The Ethics of Vaccination, Part 1

In the unstudied ethics of primary-care pediatrics, is the particularly dark and unexplored corner of vaccination.

As my readers know, I suspect that ethicists suffer from Perimortal Obsession and the natural desire to be quoted in the media commenting on the latest rara avis of medical dilemmas.  But this alone doesn’t explain why this topic is so carefully avoided.  As I’ve pointed out again and again, the common ethical problems encountered in primary-care medicine every day are apparently unattractive subjects for professional academic ethicists.

There are several important ethical issues that apply to childhood vaccination as we do it here in the United States.  Each of these is worthy of a symposium of its own, but I’ll just list these as they come to mind, and put them here on the internet for all to see.  Maybe an ethicist (who already has tenure) will dare to pick up the gauntlet.  In fact, this is just a prologue to an ethical issue associated with vaccination that only presented itself to me a few weeks ago.  The rest of this list has been smoldering for a long time.  I should note for the record that I believe childhood vaccination to be the greatest breakthrough in pediatric health ever made.  I discourage parents who choose not to vaccinate their children from joining my practice (that’s a big topic on its own!).  So these ethical issues assume a priori that the usual vaccinations we give are safe and effective.

The keystone ethical problem in pediatrics is doing something to somebody who is not giving their consent.  A lot of the general parenting problems I get asked about fall into this category as well.  Often parents will be unaware of their conflict between doing what they know is best for the child and doing what the child likes.  Broccoli vs.. ice cream.  Bedtime vs.. staying up.  This is one of the hardest parts of any good parent’s job.  But can we justify vaccination ethically on this basis?

What is the ethical obligation of the parents to other parents, to the community as a whole.  Even if we concede that parents sometimes have a sucky job and have to make decisions that hurt their baby because the baby will be better for it, should they hurt their baby in order to help some other baby?  This is just what herd immunity is all about.  At what point, ethically and epidemiologically, is there a breakeven between the suffering of one child and an abstract public health benefit?

Notwithstanding the vaccinations that are ‘required’ for school entry, what should the ethical guidelines be that determine how a parent chooses to waive these requirements.  Here in California, you don’t need to prove anything or claim anything.  Just that you sign the following statement: 

I hereby request exemption of the child, named in the front, from the immunization requirements for school/child care center entry because these immunizations are contrary to my beliefs. I understand that in case of an outbreak of any of these diseases, the child may be temporarily excluded from school for his/her protection.

It’s pretty shocking to me, honestly, that the serious consequence warned of in the statement is that your kid may be asked to stay home for a few days.  Considering the overwhelming statistical likelihood that any outbreak of one of these vaccine-preventable diseases probably started with an unvaccinated child, it’s curious and disappointing to know that the parent is being warned neither of the potential for harm their child represents to everybody else, nor of the potential for death or serious illness with life-long injuries that they have chosen for their own child.


I believe that physicians must give honest answers to patients.  That’s not an ethical problem.  But I am often asked if a baby really needs polio vaccine.  I give an honest answer:  it’s still around in certain parts of the world, but not here in the United States; it’s a really, really bad thing to get, and cause permanent disability; it seems to be preventable with the vaccine; a polio vaccine has been used for about 50 years, and the problems with it have been few.  But do they need to get the shot?   There’s plenty of cases of Japanese Encephalitis in the world, and there’s a vaccine for it.  But people get in in South Central to East Asia.  If you’re traveling to Borneo, it’s probably a good idea to get the vaccine.  But kids here probably don’t need it, so they aren't required to get it.  Polio is much less widespread in the world (thanks to vaccination) than Japanese Encephalitis, and there are no cases in North or South America.  If the parents take the child to certain parts of Africa or Central Asia, it’s probably important to be vaccinated.  Yet kids here are required to get 4 or 5 shots of it.

I get a lot of similar questions about Hepatitis B vaccine, which is often given within 1/2 hour of birth.  It’s spread, generally, by tainted blood products, sharing needles and syringes, and intimate contact.  So even a cautious parent would be right to suppose their child won’t be at risk until adolescence.  I don’t think this argument holds up, by the way, though it’s right as far as it goes.  What isn’t considered are the accidents, the hypodermic needle your happy 2-year-old brings over to you in the park to show you what she’s found, the thing your kid picked up that turned out to have some unidentified blood on it.

Is it ethical to give some vaccines in infancy just to take advantage of a time when the patient can put up the least resistance and won’t remember the assault?  Should we wait until they can willingly participate—though we know that almost none of them would?  Is it ethical to give an adult patient a medication that causes anterograde amnesia, then do something unpleasant to them?  They suffer just the same, but they don’t remember it afterward.  Is that the same as not suffering?  This is common practice, by the way for procedures like endoscopy (from either end).  Somehow not remembering the pain and choking during the procedure is considered equivalent to not having any pain.

There's a deep ethical inconsistency with this belief.  If the patient is not able to give consent (they have a serious developmental delay, they have brain damage or severe mental illness, for example)  would we allow a painful procedure without pain control measures?  I think and hope this would be considered barbaric and potentially license-losing for the physician.  In what functional way, exactly, is this hypothetical severely-impaired person different from a 12-month-old?  Maybe none of these hypothetical patients will remember the procedure.  Why is this not OK, yet doing pretty much the same thing on an adult who is drugged not to remember the procedure (same pain, same outcome) is a cottage industry?  I'm not questioning the benificence of the parent or medical guardian involved.  The difference, of course, is the adult's ability to be informed about the pain and the drug and the amnesia, and to consent to it.  (The fact that laypeople consent to such a procedure is no testimony for it.  Remember that virtually no insurance companies will pay for second opinions.  Besides, what incentive is there for the proceduralist to innovate new and less painful ways to practice?)

There’s a little bit of new research which suggests that babies may indeed remember the pain of vaccination.  Even if they don't, it's not a strong enough ethical argument to claim that the baby won't remember the pain of the shots. It's painful, they don't consent.


Perhaps it's a universal truth that so many issues eventually touch upon money.  It is a mystery to me why palliation is so often difficult for insurers.  Surely pain is something that binds us together as humans.  Is it ethical not to use devices or techniques which can make vaccination less painful?  These do exist, but they cost real money.  Given the thin margins on vaccines for most physicians, use of these products could make the doctor lose money on every shot.  Do they have an ethical obligation to pay for the privilege of giving vaccinations?  Do insurers have an ethical obligation (oxymoronic, I admit) to pay for things that reduce the pain of vaccination?  Or is that a lifestyle choice?  I think it's worth a post of its own.