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 http://www.tenthamendmentcenter.com/2011/11/08/ohio-votes-to-nullify-insurance-mandates/

[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 http://www.cato-at-liberty.org/ohios-2-1-vote-against-the-individual-mandate-is-a-wholesale-rejection-of-obamacare/

[9] GfK Roper Public Affairs & Corporate Communications. (2011, August). The AP-National Constitution Center Poll. from http://surveys.ap.org/data/GfK/AP-GfK%20Poll%20Aug%202011%20FINAL%20Topline_NCC_1st%20story.pdf

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.