Thursday, February 26, 2015

Point and Counterpoint: Vaccines

This piece and the one that follows, “The Paradox of Government Vaccine Mandates” by Tim Rubbelke, present a point and counterpoint in the current resurgence of debate over vaccines. The first, by Kristen Senetar, outlines the positives of maximum vaccination while the second examines the problematic nature of enforcing this notion.

By Kristen Senetar

If you’ve turned on the news lately, you’ve probably heard about the outbreak of measles in the United States. Although the infectious disease has been considered eliminated from the United States since the year 20001, more than 120 people have contracted it since the beginning of this year.2 How could an outbreak like this happen when there is a vaccine to protect us from measles? Should everyone be required to be vaccinated?

Vaccines are used to protect us against numerous diseases: measles, mumps, polio and countless others. The two-dose measles vaccine, which is spread out over several years, is 97% effective.3 The protection offered by this and other vaccines has helped our world become a much healthier place. While not 100% effective, vaccines have saved countless lives by offering a great defense against diseases that can often turn deadly. They are a quick and easy way to protect yourself and your family from illnesses. So why wouldn’t every parent vaccinate their child?

Some people do have concerns about vaccines. Over the past decade, there has been a growing fear that vaccines are linked to autism. However, the 1998 article, which stated that certain vaccines increase the risk of autism has been proven false, retracted from the Lancet, and the author of the paper later lost his medical license.4 There are also some individuals who cannot be vaccinated due to medical conditions such as certain allergies or suppressed immune systems. However, this number of individuals who cannot receive vaccines due to medical reasons is significantly smaller than those who can.

Should everyone be required to get vaccinated against measles and other communicable diseases?

The short answer is yes, everyone should be required to get vaccinated for everything possible, as suggested by their doctor. Except for those who have a specific medical condition and those with religious objections, most Americans can receive all vaccines. It is essential that the majority of the population gets vaccinated because it will support herd immunity. This notion is essential to public health, stating that if the number of people who are vaccinated is significantly greater than the number of those who are not, the vaccinated population can essentially protect the unvaccinated population. However, as the unvaccinated group grows larger and larger, herd immunity becomes less and less effective. Therefore, it is crucial that those who can be vaccinated do so in an effort to protect themselves and others.

There are also some people who have religious objections to vaccines. While religious freedom is a valued good, parents’ choices to not vaccinate endanger their children. If they will not vaccinate their children, then perhaps alternative actions should be put in place during periods of outbreaks, such as not allowing them to go to school. If an unvaccinated child were exposed to a disease, like the measles, and went to school before realizing what they had, they would be placing everyone at their school at risk of exposure. Even though most vaccinated children would go unharmed, the vaccine is not 100% effective. Keeping unvaccinated children out of school during times of outbreaks would help protect both the vaccinated and unvaccinated population.

Medical conditions aside, is it ethical to require everyone to vaccinate his or her children? This can be answered using two of the ethical principles: beneficence and non-maleficence. Take, for example, a newborn baby named Joe. Joe hasn’t been exposed to the germs of the outside world, like the cold virus or measles. He begins his life by staying inside most of the time, only going out for short walks or trips to the doctor’s office. Shortly after turning one, Joe receives his first MMR vaccine, as suggested by his doctor. As he continues to grow, Joe receives all the suggested vaccinations and lives a fairly healthy life. One day, while on an airplane, Joe, who is now a teenager, unknowingly sits next to someone infected with measles. Since Joe received the measles vaccine, no harm comes from the situation and he continues to be healthy as he grows into an adult. This scenario supports the principle of beneficence because the vaccines helped keep Joe healthy and protected against disease.

Now, imagine the same child, Joe, had parents who decided, for non-medical or religious reasons, to not vaccinate him as suggested by his doctor. Joe grew normally, just like kids who did receive vaccines, and led a fairly healthy childhood. One day, Joe, who is now a teenager, got on an airplane and unknowingly sat next to someone who had the measles. Since the measles is a highly communicable disease and the two were sitting so close together, Joe was exposed to the disease. Joe, who never knew the person next to him had the measles, felt fine after leaving the airport but a few days later starts experiencing symptoms. In a matter of days, Joe grows very sick and ends up in the hospital. After several long days, Joe begins to feel better and finally makes a full recovery. While the outcome of a full recovery is the best case, Joe experienced unnecessary suffering and harm. Therefore, the decision Joe’s parents made to not vaccinate him violates the ethical principle of non-maleficence.

Overall, vaccines were created to protect us from harm. No medical intervention is 100% effective or 100% safe. Some people do experience reactions to vaccines, but the majority does not. For most people, vaccines offer a greater benefit than they do the possibility of harm. Medical conditions aside, it is our duty to protect others and ourselves from diseases like the measles by following medical guidance to receive vaccinations. Who knows, the life you save might just be your own.

Kristen is currently a Regulatory Assistant at the University of Texas Southwestern.  She received a B.S. from Butler University in biology with minors in mathematics and chemistry and a Master's in Bioethics from Case Western Reserve University.  Her interests in the bioethics field include genetics, vulnerable populations and the rights of the unborn.

1,3 "Measles Vaccination." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 4 Feb. 2015. Web. 14 Feb. 2015. <>.
2 "Measles Cases and Outbreaks." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 14 Feb. 2015. Web. 14 Feb. 2015. <>.
4 Caplan, Arthur. "There Is No Other Side to the Vaccine Debate." 13 Feb. 2015. Web. 14 Feb. 2015. <>.

The Paradox of Government Vaccine Mandates

By Timothy Rubbelke

Few aspects of medicine invoke so much disagreement among people.  Vaccines have fundamentally changed the way we think about illness.  Yet, they are still rejected by a surprisingly large subset of the population.  To ward off potential public health catastrophes we engage in draconian measures, including preventing school registration without proper vaccination.  In spite of this, lack of vaccination has caused a resurgence of diseases thought to be eliminated.  This begs the question: are the mandates working or could they actually be counterproductive?

Public Mistrust of Vaccination

Vaccination is the source of much public mistrust today.  No longer just an issue for fringe groups and religious objections, vaccination bashing has become embedded in popular culture through statements made by celebrities, most famously Jenny McCarthy.  Given that data shows vaccines to be incredibly safe and yet these groups still continue to gain followers, we should look at some of what animates them.

It seems easiest to connect the anti-vaccination movement’s beginnings with the now infamous study by Dr. Andrew Wakefield published in The Lancet in 1993.  A relatively small study, Wakefield concluded that the MMR vaccination caused damage to the intestinal system of growing children, which in turn resulted in more toxins getting into the blood stream, making them more susceptible to developing autism.[1],[2]  Ultimately the Wakefield study would be proven false, the connection between vaccines and autism thoroughly severed by science, and yet this idea remains an incredible concern for many, with some people going so far as to reanalyze CDC data to find a connection.[3]

The theory of dangerous vaccines gained even more traction when the CDC began looking into the possibility that thimerosal, the mercury-based preservative used in many vaccines, was linked to autism.  This potential danger appealed to common sense as well as scientific sense.  After all as Neal Halsey, one of the CDC proponents of removing thimerosal, reasoned: we are cautious about mercury levels in fish, doesn’t it make even more sense to be cautious about the levels in vaccines given to newborns and young children.[4]  Eventually thimerosal would be removed from vaccines, out of precaution, even though the scientific evidence was sparse regarding its effects, if any, on children.  But this resulted in a ripple effect of growing distrust against vaccines.  In turn, this would open the door for groups like the National Vaccine Information Center, an organization that claims to be neutral towards vaccines although it was founded by an anti-vaccination advocate and Generation Rescue, Jenny McCarthy’s charity, to gain credibility as experts on the national stage.[5]

Those with anti-vaccination beliefs are still very much a noticeable group.  Vaccination in some schools in California, for example, has dropped below 50%, with “Personal Belief Exemptions” sometimes outnumbering the number of vaccinated students.[6]  Yet something has to underlie this mistrust for it to continue to maintain a national presence.  I would suggest that the government mandates provide the backdrop which the anti-vaccination uses to gain traction in its fight.

Americans and their Freedom

Before beginning our discussion on vaccines specifically, it may be helpful to first discuss the importance of freedom for Americans.  Freedom, of course, is a broad and somewhat vague word.  When we speak of the American notion of freedom that is of interest here, we are referring to personal liberty, specifically civil liberty.  Civil liberty entails one being free from state interference, except, at the bare minimum, to ensure the public good. Consider as an example the recent pushback against the so-called “individual mandate” included in ACA.  Since the passage of the bill, there has been an outpouring of opposition towards it.  Some 27 states filed lawsuits seeking to have the mandate overturned on constitutional grounds, an argument eventually rejected by the Supreme Court, which declared the mandate a tax.  Ten states have passed various forms of legislation that attempt to overturn the mandate at the state level.  Two of these passed with crushing margins in public elections. One in Ohio passed with a double digit margin.[7],[8]  Similarly, an August 2011 poll of Americans showed that over 80% believed the government should not have this power.[9]  Regardless of one’s individual position on the matter, I think it could be argued it is not well received by the public.  But what does this tell us about perceptions of the government?  It tells us quite a lot.  It is not necessarily that these people are opposed to the idea of purchasing healthcare insurance or even of government helping to control health cost (statistically speaking, many of these people likely already purchase health insurance).  It is the very idea of government telling them that they must do something that seems to be the problem.

And so it may be with vaccines.  Simply put, it shows that Americans tend to reject what they see as an excessive reach of government which would repress autonomy, especially in issues of healthcare.  Thus we can begin to see that if vaccination is considered, at least by some, to be an overreach of government, the result can be distrust against it.

The Paradox

It should be noted that the intent is not to convince people at the far ends of the vaccine debate -- such a goal would be impossible anyway --  but rather to try to understand how one side, in this case the anti-vaccine groups, captures the minds of those in the middle.  Having said that, we can now see how the mandates might actually be counterproductive to encouraging widespread vaccination.

All conversations about the merits of vaccination must now take place against the backdrop of government mandates and power.  This allows members of the anti-vaccine movement to place these mandates in contrast with the American liberty narrative during any discussion, fostering distrust in government and convincing people of their cause.  Considered alone, the mandates might not cause much of a problem.  After all, they have existed for some time before vaccine rates started to decline, but we must also consider that we’ve developed what might be called “societal amnesia” with regards to many of these diseases. For my grandparents, concerns about polio saturated their lives, and yet many people from my generation have never even seen a polio victim beyond clips of Franklin Roosevelt.  This leads people to erroneously conclude the vaccines have no actual benefit, further reinforcing the idea of an overbearing government.  However, if the vaccine mandates were dropped, this would take away one of the key pillars of their argument. The movement would no longer be able to frame the debate in terms of a battle between personal autonomy and an overzealous government.

Of course the obvious potential fallout from such a maneuver would be that vaccines now have to stand (or fail) on their own merits.  However, not all hope is lost.  In eliminating the vaccine mandates, we will also have severed the connection between doctors and the state, at least to some extent. As such, the trust between the patient and physician, as well as the trust between medical science and society, can be allowed to grow without being poisoned by an overarching political discourse.

There is still a potential danger in rolling back vaccine mandates.  We risk a short term drop in vaccination.  But it’s not clear that this would be any worse than where we are now, with significant numbers of people opting out for dubious reasons, and old diseases (whooping cough, measles, etc.) making their rounds once again, even with mandates in place.

Tim Rubbelke is a PhD Candidate at the Saint Louis University Albert Gnaegi Center for Health Care Ethics. This essay was chosen as a finalist for the 2014-2015 Daniel Callahan Young Writer’s Prize. 

[1] Goldberg, R. (2010). Tabloid medicine : how the Internet is being used to hijack medical science for fear and profit. New York: Kaplan Publishing.
[2] Interestingly, this is not the actual conclusions of the paper, but it is how Wakefield portrayed them in his numerous interviews following the publishing the study.
[3] Expression of concern: measles-mumps-rubella vaccination timing and autism among young African American boys: a reanalysis of CDC data. (2014). Translational Neurodegeneration, 3(1), 18. doi: 10.1186/2047-9158-3-18
[4] (Goldberg, 2010)
[5] (Goldberg, 2010)
[6] California makes for an interesting case study because it is one of the few states in which the PBE’s allow for “philosophical” objections as well as the commonly held religion based objections.  The interpretation of PBE’s is broad allowing almost anyone to get a waiver.
[7]  Ohio Votes to Nullify Insurance Mandates. (2011, November 8).   Retrieved November 13, 2011, from
[8] Cannon, M. F. (2011, November 9). Ohio’s 2-1 vote against the individual mandate is a wholesale rejection of ObamaCare.   Retrieved November 13, 2011, from
[9] GfK Roper Public Affairs & Corporate Communications. (2011, August). The AP-National Constitution Center Poll. from

Thursday, February 19, 2015

DNR Ebola: Is there a professional obligation to provide treatment?

By Avigile Baehr

Overhead pages are a staple of a busy ER. They give doctors and nurses a couple extra minutes to prepare for the quick action needed to save patients’ lives after strokes, heart attacks, or trauma. Now, imagine a case today:

Attention, ER staff. A 32 year old female at high risk for Ebola is coming in via ambulance with fever, vomiting, and unstable vital signs. If you are willing to accept the personal risk inherent in providing medical care to this patient, please report to room 3. Otherwise, please disregard this announcement.

A conditional appeal, not an imperative. A qualification that seems to run counter to the oaths that medical professionals take. And yet, a stipulation that hospitals and healthcare providers have considered as they decide how and whether to engage with this deadly infection. Ebola poses a very real threat to providers: two nurses contracted the virus while caring for a patient in Dallas, and California nurses have gone on strike in response to lack of preparedness for safely dealing with the infection. Given the disease’s documented transmission to healthcare providers, its high fatality rate, and the lack of an FDA-approved treatment or vaccine, what are our professional obligations in caring for these patients?

The classic principles of medical ethics are autonomy, beneficence, justice, and nonmaleficence. For the purposes of the ‘obligation to treat’ dilemma, I will assume that Ebola patients want to receive treatment, and I will not consider the ethics of experimental treatments as they might relate to the ‘do no harm’ principle. The principles of beneficence and justice, however, are particularly salient to this question. Healthcare providers are not merely obligated to do no harm, but we must also do good by our patients. Despite the uncertainty regarding some experimental treatments for Ebola, timely supportive care is unquestionably beneficial for these patients. Intravenous fluids help prevent shock and organ failure. Breathing tubes can keep patients alive until the virus runs its course. In certain cases, CPR can restart a heart and give someone a chance to survive. Fair and equitable treatment of Ebola patients requires that they be treated by the same clinical standards that apply to any other critically ill patient. By these core principles, the ethical imperative to provide medical treatment to Ebola patients is clear.

What argument can be made, then, for refusing to provide comprehensive medical treatment to a patient with Ebola?

Perhaps providers are only obligated by these principles once they accept someone as a patient. Can a doctor or nurse then ethically refuse to engage in a provider-patient relationship with someone suffering from Ebola, thus freeing him or her of any obligation to treat?

In routine medical care, maybe or maybe not. Most states have specific clauses that allow providers to refuse to provide certain treatment, such as abortion care, on the basis of moral objections. But, both the law and medical professional societies uniquely distinguish emergency situations as obligating medical treatment without qualification. The Emergency Medical Treatment and Active Labor Act requires that all hospitals who offer emergency care services and who receive any Medicare funding (read: the vast majority of US hospitals) evaluate and stabilize any patient who seeks medical care. This law was designed to prevent hospitals from refusing to treat uninsured or underinsured patients, but it also serves to promote fairness and ameliorate other treatment disparities. Similarly, the American Medical Association Principles of Medical Ethics dictates that physicians should be free to choose the terms in which they agree to provide medical care, except in emergencies. By virtue of their agreement to serve as medical professionals, providers implicitly engage in a patient-provider relationship with anyone who seeks urgent care at their facility.

But, perhaps there should be an exception for personal risk. A similar dilemma with concern for provider safety arose in the early days of the HIV/AIDS epidemic, but both the American Medical Association and the American Dental Association explicitly reaffirmed the duty to treat. Both professional societies appealed to fairness, stating that a patient should not be subjected to discrimination based on any characteristic, including disease status. There is a utilitarian argument to be made in support of this personal risk exception: if a provider treats and subsequently contracts Ebola from one patient, then that provider’s other patients might suffer. However, in the United States, healthcare associated transmission of Ebola remains an incredibly rare event, and a utilitarian analysis does not fall in favor of refusing to treat Ebola patients. Two of the 170+ people who had direct or possible contact with the three Ebola patients from Dallas contracted the virus, and no healthcare provider has died from Ebola transmission in the United States. To put this number in context, an estimated one in ten healthcare workers experiences a needle stick each year, placing them at risk for blood borne pathogens such as HIV and Hepatitis C. Providing care for sick patients inherently carries a certain degree of risk, but so long as providers are able to mitigate that risk through personal protective equipment and standard precautions, this does not excuse them from their professional responsibilities.

In conclusion, the basic principles of medical ethics unequivocally support treatment of Ebola patients. Ebola patients can present in critical condition and require timely medical care, thus placing them in the category of a medical emergency and further obligating providers and hospitals to accept these patients for treatment. Personal risk might be an important consideration, but the risk of transmission can be appropriately mitigated through proper protective equipment in the United States. Ebola patient in room 3? That announcement will never sound routine, but we must treat even these patients fairly and by the highest standards of medical care. 

Avi is currently an MD/MBE candidate at the University of Pennsylvania. She graduated from Vanderbuilt University in 2011 with a degree in biology and philosophy. This post was chosen as a finalist for the 2014-2015 Daniel Callahan Young Writer’s Prize. 

Thursday, February 5, 2015

A Misguided Race to Solve the African American Kidney Access Problem

By Pooja Patel

“A renewed trust in inherent racial differences provides a convenient but false explanation for persistent inequities despite the end of de jure discrimination.”           - Dorothy Roberts

African Americans comprise 34% of the kidney transplant waiting list yet they are recipients of only 25% of cadaveric renal transplants and experience a wait time double that of their white counterparts (1;2).  The most popular explanation for this problem is a race-based human leukocyte antigen (HLA) differential.  HLA match is among the criteria used by the United Network for Organ Sharing to assign priority to kidney waiting list members (2).  Race-based HLA studies suggest that African American patients have distinct HLA patterns and are therefore best matched with African American donors (1).  Clinicians thereby mistakenly conclude that the issue of African American access to cadaveric kidneys is intimately tied up with their reluctance to become organ donors.

Using race-based HLA studies to explain the issue of African American access to cadaveric kidneys is problematic.  Race, a social construct, cannot be used to explain biological phenomenon like immunological difference (1).  The use of race in medicine stems from the common understanding that race accurately categorizes people who share distinct physical features.  The idea is that since physical features are genetically inherited, racial categories represent genetically distinct groups of people, thereby giving race a natural place in medicine.  In reality, however, racial boundaries are drawn along historical and sociopolitical lines.  In fact, studies have shown that the genetic difference between members of the same racial groups is comparable to the genetic difference between members of different racial groups (3). This alone disqualifies linkage between race and genetics. 

Race-based HLA studies operate under the same problematic assumptions of race-based medicine in general.  The fact that the researchers determine the race of the participants based on phenotype introduces social and cultural biases into the studies.  There is no scientific mechanism for determining whether an individual is black, white, or a member of any other racial group.  Therefore, clinicians rely only on socially prescribed ideas of what it means to be a member of a particular race phenotypically (1).  For example, conventionally, individuals who are identified as black typically have darker skin than individuals who are identified as white.  A clinician conducting a race-based HLA study must rely on this loose distinction alone when categorizing individuals in a study.  A lack of stringent criteria for differentiating between racial groups invites great potential for error. Further, the use of researchers’ beliefs to assign patient categories is a far cry from the principles of evidence-based medicine in which the scientific community takes immense pride. 

The results of these flawed studies incorrectly demonstrate that the HLA patterns found on the kidneys of white and black patients are significantly different (4).  This implies that a kidney coming from a white donor is unlikely to be a match for a black patient in need of a renal transplant.  Reliance on these studies provides a false but convenient explanation for the high wait times experienced by African American patients on transplant wait lists: because most donors in the registry are white, black ESRD patients are at a disadvantage in terms of organ access because there are not enough donors that are a good immunological match for them (1).    The solution that follows from this logic, then, is to put time and energy into convincing African Americans, who typically have a low organ donation rate, to become organ donors (5). 

However, the fact that African Americans are less likely to donate their organs has little to do with the kidney access problem in the community, demonstrated by long wait times.  This solution will not adequately address the kidney access problem, which likely has roots in social issues. It potentially exacerbates mistrust in the healthcare system based on a history of misinformation, which makes African Americans reluctant to donate in the first place.  It is an attempt to solve a problem deeply rooted in social issues without engaging social problems and relies instead on flawed data to effectively mislead African Americans into serving the needs of organ procurement agencies in the name of directly improving problems in their own communities.  This solution is problematic not because more African American organ donors would be a bad thing, but because it is being touted as a solution for a problem that it may not fix. 

Using race-based HLA studies as evidence for the assertion that increased African American organ donation rates will shorten wait times for African Americans will slow the process of achieving transplant equity.  The appeal to race-based HLA differences also places the burden on African American communities, instead of a potentially unjust healthcare system, for solving the problem of equity in transplant access.  Because race-based HLA studies are flawed, they cannot be used to explain the delays that African Americans experience in receiving cadaveric kidneys once on the wait list.  Thus, it is not certain that increased African American donors will decrease wait list times for African Americans, and it will take time before African American donor levels increase to appreciable levels that demonstrate whether they help with wait times or not.   

Organ procurement agencies use what is essentially propaganda to encourage minority organ donation, asserting that “all individuals waiting for an organ transplant will have a better chance of receiving one if there are large numbers of donors from their racial/ethnic background (6).” It is unfair and ineffective to attempt to change the attitudes of a community that has strong reservations about donating due to a historical mistrust in the healthcare system by ignoring this mistrust and using convenient but misinformed explanations instead.   Today, about thirty-eight percent of African Americans refuse to donate their organs (7).  The most alarming reason for this lack of enthusiasm that regularly appears in the literature is a mistrust of the medical community. 

The results of HLA studies are being used to make it seem as though increasing African American organ donation rates is the key to solving the kidney access problem.  However, like the reluctance of African Americans to become organ donors, the kidney access problem likely has deep social roots and is more complex than a simple case of supply and demand.  Although their intentions may be noble, organ procurement agencies are exploiting African American communities by using the results of race-based HLA studies in this way.  Efforts should be made, instead, to use well designed studies that investigate and address the social issues at the heart of both the kidney access problem and reluctance to donate in the African American community.  

Pooja is a recent graduate of Northwestern University, where she received a B.A. in English Literature.  Her research interests include the causes of health disparities among ethnic and racial groups and health issues pertaining to medically underserved populations. 

1. Gordon, EJ. (2002). What “race” cannot tell us about access to kidney transplantation. Cambridge Quarterly of Healthcare Ethics, 11.02, 134-41. 
2. Organ Procurement and Transplantation Network. (2014). OPTN Policies. Retrieved from
3. Krieger, N., Basset, M. (1986). The health of black folk: disease, class, ideology, in science. Monthly Review, 38.3, 74-85.
4. Mori, M., Beatty, PG., Graves, M., Boucher, KM., Milford, EL. (1997). Hla gene and haplotype frequencies in the North American population: the national marrow donor program donor registry. Transplantation, 64.7, 1017-027.
5. Kasiske, BL., Neylan, JF., Riggio, RR., Danovitch, GM., Kahana, L., et al. (1991). The effect of race on access and outcome in transplantation. New England Journal of Medicine, 324.5, 302-07.
6. U.S Department of Health and Human Services. (2014). Why Minority Donors are Needed. Retrieved from
7. Minniefield, WJ., Yang, J., Muti, P. (2001). Differences in attitudes toward organ donation among African Americans and whites in the United Sates. Journal of the National Medical Association. 93.10. 372-79.