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immuniseQuestion

It is Autumn and GPs surgeries everywhere are going to be busy vaccinating. As well as normal childhood immunisations and seasonal flu we are vaccinating pregnant mums against Whooping Cough. The Health Protection Agency has reported a big rise in Whooping Cough cases and in measles.

Whooping cough affects small babies particularly badly but babies can not make a proper immune response till about 8 weeks. The only way to protect the very young is to vaccinate mothers and a small amount of immunity will cross the placenta to the baby.

I work in South West London which has some of the worst uptake rates. IT is predominately middle class and educated that are more likely to exercise their right to refuse to vaccinate their children. However other patients such as a pregnant lady I spoke to today complain bitterly that refusal to immunise is responsible for the increased incidence of serious, preventable diseases. Parents who refuse will put her new born baby and others at greater risk because of the increased prevalence of diseases such as Whooping cough.

Should we have compulsory vaccinations as they do in the USA? Perhaps it is no coincidence that the only disease to be eradicated was smallpox – vaccination against which was compulsory.

ANSWER

This ethical problem can be considered by using the 4 pillars of medical ethics.

Autonomy[the patient’s right to control over their life],Beneficence [the doctors duty to act in the best interest of the patient] Non- Maleficence[avoiding harm to the patient] and Justice [what does the law say and what is fair for society] – see my book P74 –P80 ‘Medical School Interviews The Knowledge’.

Autonomy:In this case the patient is a child and does not have capacity to consent to a procedure. Treatment depends on obtaining proxy consent from someone with parental responsibility. The parents have the right to refuse to have their child vaccinated. But should parents have the right to make ‘wrong’ decisions’ for their children. In the recent case of Neon Roberts the judge ordered that the child should receive radiotherapy against the wishes of his mother.

Beneficence: The medical view is clear. There is overwhelming evidence that immunisations are relatively safe procedures that protect populations effectively against the risk of serious disease. When I was young my sister’s best friend’s brother was brain damaged because of measles. The majority of the Iranian Paralympic basketball team this year were shuffling on their bottoms because they had contracted polio when young. It is easy to forget how thankful we should be to the protection that immunisation has given us. It is undoubtedly one of the major causes of the increase in life expectancy in the 20th Century. Bill Gates, with his intelligence, has chosen to invest much of the millions he made in GAVI, which researches into and provides vaccines world wide. I constantly repeat to my sceptical middle class parents that I believe that immunising your child is one of the best things you can do for your children better than Kumon maths and fish oil capsules!

Non-maleficence [harm]: Is there any risk? There have been numerous scare stories about immunisations as any search on the internet will show. The last major scare involved Andrew Wakefield who appeared to show a link between the MMR vaccine and autism and a bowel disease [Crohn’s Disease]. It was later revealed that much of his research [which involved risky procedure on children] had been fabricated and he had been paid hundreds of thousands of pounds by lawyers acting for anti-vaccine court cases. The dip in vaccine uptake undoubtedly led to deaths.
However although the risk of harm is very low there are small risks involved. Vaccines like other medical treatments such as antibiotics are not 100% safe, 100% of the time. The risk of most vaccines is comparable with that of crossing roads for example and is about 1/10 of the life time risk of getting struck by lightning[seehttp://besthealth.bmj.com/x/static/514517/decision-support.html%5D

Justice: People have the right to refuse treatment and to make bad decisions for themselves but do they have the right to refuse treatment for others even if it is for their children? At present in the UK the law allows parents to have this right in most cases including vaccination. [See previous ethical scenario on the Jehovah Witness boy].

Reduced uptake of vaccination results in more cases of the disease. If vaccination rates fall below 95% there will be a loss in what is termed ‘herd immunity’. Herd immunity occurs when the vast majority of a population is so resistant to an infection that that infection is undetectable in that population. Those who can’t be vaccinated for medical reasons or those with reduced immunity such as cancer patients are thus protected from the illness. In the USA it is compulsory to show that a child has been vaccinated when it attends school because a non-vaccinated child can be a source of an infectious disease.

Conclusion
Vaccinations are an emotive subject for many parents who are anxious not to take any risks with the health of their children. An injection intrinsically seems to cause much more fear than a tablet and as a profession I do not think we explain risks well. Risks are unavoidable in life and the risks from vaccinating are small, certainly smaller than the risk from large numbers not being vaccinated. However patients have autonomy, the right to refuse treatment and refuse treatment for their children. To deny them this would certainly harm the doctor- patient relationship. So, as long as we are not dealing with an illness such as smallpox or SARS I think on balance it is better to leave the law as it is and put more effort into persuasion.

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