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. <http://www.cdc.gov/measles/vaccination.html>.

² "Measles Cases and Outbreaks." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 14 Feb. 2015. Web. 14 Feb. 2015. <http://www.cdc.gov/measles/cases-outbreaks.html>.

⁴ Caplan, Arthur. "There Is No Other Side to the Vaccine Debate." Chicagotribune.com. 13 Feb. 2015. Web. 14 Feb. 2015. <http://www.chicagotribune.com/news/opinion/commentary/ct-measles-vaccine-jenny-mccarthy-autism-ebola-perspec-0213-jm-20150212-story.html>.

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. 

Medical Doctors Should Remain "Medical" Doctors

By Naomi Scheinerman

Earlier this year, Britain’s Faculty of Sexual and Reproductive Health, a faculty of the Royal College of Obstetricians and Gynaecologists (RCOG), issued guidelines establishing that the faculty’s Diploma qualifications include a “willingness to prescribe all forms of hormonal contraception, including emergency contraception, regardless of personal beliefs.” Though welcome to undergo the training, those who “hold moral or religious reservations about any contraceptive method,” will not be able to “complete the syllabus [rendering] candidates ineligible for the award of FSRH Diploma” - a legal requirement to practice obstetrics and gynecology in England. Though clinicians may abstain from both performing and counseling regarding abortions, they are required to provide full information on options for unplanned pregnancy and make “timely arrangements” for the patient to see a doctor who is comfortable counseling on abortions.

In this post, I will address three questions: Does the Faculty have the authority to issue guidelines on this matter? If so, are these the correct guidelines to issue? And should we make exemptions to those who hold conscientious objections for religious reasons?

Does the Faculty have the authority to issue guidelines on this matter?

The medical world offers numerous examples of authoritative bodies passing rules of ethical and appropriate treatment. For example, guidelines have codified that informed consent must be acquired from a patient undergoing a medical procedure or participating in a clinical drug trial. Another example: U.S. federal law (HIPPA) protects a patient’s privacy of personal health information such that doctors may not share information with others without the patient’s permission. The authority of the Faculty to issue program guidelines regarding its training is perfectly consistent with our expectations that the medical community governs practitioners’ medicine to ensure ethical and safe care. Medical care cannot be divorced from value judgments, and thus medical training must be considered alongside medical decision making.

Is requiring willingness to prescribe contraception an acceptable use of the Faculty’s power to dictate appropriate medical practice?

I argue that the job of prescribing birth control has become a central part of the job of a gynecologist, and it should be for a number of reasons. Birth control is an ethical and safe option. Women have the right to control their reproduction, and doctors therefore have an obligation to provide access to the means to do so. Patients do not have unlimited rights to services from their doctor - a doctor could and should refuse to operate on an individual who does not need to be operated on. Contraceptive access, in contrast, is not an extravagance, but rather is an important tenant of women’s health. More than just allowing her to regulate her period and perhaps mitigate the negative and uncomfortable experiences of her “natural” cycle, contraception allows women to practice family planning, which has far reaching implications for her overall wellbeing by affecting her job, income, relationships, social network, and status. These results may also be beneficial for her family relations and friendships, as well as, of course, the wellbeing of a child from a pregnancy she neither planned nor wanted. Furthermore, denying a woman access to birth control denies her valid medical desires. Granted, what constitutes a medical necessity is illusive: ultimately numerous medical and nonmedical treatments lead to better welfare and happiness, but it seems strange to classify them all as necessary. However, because birth control affects the body chemically and hormonally, it should be classified under the purview of medicine, and therefore falls within the medical profession.

Should we make exceptions for conscientious objectors, particularly religious conscience objectors?

Just as a conscientious objector to informed consent should be barred from conducting clinical trials, so too should a gynecologist who refuses birth control to women. First, the merits of an argument for conscientious objections must be evaluated, regardless of whether it is religious or nonreligious. One of the primary arguments against contraception is that they are akin to abortions and therefore immoral. This argument is invalid because it relies on a false claim: contraception prevents pregnancy, it does not terminate it. Take for example the anti-vaccine movement: when deciding whether to allow doctors to refuse to vaccinate children, we should only give weight to arguments that are based on scientific claims regarding the safety of vaccines.

Another argument given against contraception is that it increases the rate of casual sex, in particular sex out of wedlock. First, this is a faulty understanding of statistics: access to birth control neither increases nor decreases rates of sexual intercourse, but instead makes it safer. A similar argument was made in the case against the HPV vaccine trials: developing a vaccine that protects against certain kinds of cervical cancers would make girls more promiscuous. This value-loaded claim attempted to maliciously bar an important way to increase sex safety for women and was then proved to be factually incorrect. Even if contraception did increase the rates of sex, either before or after marriage, the argument must prove why this is negative.

Religious reasoning should be scrutinized as vigorously as nonreligious reasoning. For example, the value of having a family is often cited in opposition to contraceptive use by referring to religious texts. However, one could just as easily interpret the value of family in another way: birth control allows women (and their partners) to choose when to have a family, thereby making a more secure, safe, and well-off household. Religious preferences in the medical world should be tolerated only if they do not harm the patient’s welfare. Denial of birth control can and does cause such harm. Religious objectors claim that a patient could see a different doctor, but there are many examples in which this is unfeasible. For instance, a young teenager who wants to become sexually active and is hiding her doctor’s visit from her parents may not simply be able to switch physicians or may be too intimidated to try after being driven off the first time.

The Faculty’s rules are not only permissible, they are imperative for women’s health. They do not suggest that all women should seek birth control or will, nor do they demand that all gynecologists prescribe birth control to all women. Ultimately, the Faculty’s rules are valid because they demand that doctors provide ethically valid and vital medical options to their patients.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.

Thinking Ahead, Preventing Tragedy

By: Mohini Banerjee

When natural disasters become central to bioethics discussions, it usually invokes a public health lens. Furthermore, the ethics involved concern disaster response, otherwise known as the aftermath. As detailed in Sheri Fink’s Five Days At Memorial, ethical quandaries arose when they were unable to evacuate certain patients from a flooded hospital. Health care professionals faced the demand to both create and execute a moral equation determining who could survive if moved and who would most likely survive. In the midst of Hurricane Katrina’s wrath, some doctors euthanized patients that could not be evacuated, saving them from languishing in agony as their machines failed. These physicians had some ethics training, but nothing that could have prepared them for that situation.

If we had to make difficult decisions in the midst of a disaster, what would we choose? During Hurricane Katrina many also took to the streets to find food and services when no help came. This led to horrific police and civilian violence. The racial and socio-economic implications of the fallout in the Gulf states only add to the tragedy. Although there are immense problems with the response to Katrina, we must also consider disaster preparedness. Foresight and energy could preempt and thus mitigate many of the worst disaster outcomes.

One difficulty in the ethics of disasters, as opposed to issues that arise in clinical settings, is that one cannot assume a controlled environment. There is no time to consult an ethics board, family members, or the courts. Disaster situations involve technological and communication failure on massive scales, such as falling telephone lines and power outages. Health care professionals also grapple with their own safety in ways foreign to most instances of medical care. For example, as Fink outlines in her book, many of the doctors at Memorial struggled with dehydration and injuries themselves from the hospital conditions. Lastly, national and state-based plans often cannot be implemented on the local level, lacking a detailed understanding of the community’s needs. For all these reasons, work done ahead of time could insure fairer outcomes in the aftermath.

Disaster preparedness is not a new phenomenon, and it would be foolhardy to dismiss the long efforts to mitigate ensuing chaos. Yet, in the world of ethics, how we prepare is less discussed than what happens when the chaos is in full force. What I suggest is a closer look at the methods for protecting ourselves and our communities when the unimaginable hits. The principles that govern disaster response, such as the responsibility to provide each person with life-saving care and protection, will only go so far. Since disasters often undermine the infrastructure facilitating medical care, evacuation, or housing, it is especially important to implement community-based initiatives to meet these needs.

The San Francisco partnership, established by Mayor Edwin M. Lee this past summer, epitomizes a community ethic in disaster preparation. It is a coalition between the Department of Emergency Management and Bayshare, a collection of sharing economy organizations. The partnership insures that during disasters people could use sharing economy mechanisms for free. Services include Lyft, a ride-share service that would transport emergency medical care and basic supplies. Another is the room rental scheme, Airbnb, which provides housing for people with nowhere to go. Providing these services in a disaster’s fallout would use the community’s resources to help itself. The San Francisco model demonstrates how members of the local community could use their resources to aid one another.

Although internationally recognized ethics standards for disaster response exist, preparedness is seldom discussed considering equality or fairness. Oftentimes preparing for disasters is left to the government or to the individual, such that those with less lose out. Further, the obligations of individual families extend beyond themselves and complying with the government’s safety measures. Strategies, such as San Francisco’s, which distribute much needed and underutilized resources facilitate a community’s ability to help itself.

It is not only preferable, but ethically necessary, to have a system in place that ensures sharing resources. Governmental bodies should not be the sole providers of resource planning. Community members understand best what is available locally and are situated to help first responders prevent harms within a chaotic situation. While each person will first provide for her own family’s safety, the next considerations should extend to those in one’s proximity. Preparing as a community will help foster social cohesion, which again feeds back to those difficult decisions. Gaining more responsibility for ourselves and for those around us can avert the desperation that so many have already suffered.  

Mohini graduated from Smith College in May 2013 and is a research assistant at The Hastings Center, an independent non-profit research institute in bioethics. She founded Bioethx Under 25 in January and acts as Editor in Chief. For interest in the blog please email her at bioethicsunder25@gmail.com.