Social ethics becomes particularly critical when public health is at stake. We are not under attack by giants, and defended by elves; we are under attack by germs, and defended by vaccines. We aren’t so much asked to pay the bill for vaccines, but to "pay” for other people’s participation by participating ourselves.

Seconds after birth, children start to be immunized: they receive the Hepatitis B vaccination, unless parents take steps to opt out. Later, with your consent, your child will receive dozens of vaccines over the years, with the exact list of specific vaccines determined by state mandate. There is no enforcement of vaccination until a child enrolls in elementary school; at that point, you will be asked for proof of compliance with state vaccination regulations. In Texas, for example, vaccinations against ten diseases are mandated, and this mandate appears to have a huge effect on vaccination behavior. The percentage of children starting public or private kindergarten who had completed the polio series in 2013-2014 was over 97.4 percent. The percentage completely vaccinated against chickenpox stood at 97.2 percent; the percentage vaccinated against measles, mumps, and rubella (the “MMR” vaccine) was 97.5 percent; and the percentage vaccinated against hepatitis B was 98.1 percent. There is much less use of the HPV vaccination, which is mandated in only a few states but strongly recommended by the Centers for Disease Control (CDC); by age seventeen, about 50 percent of girls and 23 percent of boys in the United States had completed the three- dose series, according to a CDC survey conducted in 2014.

Given the very high compliance rates for mandated vaccinations, it’s surprising that Texas parents don’t really have to vaccinate their children in order for them to attend school. Parents can declare their child exempt for "reasons of conscience” without saying anything at all about their reasons. The exemption can be made for specific vaccines, so a person could exempt their child from the MMR vaccine, for example, but not from the polio vaccine. Nobody is under any obligation to explain what specific "reasons of conscience” might lie behind such a declaration. Parents do have to sign a statement about the benefits and risks of vaccination in front of a notary public. There is also an option of exempting a child for medical reasons, but there are far more conscientious exempters than medical exempters. (For example, in 2013-2014 there were about ten times as many conscientious exemptions as medical exemptions.)

I met a vaccination refuser once when my kids were under school age—around two or three—and up to date on all their immunizations. I had taken them to a Dallas recreation center for an organized public activity. While the kids ran around, parents sat on the bleachers chatting—mostly moms and a few dads. I don’t recall how it came up, but one mother announced that she wasn’t vaccinating her children, as if this should cause no particular concern. It was a personal choice, in her eyes, like choosing circumcision or breastfeeding or using car seats or exposing children to secondhand smoke—all decisions that primarily affect your own child. Contrary to her attitude, decisions like this are not beyond public scrutiny, but it’s true that we accord parents a certain degree of privacy and autonomy about them. If we judge, we do so quietly, so long as parental decisions don’t descend to outright neglect and abuse. Nobody reacted vociferously to this woman.

The truth is, only one vaccination decision is, in fact, exclusively about your own child: the decision whether to vaccinate against tetanus. According to Paul Offit, MD, a vaccine advocate and author of the book Deadly Choices, tetanus is caused by a bacterium (clostridium tenani) that comes from the soil, entering the body through puncture wounds and insect bites; it doesn’t travel between people. So nobody but your own child is affected if you decide to immunize against tetanus or not to immunize (apart from more indirect effects based on use of hospitals, ambulances, and other resources).

Some vaccination decisions are partly about your own child, but mostly about protecting other people. If you protect your healthy twelve-year-old by having her get flu vaccines every year, you could certainly make the case that the benefit accrues even more to the vulnerable elderly people she comes into contact with when she visits her grandfather in a nursing home.

For most childhood vaccinations, however, the motivation to opt in has to do with everyone. The MMR vaccine protects your child from three diseases with very serious potential consequences, but it also stops your child from infecting others with those diseases. On top of that, there’s additional concern for vulnerable people who may be in contact with your child—people too young to be immunized or medically unable to be immunized, due to immune- deficiency problems.

There is one more fact about vaccination that’s central in vaccination ethics: we each not only actively affect others, but are also passively affected by others. Simply by standing in the middle of the herd, my child can be protected by what other parents have done (except in the case of tetanus). This "herd immunity” is achieved when different percentages of the population are vaccinated, depending on the infectiousness of a disease. The more infectious the disease, the more people have to be vaccinated before the whole herd is immune, including the small minority who don’t vaccinate. Other people can protect my child completely, even if I refuse to vaccinate.

May I refuse to vaccinate my child? People give lots of different reasons for doing so.

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