Let me begin by clarifying that I am not anti-vax…nor anti-science…nor, as you may have already seen in my other blog posts, anti-medicine. What I am is anti-bullying, pro-informed consent, pro-critical thinking (and giving safe space for others to think critically) and pro-transparency. In the realm of vaccinations, my expectations of any of these things remaining within the practitioner-patient encounter are constantly, and sorely, deflated. There are a number of ways in which I would like to see the delivery of immunization programming evolve into a more transparent and ethical exchange between public health care bodies, advocates for and against vaccination, and individuals.
What do I mean by this?
In Western bioethics thought, the principle of autonomy – or self-determination – is a subcategory of ‘respect for human persons'. This involves being given the opportunity to provide informed consent for, or refusal of, an intervention without coercion or fear of reprisal. In other words, don't push a patient into anything against their will, and don't punish them if you don't like what they choose. More and more, this paradigm is considered a hallmark of quality patient-centered care. But, let's examine what happens to it in the context of immunization programs.
I would say very few people give truly informed consent when they agree to an immunization – this is especially true when it comes to the possibility of adverse effects from a shot. Adverse effects that are commonly mentioned – and even these may be brushed over – include the minimal possibilities for swelling and pain in the arm where the shot is given and the chance of a fever. However, reports are available in the scientific literature of instances of severe adverse effects. Let's leave out the autism claims, for now – I am referring to other adverse effects. For instance, over the past four decades, there has been a real, if diminishing, association between getting the flu shot and contracting Guillain-Barre Syndrome. Presently, the risk is small but present. Other examples abound. This sort of thing should be disclosed to patients, but very often is not. Furthermore, if a patient enquires about it, there is a good chance their questions will be shut down. But the lack of transparency in immunization programs doesn't end there.
Although most jurisdictions have forms to opt out of vaccinations due to matters of conscience or because some vaccinations may go against certain individuals' religious beliefs, this option is seldom, if ever discussed with patients – this is especially so in school immunization programs where children are bullied with threats of suspension if they don't keep up with their immunizations. (Please be aware that I use the term ‘bullied' quite deliberately. I will get back to this in a minute.) When medical personnel leaves out possible alternatives to receiving a particular intervention, the individual's autonomy is over-ridden. Is this, in any way, OK?
One point that is often raised is whether public health measures should require informed consent in the same way that other invasive, non-public health, medical procedures do. If the protection of a society is at stake, we ponder, do we need to ask, "May I", before pushing the plunger? I would argue that only in very specific and threatening situations could a case be made to override an individual's right to self-determination and compel them to submit to a public health measure – quarantining individuals with fatal infectious disease may be one example of this. My sense is, if the situation were that dire, the individual would go ahead and submit anyway…threats and coercion would seldom, if ever, be necessary. Let's talk about ‘threats and coercion' for a minute, now.
Above, I alluded to bullying school children into getting their vaccinations, at school or otherwise. Public health departments, with the help of school boards, are setting up programs in which, if students don't keep up with vaccination schedules, they are threatened with suspension – not being vaccinated, then, is treated as tantamount to committing a crime. And yet, in using this approach, teachers and public health nurses are actually threatening kids (and, incidentally, freaking them out) and marginalizing them before their peers, if they do not submit to the vaccines. Furthermore, once again, the option to opt out for reasons of conscience, etc, is not presented to these kids.
Using coercive methods, threats/bullying and lies of omission to get minors to submit to invasive medical procedures are, in my opinion, a special level of unethical medical behavior – and yet, in the context of vaccines, it seems to be considered acceptable. The same coercion is utilized with adults – the angle also seems to be that one is, somehow, a substandard citizen if one does not submit to vaccinations.
I would suggest that, if good science has revealed that vaccines offer a favorable risk/benefit ratio, it is a time that we develop a more ethical, dignified and open-discussion manner to promote their use to the public. We need to build trust that has been sore – and with good reason, I would say – lost while ensuring that optimal public health is balanced with respect for persons when administering vaccination programs.
Remember it's not ‘who's right' – or who profits – but what's right that should be at the bottom of every patient-practitioner encounter.
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