to accept the risk of morbidity and mortality that may attend the occurrence of a vaccine-preventable illness. Not only would much guilt likely result in such instances, the child might suffer life-long complications or even loss of life—outcomes which could have been avoided.
In conclusion, vaccinations are important to both our individual and societal health. Whereas minimal distinct risks do exist for certain vaccination products and moral concerns may be raised, I believe that careful and thoughtful evaluation of such matters leads to the conclusion that vaccination programs are not only acceptable, but should be strongly encouraged.
References
[1] Izurieta HS, Kenyon TA, Strebel PM, et al., "Risk Factors for Pertussis in Young Infants During an Outbreak in Chicago in 1993." Clin Infect Dis, 1996; 22:503–507.
[2] "Rotovirus Infections," Red Book, American Academy of Pediatrics (Elk Grove Village, IL), 2003, p.534.
[3] "Notice to Readers: Summary of the Joint Statement on Thimerosal in Vaccines". MMWR Weekly 49(27); 662–631.
[4] Grabenstein, J D, "Moral Considerations with Certain Viral Vaccines," Christianity & Pharmacy, 1999, Vol. 2, No. 2, p.3–6.
[5] Etkind Paul, Lett Susan, Macdonal Patricia D, et al, "Pertussis Outbreak in Groups Claiming Religious Exemptions to Vaccinations," Am J Dis Child 1992; 146:173–176.