Vaccination Refusal: Ethics, Individual Rights, and the Common Good

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Potential causes of vaccine hesitancy

Recent controversies regarding vaccine safety have contributed to a surge in information available to parents and providers about vaccines and vaccine-preventable diseases. The quality and accuracy of this information varies widely, particularly on the Internet. Distinguishing reputable resources among these materials can be challenging for members of the public.1 Of particular concern are allegations linking routinely administered vaccines to a variety of chronic and acute medical conditions.

Individual decision making and public health

Patients and parents bring a broad range of perspectives and attitudes regarding vaccines to their health care providers. Simple classifications such as “pro-vaccine” and “anti-vaccine” fail to appreciate the spectrum of opinions that exist about vaccination and the distinct responses required from physicians. Vaccine hesitancy is distinct from vaccine refusal, and care should be taken in all cases to understand the scope of any concerns, their source, and the responses that are warranted.

While

Addressing confusion and uncertainty

Of the 3 types of vaccine-hesitant individuals, the most numerous are those historically supportive of vaccination but with questions about specific vaccines or theories that have been discussed in the media or among friends and family. These kinds of inquiries may create challenges for providers, but they also provide an opportunity to educate and build trust. Earning and preserving this trust will serve both the physician and patient well throughout the duration of the doctor-patient

Alternative vaccination schedules

Whereas some parents or patients are primarily looking for reassurance that their support for vaccines is justified, a second group has explored issues related to vaccine safety and believes that action is warranted. A particular challenge is those patients who prefer a customized approach to the recommended vaccination schedule.15

Vaccination schedules like those proposed by “Dr Bob” Sears in his widely read book are described as “compromises,” prioritizing vaccines deemed more important while

Refusing recommended vaccines

Parents preferring a nontraditional approach to routine vaccination present difficulties for health care providers, but the unique risks raised by alternative schedules are generally limited to the additional time needed to complete all recommended vaccinations. However, 85% of pediatricians in one survey reported encountering at least one family in their practices that refused vaccines entirely.21 Those wanting to decline one or more vaccines present far more significant ethical, clinical, and

Physician responses to vaccine refusal

Similar to patients seeking alternative vaccination schedules, physician communication with parents or patients refusing vaccines may reveal a fundamental difference of opinion unable to be resolved satisfactorily. For minors, legal interventions that provide necessary medical care against parental wishes have not been used for vaccination, nor are they ethically justified in the absence of an outbreak or similar public health emergency. Although the individual and community benefits of

Health care worker influenza vaccination

Discussions of vaccination refusal most often focus on parents hesitant about vaccines for their young children. While this group is the largest focus of vaccination programs and the most prominent source of controversies, reluctance to receive recommended vaccines is common among many populations. Increased attention in recent years has been directed toward the particular challenge of vaccination of health care workers against influenza.34 Despite a long history of the prevention of influenza

Summary

Resistance to vaccination is as old as vaccination itself.40, 41, 42 Throughout this history, programs that have aimed to aggressively impose vaccination on an unwilling populace have largely failed, replaced by policies that educate and inform citizens while accepting that unanimity is a very difficult goal. Physicians, other health care providers, and the overall medical and public health communities should continue to unapologetically advocate for vaccination as one of the most valuable and

Acknowledgments

The authors wish to thank Laura Backup for research assistance in the development of this article. They also wish to acknowledge the support of The Greenwall Foundation and the Center for Vaccine Ethics and Policy of the Children’s Hospital of Philadelphia, The Wistar Institute, and the Center for Bioethics of the University of Pennsylvania.

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      Indeed, it has been argued that, “vaccination is victim of its own success (p.1767).” When vaccination programmes are successful in preventing the spread of the diseases, the risks of contracting the specific diseases may become less visible to the public (Schwarz & Caplan, 2011). Attention may, instead, be directed to the safety issues of the vaccination programme.

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      Understandably, many people have trouble recognizing the benefits of vaccination since they have not had first-hand knowledge of these vaccine-preventable diseases (Glanz et al., 2011), drastically shifting public concern from disease prevention to vaccine safety (Freed et al., 2010). Past controversies about vaccine safety, specifically, an association between vaccines and rising autism rates, have further fueled the shift in public focus (Schwartz and Caplan, 2011). While the theory linking vaccines to autism has been discredited (Godlee et al., 2011; Kirkland, 2012), a recent Pew Research Center poll found that 43% of Americans believe that the MMR vaccine has medium to high risks to health (Funk et al., 2017).

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      Growing apprehensions about the risks of vaccines among the general public [1] have been accompanied by more frequent outbreaks of vaccine-preventable disease [2,3]. Concerns about vaccine safety lead some parents to postpone vaccination of their children, against the recommendation of their pediatrician, while other parents reject all vaccinations for their children [4–6]. These concerns motivate many parents to seek information about vaccines from other parents, traditional media, and the Internet [7].

    • United states private schools have higher rates of exemptions to school immunization requirements than public schools

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      A parent's decision not to immunize a child is complex and can be challenging for a medical provider. Vaccines provide direct medical benefits to the child and extended benefits to the community through prevention of outbreaks.31 The tension between an individual's freedom to choose medical care and the impact of that choice on the public has raised an important question of justice.

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    This work was supported by a grant from The Greenwall Foundation.

    The authors have nothing to disclose.

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