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The ethics of opting out of vaccination.

The views expressed are those of the author and are not necessarily those of Scientific American.

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At my last visit to urgent care with one of my kids, the doctor who saw us mentioned that there is currently an epidemic of pertussis (whooping cough) in California, one that presents serious danger for the very young children (among others) hanging out in the waiting area. We double-checked that both my kids are current on their pertussis vaccinations (they are). I checked that I was current on my own pertussis vaccination back in December when I got my flu shot.

Sharing a world with vulnerable little kids, it’s just the responsible thing to do.

You’re already on the internet reading about science and health, so it will probably come as no surprise to you that California’s pertussis epidemic is a result of the downturn in vaccination in recent years, nor that this downturn has been driven in large part by parents worried that childhood vaccinations might lead to their kids getting autism, or asthma, or some other chronic disease. Never mind that study after study has failed to uncover evidence of such a link; these parents are weighing the risks and benefits (at least as they understand them) of vaccinating or opting out and trying to make the best decision they can for their children.

The problem is that the other children with which their children are sharing a world get ignored in the calculation.

Of course, parents are accountable to the kids they are raising. They have a duty to do what is best for them, as well as they can determine what that is. They probably also have a duty to put some effort into making a sensible determination of what’s best for their kids (which may involve seeking out expert advice, and evaluating who has the expertise to be offering trustworthy advice).

But parents and kids are also part of a community, and arguably they are accountable to other members of that community. I’d argue that members of a community may have an obligation to share relevant information with each other — and, to avoid spreading misinformation, not to represent themselves as experts when they are not. Moreover, when parents make choices with the potential to impact not only themselves and their kids but also other members of the community, they have a duty to do what is necessary to minimize bad impacts on others. Among other things, this might mean keeping your unvaccinated-by-choice kids isolated from kids who haven’t been vaccinated because of their age, because of compromised immune function, or because they are allergic to a vaccine ingredient. If you’re not willing to do your part for herd immunity, you need to take responsibility for staying out of the herd.

Otherwise, you are a free-rider on the sacrifices of the other members of the community, and you are breaking trust with them.

I know from experience that this claim upsets non-vaccinating parents a lot. They imagine that I am declaring them bad people, guilty of making a conscious choice to hurt others. I am not. However, I do think they are making a choice that has the potential to cause great harm to others. If I didn’t think that pointing out the potential consequences might be valuable to these non-vaccinating parents, at least in helping them understand more fully what they’re choosing, I wouldn’t bother.

So here, let’s take a careful look at my claim that vaccination refuseniks are free-riders.

First, what’s a free-rider?

In the simplest terms, a free-rider is someone who accepts a benefit without paying for it. The free-rider is able to partake of this benefit because others have assumed the costs necessary to bring it about. But if no one was willing to assume those costs (or indeed, in some cases, if there is not a critical mass of people assuming those costs), then that benefit would not be available, either.

Thus, when I claim that people who opt out of vaccination are free-riders on society, what I’m saying is that they are receiving benefits for which they haven’t paid their fair share — and that they receive these benefits only because other members of society have assumed the costs by being vaccinated.

Before we go any further, let’s acknowledge that people who choose to vaccinate and those who do not probably have very different understandings of the risks and benefits, and especially of their magnitudes and likelihoods. Ideally, we’d be starting this discussion about the ethics of opting out of vaccination with some agreement about what the likely outcomes are, what the unlikely outcomes are, what the unfortunate-but-tolerable outcomes are, and what the to-be-avoided-at-all-costs outcomes are.

That’s not likely to happen. People don’t even accept the same facts (regardless of scientific consensus), let alone the same weightings of them in decision making.

But ethical decision making is supposed to help us get along even in a world where people have different values and interests than our own. So, plausibly, we can talk about whether certain kinds of choices fit the pattern of free-riding even if we can’t come to agreement on probabilities and a hierarchy of really bad outcomes.

So, let’s say all the folks in my community are vaccinated against measles except me. Within this community (assuming I’m not wandering off to exotic and unvaccinated lands, and that people from exotic and unvaccinated lands don’t come wandering through), my chances of getting measles are extremely low. Indeed, they are as low as they are because everyone else in the community has been vaccinated against measles — none of my neighbors can serve as a host where the virus can hang out and then get transmitted to me. (By the way, the NIH has a nifty Disease Transmission Simulator that you can play around with to get a feel for how infectious diseases and populations whose members have differing levels of immunity interact.)

I get a benefit (freedom from measles) that I didn’t pay for. The other folks in my community who got the vaccine paid for it.

In fact, it usually doesn’t require that everyone else in the community be vaccinated against measles for me to be reasonably safe from it. Owing to “herd immunity,” measles is unlikely to run through the community if the people without immunity are relatively few and well interspersed with the vaccinated people. This is a good thing, since babies in the U.S. don’t get their first vaccination against measles until 12 months, and some people are unable to get vaccinated even if they’re willing to bear the cost (e.g., because they have compromised immune systems or are allergic to an ingredient of the vaccine). And, in other cases, people may get vaccinated but the vaccines might not be fully effective — if exposed, they might still get the disease. Herd immunity tends to protect these folks from the disease — at least as long as enough of the herd is vaccinated.

If too few members of the herd are vaccinated, even some of those who have borne the costs of being vaccinated (because even very good vaccines can’t deliver 100% protection to 100% of the people who get them), or who would bear those costs were they able (owing to their age or health or access to medical care), may miss out on the benefit. Too many free-riders can spoil things even for those who are paying their fair share.

A standard reply from non-vaccinating parents is that their unvaccinated kids are not free-riders on the vaccinated mass of society because they actually get diseases like chicken pox, pertussis, and measles (and are not counting on avoiding the other diseases against which people are routinely vaccinated). In other words, they argue, they didn’t pay the cost, but they didn’t get the benefit, either.

Does this argument work?

I’m not convinced that it does. First off, even though unvaccinated kids may get a number of diseases that their vaccinated neighbors do not, it is still unlikely that they will catch everything against which we routinely vaccinate. By opting out of vaccination but living in the midst of a herd that is mostly vaccinated, non-vaccinating parents significantly reduce the chances of their kids getting many diseases compared to what the chances would be if they lived in a completely unvaccinated herd. That statistical reduction in disease is a benefit, and the people who got vaccinated are the ones paying for it.

Now, one might reply that unvaccinated kids are actually incurring harm from their vaccinated neighbors, for example if they contract measles from a recently vaccinated kid shedding the live virus from the vaccine. However, the measles virus in the MMR vaccine is an attenuated virus — which is to say, it’s quite likely that unvaccinated kids contacting measles from vaccinated kids will have a milder bout of measles than they might have if they had been exposed to a full-strength measles virus out in the wild.
 A milder case of measles is a benefit, at least when the alternative is a severe case of measles. Again, it’s a benefit that is available because other people bore the cost of being vaccinated.

Indeed, even if they were to catch every single disease against which we vaccinate, unvaccinated kids would still reap further benefits by living in a society with a high vaccination rate. The fact that most members of society are vaccinated means that there is much less chance that epidemic diseases will shut down schools, industries, or government offices, much more chance that hospitals and medical offices will not be completely overwhelmed when outbreaks happen, much more chance that economic productivity will not be crippled and that people will be able to work and pay the taxes that support all manner of public services we take for granted.

The people who vaccinate are assuming the costs that bring us a largely epidemic-free way of life. Those who opt out of vaccinating are taking that benefit for free.

I understand that the decision not to vaccinate is often driven by concerns about what costs those who receive the vaccines might bear, and whether those costs might be worse than the benefits secured by vaccination. Set aside for the moment the issue of whether these concerns are well grounded in fact. Instead, let’s look at the parallel me might draw: 
If I vaccinate my kids, no matter what your views about the etiology of autism and asthma, you are not going to claim that my kids getting their shots raise your kids’ odds of getting autism or asthma. But if you don’t vaccinate your kids, even if I vaccinate mine, your decision does raise my kids’ chance of catching preventable infectious diseases. My decision to vaccinate doesn’t hurt you (and probably helps you in the ways discussed above). Your decision not to vaccinate could well hurt me.

The asymmetry of these choices is pretty unavoidable.

Here, it’s possible that a non-vaccinating parent might reply by saying that it ought to be possible for her to prioritize protecting her kids from whatever harms vaccination might bring to them without being accused of violating a social contract.

The herd immunity thing works for us because of an implicit social contract of sorts: those who are medically able to be vaccinated get vaccinated. Obviously, this is a social contract that views the potential harms of the diseases as more significant than the potential harms of vaccination. I would argue that under such a social contract, we as a society have an obligation to take care of those who end up paying a higher cost to achieve the shared benefit.

But if a significant number of people disagree, and think the potential harms of vaccination outweigh the potential harms of the diseases, shouldn’t they be able to opt out of this social contract?

The only way to do this without being a free-rider is to opt out of the herd altogether — or to ensure that your actions do not bring additional costs to the folks who are abiding by the social contract. If you’re planning on getting those diseases naturally, this would mean taking responsibility for keeping the germs contained and away from the herd (which, after all, contains members who are vulnerable owing to age, medical reasons they could not be vaccinated, or the chance of less than complete immunity from the vaccines). No work, no school, no supermarkets, no playgrounds, no municipal swimming pools, no doctor’s office waiting rooms, nothing while you might be able to transmit the germs. The whole time you’re able to transmit the germs, you need to isolate yourself from the members of society whose default assumption is vaccination. Otherwise, you endanger members of the herd who bore the costs of achieving herd immunity while reaping benefits (of generally disease-free work, school, supermarkets, playgrounds, municipal swimming pools, doctor’s office waiting rooms, and so forth, for which you opted out of paying your fair share).

Since you’ll generally be able to transmit these diseases before the first symptoms appear — even before you know for sure that you’re infected — you will not be able to take regular contact with the vaccinators for granted.

And if you’re traveling to someplace where the diseases whose vaccines you’re opting out of are endemic, you have a duty not to bring the germs back with you to the herd of vaccinators. Does this mean quarantining yourself for some minimum number of days before your return? It probably does. Would this be a terrible inconvenience for you? Probably so, but the 10-month-old who catches the measles you bring back might also be terrible inconvenienced. Or worse.

Here, I don’t think I’m alone in judging the harm of a vaccine refusenik giving an infant pertussis as worse than the harm in making a vaccine refusenik feel bad about violating a social contract.

An alternative, one which would admittedly required some serious logistical work, might be to join a geographically isolated herd of other people opting out of vaccination, and to commit to staying isolated from the vaccinated herd. Indeed, if the unvaccinated herd showed a lower incidence of asthma and autism after a few generations, perhaps the choices of the members of the non-vaccinating herd would be vindicated.

In the meantime, however, opting out of vaccines but sharing a society with those who get vaccinated is taking advantage of benefits that others have paid for and even threatening those benefits. Like it or not, that makes you a free-rider.
* * * * *
An earlier version of this essay originally appeared on my other blog.

Janet D. Stemwedel About the Author: Janet D. Stemwedel is an Associate Professor of Philosophy at San José State University. Her explorations of ethics, scientific knowledge-building, and how they are intertwined are informed by her misspent scientific youth as a physical chemist. Follow on Twitter @docfreeride.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. ErnestPayne 12:20 pm 06/29/2013

    Good luck in preaching common sense to the terminally ignorant. Unfortunately it will be their children that win the Darwin award.

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  2. 2. Chaucer 6:00 pm 06/29/2013

    Who cares how many refuseniks there are. I mean really. We have a whole society full of refusniks. Bill Clinton is a refusenik. He refused to join in the common defense of the country. A person must protect allies. Before Sassanid Persian Devastated Byzantium and led to its fall, its; 1st step was (yup, you did not guess it) to take Armenia away from Byzantium as a client state/ally. As a great leader would say “Armenia is just a little country it can’t hurt or help us!”

    We have refuseniks who refuse to curb their extravagant, fabulous lifestyles. an example is Al Gore. His house has a utility bill which 20X that of the average family.

    We have refuseniks who only recourse to fighting crime is to call 911. The courts have rule that the police do not have to respond to a 911 call with in a set amount of time or at all. They are there to provide a general level of security. People who do not own guns are refuseniks.

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  3. 3. PatriciaJH 9:58 pm 06/29/2013

    You’ve left out the social costs of supporting unvaccinated children who contract diseases, develop not-so-uncommon complications, and become blind, deaf, or mentally disabled. People have forgotten, but measles, for one, was a terrible crippler — arguably worse than polio, when one digs into the details and incidence of death and disability for both.

    My father lost most of his hearing to childhood measles. I grew up knowing how glad my parents were for every vaccine we were able to receive. Those who conduct fake science in order to lower public confidence in vaccines for personal gain are the absolute lowest of the low.

    Thank you for this article.

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  4. 4. Twyla2 10:36 pm 06/29/2013

    There is so much wrong with this article, it is hard to know where to begin.

    You apparently believe the following:
    1) All of the diseases which we vaccinate against are very very dangerous and communicable.
    2) Vaccines are very very safe.
    3) People who don’t vaccinate are free-riders. Vaccinaters are paying a cost so that non-vaccinators can have a free ride.

    If vaccines are so safe, what cost is being paid by the vaccinated? Generally the monetary cost of vaccines is paid for by insurance or the government. And if the diseases are so dangerous, how can not vaccinating be a free ride?

    You also say that, “If I vaccinate my kids, no matter what your views about the etiology of autism and asthma, you are not going to claim that my kids getting their shots raise your kids’ odds of getting autism or asthma.” But, guess what? Society as a whole pays the cost of autism, asthma, and a number of other immunological and neurological disorders which have increased over the past 25 years at the same time as the vaccine program has greatly expanded, including inflammatory bowel disease, diabetes, ADHD, bipolar, and more. Society pays higher costs for special education, therapies, rising insurance costs due to factors such as the cost of increased prescription drug use, and more. And, as this generation of children grows into adults, and then we their parents die, society will be paying the cost of caring for many more adults with significant disabilities than in past generations. So, if our current vaccine program is causing high rates of serious chronic conditions and disabilities this is something that affects everyone.

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  5. 5. David Cummings 12:37 am 06/30/2013

    Great article, Janet, written in long detail and carefully constructed supporting logic that will be completely lost on the “terminally ignorant”, as ErnestPayne noted in the first comment.

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  6. 6. Linda Tick Tock 6:11 am 06/30/2013

    The only thing that’s wrong Twyla is you.

    All of the diseases we vaccinate ARE dangerous and/or communicable. Can you think of a single disease which we vaccinate against (other than perhaps tetanus) which isn’t communicable?

    We vaccinate against diseases which can kill, maim or disable children and adults.

    Vaccines ARE very safe; especially compared to the risks of naturally acquired diseases. Are they 100% safe? No – nothing is. Again, you favor the naturalistic fallacy – that if it can’t be 100% safe, it must be 0% safe.

    Seatbelts aren’t 100% safe, there are a number of incidences where using the seatbelt properly has actually CAUSED the death of the passenger. However, those occurrences are few and far between – much like the serious adverse effects of vaccination. Far more children are injured (and killed) yearly from measles infection than from injury from the MMR.

    People who don’t vaccinate ARE freeloaders. They’re complacent in their choice to not vaccinate and ‘risk’ an adverse event post vaccination, because they know that the community around them vaccinates – which protects their child. It’s the ultimate in selfishness. You reap the benefits of herd immunity, contribute nothing (in fact, you erode the benefit), and have no risk from the vaccine. You blithely ignore the risk of the disease because the folks around you are vaccinated and therefore can’t infect you or your child.

    Vaccinators make the correct risk analysis. The risk(s) associated with vaccinating are minuscule in comparison to the risks associated with the wild disease. You still can’t get your head around the math.

    “But, guess what? Society as a whole pays the cost of autism, asthma, and a number of other immunological and neurological disorders which have increased over the past 25 years at the same time as the vaccine program has greatly expanded, including inflammatory bowel disease, diabetes, ADHD, bipolar, and more.”

    …and none of these things has anything to do with vaccines. These diagnoses have expanded at the same time as the increase in use of SUV’s, increase of use of sunscreen, increase in consumption of organic foods, etc. It’s called correlation without causation, and it is the poster child for you and the rest of the antivaccine movement.

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  7. 7. Twyla2 1:18 pm 06/30/2013

    re: “The only thing that’s wrong Twyla is you.”
    Actually, I’m a person, not a thing. And there are many things and people that are wrong, so even if I were wrong I would not be the only one. So, you’re not making sense.

    My son was vaccinated for hepatitis B the day he was born. He was not even at risk for hep B, because I am not and have never been infected with hepatitis B. The CDC added this to the schedule for everyone in order to catch the very small number of mothers who were infected with hepatitis B and didn’t know it. This is an example of the faulty weighing of risks and benefits which has become our vaccine program’s philosophy. Hepatitis B is generally not communicable through casual contact, but through exchange of bodily fluids such as via sex or shared needles.

    re: “Again, you favor the naturalistic fallacy – that if it can’t be 100% safe, it must be 0% safe.”
    I never said that. I never said anything like that. I said that we need to understand the adverse effects better, for the sake of both prevention and treatment. And people need to have the right to make choices, as there are risks on both sides of theses choices – poorly understood risks.

    re: “You reap the benefits of herd immunity…”
    I’m not vaccinated for measles because I grew up before the vaccine existed. I came down with measles as a child and from that I have immunity. My children were vaccinated against measles. Are you assuming that I don’t vaccinate? Again why does the statement “I have concerns about vaccinations” get translated into, “I never vaccinate.” Did you not read my comments? Go back and read them again.

    I have never advised anyone on whether to vaccinate. I have never told anyone not to vaccinate. But I think our vaccine program consists of too many vaccines too soon, with disregard for the adverse effects. We can’t just add on more and more vaccines and assume that we understand the impact on developing immune systems.

    You make a lot of declarations about comparative risks with no citations. There is a lot that we don’t know.

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  8. 8. lizditz 1:50 pm 06/30/2013

    Hi Prof Stemwedel, thank you for the clear article.

    I do however want to take issue with one thing you wrote,

    so it will probably come as no surprise to you that California’s pertussis epidemic is a result of the downturn in vaccination in recent years

    That isn’t exactly correct. What may be closer to accurate is: 1. Pertussis is a disease that is cyclical in nature. Even before a vaccine became available (in 1939), some years saw much higher rates of infection than other years. 2. Having pertussis confers natural immunity, but even this natural immunity wanes over time, and the immunity conferred seems to vary among individuals. 3. The ability to accurately and economically diagnose pertussis has also improved in the last 2 decades, which may change reporting rates. 4. The whole-cell vaccine (1939; combined with tetanus and diphtheria vaccines in 1948; discontinued in mid-1990s) gave much longer immunity than the acellular formulation (given from the 1990s on). 5. Adults vaccinated against pertussis in childhood may no longer have immunity. 7. In prior years, adults were not given a booster vaccine against pertussis. 6. Adults with lapsed immunity are the most common source of infant pertussis infection.

    So it’s not quite fair to blame vaccine-refusing parents, or unvaccinated children, for the 2009-2010 California pertussis epidemic.

    The 2013 measles outbreaks in Wales and England, however, are directly attributable to vaccine-refusing parents.

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  9. 9. lizditz 2:01 pm 06/30/2013

    Twyla wrote (as she has many times elsewhere) a falsehood, to wit,

    ” Hepatitis B is generally not communicable through casual contact, but through exchange of bodily fluids such as via sex or shared needles.”

    This is not true. As has been explained to you, Twyla, many times.
    Eric Mast, M.D., M.P.H :
    “In household settings, non-sexual transmission of HBV occurs primarily from child to child, and young kids are at highest risk of infection. We’re not sure exactly how transmission occurs, but frequent contact of non-intact skin or mucous membranes with blood-containing secretions including, perhaps, saliva, are the most likely means of transmission. HBV remains infectious at mild temperatures for extended periods and can be found on and transmitted through sharing of inanimate objects such as wash towels or toothbrushes.”

    “Although transmission of HBV is apparently rare in sports, 2 reports document such transmission. An asymptomatic high school sumo wrestler who had a chronic infection transmitted HBV to other members of his team. An epidemic of HBV infection occurred through unknown means among Swedish athletes participating in track finding (orienteering). The epidemiologists concluded that the most likely route of infection was the use of water contaminated with infected blood to clean wounds caused by branches and thorns.”

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  10. 10. lizditz 2:14 pm 06/30/2013

    I didn’t phrase my previous post correctly. Twyla asserts that Hep B is spread by sexual contact or dirty needles. Not so.

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  11. 11. DanRhoads 3:50 pm 06/30/2013

    “But if you don’t vaccinate your kids, even if I vaccinate mine, your decision does raise my kids’ chance of catching preventable infectious diseases.”

    I would have thought that, if I vaccinated my kids, “your” unvaccinated kids couldn’t hurt mine. Do you have a citation for this claim?

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  12. 12. Twyla2 11:32 am 07/1/2013

    Liz Ditz, how many infants are engaging in sumo wrestling or track?

    From the CDC:

    How is Hepatitis B spread?

    Hepatitis B is spread when blood, semen, or other body fluid infected with the Hepatitis B virus enters the body of a person who is not infected. People can become infected with the virus during activities such as:

    Birth (spread from an infected mother to her baby during birth)

    Sex with an infected partner

    Sharing needles, syringes, or other drug-injection equipment

    Sharing items such as razors or toothbrushes with an infected person

    Direct contact with the blood or open sores of an infected person

    Exposure to blood from needlesticks or other sharp instruments

    What I wrote was not a “falsehood”. “Hepatitis B is generally not communicable through casual contact, but through exchange of bodily fluids such as via sex or shared needles” is consistent with the above quote from the CDC’s web site. I guess you missed the words “generally” and “such as”. Yes, there is a very small chance of Hep B contagion through intimate contact such as contact sports. But sports contact is not relevant to an infant. If the mother is not carrying the hep B virus at time of birth, an infant is generally not at risk. You managed to find someone describing cases of transmission via shared physical objects, but that is extremely rare. In fact, at the same CDC page linked to above is this statement:

    Can Hepatitis B be spread through food?

    Unlike Hepatitis A, it is not spread routinely through food or water. However, there have been instances in which Hepatitis B has been spread to babies when they have received food pre-chewed by an infected person.

    What are ways Hepatitis B is not spread?

    Hepatitis B virus is not spread by sharing eating utensils, breastfeeding, hugging, kissing, holding hands, coughing, or sneezing.

    Who is at risk for Hepatitis B?

    Although anyone can get Hepatitis B, some people are at greater risk, such as those who:

    Have sex with an infected person

    Have multiple sex partners

    Have a sexually transmitted disease

    Are men who have sexual contact with other men

    Inject drugs or share needles, syringes, or other drug equipment

    Live with a person who has chronic Hepatitis B

    Are infants born to infected mothers

    Are exposed to blood on the job

    Are hemodialysis patients

    Travel to countries with moderate to high rates of Hepatitis B

    So, other than getting Hep B at birth from an infected mother, there is an extremely small chance of an infant being exposed to Hep B.

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  13. 13. Janet D. Stemwedel in reply to Janet D. Stemwedel 12:21 pm 07/1/2013

    Twyla, this post is not an invitation to disagree about the details of what we know or think we know about particular vaccinations. (You’ll note that, up there in the original post, I mentioned that people sharing the world have some disagreements about the facts here, and also about how to weight different kinds of risks in making their decisions.) Rather, this post is about what follows ethically from making a certain calculation about your own (or your child’s) risks without taking into account the risks borne by others with whom one is sharing a world.

    If you won’t engage with that ethical question, you’re derailing the conversation, and your comments won’t get approved.

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  14. 14. bpatient 3:57 pm 07/1/2013

    Bioethicist Art Caplan recently commented in the Harvard Bill of Health and reached similar conclusions: “When the subject is vaccines a tiny minority continue to put the rest of us at risk. We are willing to let them choose to do so without penalty. That should change.”

    FWIW, a paper published last month should allay Twyla’s fears:

    Although children in Iceland are NOT vaccinated against Hepatitis B, the prevalence of autism there (1 in 83 children in 2009) is comparable to that in the US (1 in 88 children in 2008). [Saemundsen E et al. Prevalence of autism spectrum disorders in an Icelandic birth cohort. BMJ Open. 2013 Jun 20;3(6). pii: e002748]

    I suppose that, although that paper is supported by a large body of similar work, in and of itself it should also adequately refute many other reasons that some parents may fear a vaccine-autism connection and become free riders:

    (a) Thimerosal is not responsible for an epidemic of autism: The children in the study were born years after thimerosal was removed from pediatric vaccines in Iceland, yet (as in Denmark, Sweden, Canada, and California) the prevalence of ASD was higher than before thimerosal was removed, and it continued to climb throughout the study period. (b) The continuing increase in ASD prevalence in Iceland cannot be due to thimerosal-containing influenza vaccines: influenza vaccination is recommended in Iceland only for adults 60 years of age and older, and uptake of the vaccine is very much lower than in the US. (c) The “too-many-too-soon” and “the ever-expanding vaccine schedule” ideas are also discounted: children in Iceland receive about one-half as many vaccines as US kids, but have the same rate of ASD—and, moreover, the vaccines that are administered are generally given a bit later than in the US. (d) It can’t be MMR that is responsible—MMR administration remained unchanged as the prevalence climbed.

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  15. 15. cphickie 4:25 pm 07/1/2013

    Dr. Stemwedel,

    Thank you for your excellent article. Parents who, for no valid medical reason, opt out of vaccinating their children are truly free-riders (they may also have severe deficits in understanding the cause and effect relationship between high rates of vaccination and low rates of vaccine-preventable diseases as well).

    I would like to mention–and this also ties in with Liz Ditz’s comments about the 2010 pertussis outbreak in California (that killed 10 infants)–that California is also the home to two very anti-vaccine pediatricians, Dr. Bob Sears and Dr. Jay Gordon. These two snake-oil salesmen (they sell books, DVDs and webinars telling parents vaccines are not safe/effective and that diseases like pertussis and measles are not serious) continue to “hide in the herd” of the vast, vast majority of pediatricians who do vaccinate and who do understand just how important vaccination is. As a pediatrician who has seen unvaccinated children hurt and die from these vaccine-preventable diseases, I have to work with parents who come in weekly wanting to follow “Dr Bob’s alternate schedule” (which delays/skips vaccines) or wanting to hold all vaccines until their infant is 6-12 months of age (per Dr. Gordon’s advice). Sadly, although neither “Dr. Bob” or “Dr. Jay” have done any actual research on vaccines or bothered to test their “schedules”, they are very mediagenic on TV, radio, print and internet—making it almost impossible for me to convince parents that the advice of these two fools should not be followed. It is also extremely frustrating that these two pediatricians have yet to be called out publicly and by name by any large medical group, such as the AAP, AAFP, AMA or the CDC as they should have been 5-10 years ago when they started peddling their lies. Thus, some parents who don’t vaccinate are doing so because of the unchallenged medically negligent advice of these two pediatricians who, in my opinion, are guilty of medical malpractice.

    I do think, Liz, that a big part of the 2010 California pertussis outbreak was due to the parental misguidance of Sears and Gordon (again, they both live and practice in California), which lead to a large number of unvaccinated children in California (especially in areas where the outbreaks were largest) who then became vectors for pertussis–not only to infants, but also to adults who previously hadn’t had to worry much about pertussis because the herd immunity rates in children were very high (prior to Sears and Gordon). What helped end this outbreak was a massive pertussis immunization push by the State of California.

    Chris Hickie, MD, PhD
    Tucson, AZ

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  16. 16. David Cummings 7:46 am 07/2/2013

    Claiming that vaccination (in general) has not proven itself as an extremely valuable and important part of modern public health, and persisting (against all evidence) that vaccinations cause autism is a mind set that is equivalent to claiming the earth is 6,000 years old and that “creation science” belongs in the science classroom.

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  17. 17. Sylvie66 5:31 pm 07/3/2013

    Thank you for posting what is, unfortunately, still a controversial topic. My kids were allergic to something in the immunizations – the reactions were terrifying (febrile seizures and asthmatic attacks). I delayed immunizations, and only used attenuated vaccines, and chose very, very carefully. I knew the risk I was taking with them, and within the community.
    My kids got pertussis, measles, mumps, and chicken pox. I did what I could to “stay out of the herd” – keeping them away from the county fair, childcare centers, and public schools and swimming pools. My kids are all healthy adults now.
    “If you’re not willing to do your part for herd immunity, you need to take responsibility for staying out of the herd.” is the best statement I’ve seen about proper immunization.

    Link to this
  18. 18. Janet D. Stemwedel in reply to Janet D. Stemwedel 5:41 pm 07/3/2013

    Sylvie66, to my mind kids like yours are precisely the members of the herd the rest of us should be stepping up to protect! Glad to know that they’ve grown to healthy adulthood.

    Link to this
  19. 19. PatriciaJH 3:14 pm 07/4/2013

    @Twyla — According to the CDC you cited, Hep B is 50-100% times more infectious than HIV, and the younger infection occurs, the likelier it is to become chronic, leading to cirrohisis of the liver and liver cancer; 90% of infected infants develop chronic infections, and are then life-long carriers; there are somewhere around 1,000,000 people with chronic HBV infection in the US. Also, *living with someone who has chronic HBV is considered an HBV risk* — unlike HIV. HBV can remain alive outside the body for 7 days (HIV, 15 minutes.)

    I think all of the above had something to do with the decision to vaccinate against Hep B at birth.

    According to Paul Offit’s excellent book _Vaccinated_, it’s the third most-common cause of cancer (behind sun-caused skin cancer, and smoking); HBV vaccination in Taiwan led to a 99% drop in liver cancer; and in the US, a 95% decrease in HBV infection in children and teens, and a dramatic increase in livers available for donation.

    Read _Vaccinated_ — it’s a history of vaccine development in the US, as seen through the career of scientist Maurice Hillerman, a VERY interesting and colorful character. Reading it may or may not give you some useful perspective on the controversies around vaccination.

    Link to this
  20. 20. jtreml 12:41 am 07/7/2013

    Thank you for a very interesting article, Dr. Stemwedel. I was happy to see someone address the the ethics of non-vaccination with respect to the social contract. Although it may be mentioned in other articles, it is seldom given such thorough treatment.
    I find it rather comical that parents can bypass the social contract and decline to vaccinate their children but still send them into public school (etc.).
    Are all obligations of the social contract as easily dispensed with while still keeping the benefits?
    Can I send my son to school with a pack of Marlboros because we don’t agree about the dangers of secondhand smoke? After all, it’s just my one son who will be smoking in class. -I know this is an absurd argument, but don’t we forbid smoking in class for the same reason we insist on vaccination? And I would be pretty disappointed if my son started smoking.

    Link to this
  21. 21. Zaboulino 5:43 pm 07/9/2013

    To answer your concerns as you stated, “We can’t just add on more and more vaccines and assume that we understand the impact on developing immune systems,” here’s a great article:
    “Current studies do not support the hypothesis that multiple vaccines overwhelm, weaken, or “use up” the immune system. On the contrary, young infants have an enormous capacity to respond to multiple vaccines, as well as to the many other challenges present in the environment.”

    Link to this
  22. 22. adamhart 1:20 am 10/6/2013

    most parents opt out because of lack of proper information. they here influenced too much with heresy instead of the facts. the whooping cough is a serious disease and vaccination is important.

    Link to this

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