By Louise Kuo Habakus
I received a great deal of feedback on and offline to my recent 9/27/10 post (HERE) about the Vaccine Mandates conference sponsored by the Center for Bioethics. In particular, there were strong comments in response to the desire of PA-AAP’s Amy Wishner to correct the record. She believes I misrepresented her comment regarding the selfishness of lack of civic responsibility in parents. In response, I decided to transcribe Wishner’s portion of the proceedings. The relevant portion is in the fifth paragraph. I also highlighted other areas of her remarks offer context for my representation of her remarks (in bold). Now you can read and decide for yourself. (I’m grateful to Susan Kreider for providing me with an audio recording of the event.)
, MSN, RN, represents the Pennsylvania Immunization Education Program HERE She said the only reason she can think of why people do not vaccinate is, frankly, “increased selfishness” and “no sense of civic responsibility.” She said that parents should not expect their doctors to certify their unvaccinated children for camp and other activities.
Dear Friends - You misrepresented my comment above re: selfishness and lack of civic responsibility as reasons SOME may choose not to vaccinate their children. I am quite sure I said something along the lines of that an ADDITIONAL reason NOT MENTIONED EARLIER (I did not speak until 2 PM) were the reasons above; many other reasons had previously been mentioned at the conference. My thinking was that I have seen first hand how little corporate loyalty there is to maintaining employment, that people are treated as easy-to-replace, and so I find is a change in our society from a more cooperative social environment to one where people feel forced to kind of fend for themselves as some of the previous trust and mutual loyalty between employers and employees has been damaged with this economy, outsourcing, etc. So, my point was that is is very understandable how parents can feel that no one is going to be as careful with their child as the parents and to be skeptical about recommendations. In the particular case of vaccines, I disagree with many on this website in that I do feel that pediatricians and family medicine physicians recommend immunization because clear, reproducible science supports that this is in the individual child's best interest and in the larger community interest. But I am by no means unsympathetic toward people who believe otherwise.
Good afternoon, my name is Amy Wishner, I am the director of the Pennsylvania Immunization Education Program, which is a program of the Pennsylvania chapter of the American Academy of Pediatrics. I’m not here representing sort of official PA-AAP or American Academy of Pediatrics as organizations but rather in my work, working with pediatric and family medicine practices across the state and talking with people who run similar programs in other states.
Most immunizations are given in the private sector. In Pennsylvania, 85% of childhood immunizations are given in the private sector, so that means pediatric and family medicine practice offices. And some would be because of the VFC program as has been discussed earlier but also because of people who have private insurance. So, who are the people who consent for children? It’s parents. And yet it’s not sort of continuous, it’s not the same thing, consent for an infant as it is consent for an adolescent. So again there’s sort of an increasing autonomy as children get older. And once children are 18 who fit into some other category, such as married, legally emancipated, or some other categories like that. But for the most part, up until the age 18, parents are the deciders about medical care for their children.
In terms of refusal, the AAP Committee on Bioethics says parents are free to make choices regarding medical care unless these choices place their child at substantial risk of serious harm. So those two phrases… “substantial risk” and “serious harm”… are kind of what we’re talking about here. And there’s one case that I’ve heard used by ethicists that is kind of at one end of the spectrum which is… a child in an emergency room for a puncture wound, his tetanus vaccine is out of date. And in that circumstance, people think they would go to the extreme of really going to compulsory vaccination, actually going and getting a court order, immunizing that child against the parents’ wishes, if,… if going to that extreme. Another instance of that, in Philadelphia, there was a measles outbreak in 1991, when five children died in one week from measles in a community of children who were unvaccinated. The same thing. The Commissioner at that time, Dr. Robert Ross got a court order to immunize those children against their parents’ wishes. The parents were not neglectful, otherwise, of those children. They were well-fed, well-clothed, went to school, etc. And yet, in that case, the ethical dilemma came up because those children who were unvaccinated had already been exposed to measles, so in that case, what was the correct thing to do? But that “substantial risk of serious harm” those factors can change as we have seen in pertussis in California, where pertussis two years ago, you might have said, ok, is the risk that serious? The disease is still the same now but now in California, the pertussis outbreak, the risk has certainly risen to a level of substantial risk. And in California they have in fact changed some of the immunization requirements, recommendations where they are now recommending certain vaccines be given off label to include other age groups and have put into effect school exclusion criteria. So… “substantial risk of serious harm” can affect… when ethically you might feel that parent choices might be affected.
In addition to the reasons for parent refusal that have been talked about earlier, I want to also just add a couple… which is a general skepticism about science or even the germ theory and certainly mistrusting epidemiology, a different understanding of what probability is. And some of the ways that probability is explained may not be that clear and in some cases I have seen some nice graphic representations of probability that I think can be more effective.
And also, I don’t really know what sort of a nicer way of saying it, just an increase in selfishness essentially where you know parents may have this idea that I am going to do what is only right for my individual child (which vaccines are, I would argue) but just not even having a sense of civic responsibility and I think there are a variety of reasons for that, I think certainly you know there’s a sense of people as more disposable by organizations, that idea that I’m the government and here to help you is certainly one that people are skeptical of.
On the other hand, the people who are for the science and for vaccines have a different sense which is, in this case and this instance, I do trust that the government as represented by the CDC and FDA are in this case making a good decision and having confidence in the safety testing for children and for vaccines.
I just want to mention a couple of the consequences of refusal to immunize. Of course, the child is susceptible. School exclusion as I mentioned. And also, a parent can refuse an immunization but by the same token, a physician or nurse practitioner or a practice is not obligated to certify that child for something like a camp form or participation in some other activity. So yes, the parent can refuse but then that does not obligate on the other hand the provider to say, “Well, ok, your child can do anything else they want.”
Also, we haven’t said very much about childcare. Certainly people who work in childcare, we have to be concerned about their immunization status. But a lot of childcare centers are private entities, and they have a different ability to say that they can set policies where they may say that participation in immunization is a condition of going to a particular childcare.
One of the things that providers are asked to do a lot these days is to delay vaccines or follow alternative schedules. And that requires them to make kind of impossible decisions about which diseases are less serious or which vaccines are most effective. And that kind of slippery slope if you decide to not follow certain scientific recommendations, where does that leave you in terms of other things? And a physician I work with – Dr. Michael Harkness (sp?) - has come up with this analogy which I like of car seats. If a parent came to him and said, I don’t feel comfortable putting my child in a car seat, they’re you know restrained back there. I really want to hold my child, can you show me how to hold my child safely? And the physician obviously you know can’t. There is no way to do it, to do that.
In terms of the religious and philosophical exemptions, I was going to make a similar point as to the one Dr. Schwarz made where he has seen a map of various with high exemptions in Washington state, you know Pennsylvania it has hovered around 1% with private schools recently going up to 3.75% of exemptors, but Washington state has a 6% rate of exemptors, with counties ranging from 1.2% to 26.9% so there is a county where a quarter of the people are not immunized. I think those kinds of maps are very useful in terms of, you know, public health intervention.
In the practice setting, I think we all might agree that it would be ideal to have to have time to fully discuss all immunizations with every parent about every vaccine every time it’s given. This runs smack into the real world where that just isn’t possible and I think that there are practices of providers being asked to spend large amounts of time with a lot of people on a daily basis, just is very difficult and you know impossible essentially. So some of the things, and yet, you know, that you would say, every parent deserves that, every child deserves that, so what do we do with that ethically? I think that some of the things that we can do that are helpful are that one, some practices have written policies that are very strong statements. All Star Pediatrics in Pennsylvania has put out a policy that has become a national model. The medical code [unclear] encouraging them, the home is obviously the best place to for these kinds of discussions to take place and for trust to be built. And the idea of mapping data and those data from the Immunization Registry are being used to really inform public health activity and focus public health activity. And also that the pediatric and family medicine practices where at the moment this burden largely falls, really can’t do it by themselves. So that prenatal care, OB/GYN, breastfeeding classes, all these areas have to really do more.
And the other thing I just wanted to say briefly is, this is a true story… coughing mom with a coughing kid and three unimmunized siblings came into a pediatric practice. New patients. When the people at the front desk realized what was going on, that she was coughing, they ushered her out which was very alarming to other people in the waiting room, some of whom had infants. After a long time, eventually convinced this mom to allow immunization on the siblings, and including a physician who came out on his day off and spent several hours talking with her. And then because the mom worked in a day care center, public health got involved in working with the daycare center, other parents with kids there, the people who worked there. And all of this happened, all these people’s time, energy, worry of the other people in the waiting room, this is all preventable by on-time routine vaccination. So I think what we say is, ideally we want people to have this freedom, this ability, all this time spent discussing and talking, of course this is what we want but there are real life implications involving time, money and exposure to disease by people’s exercise of those risks.