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October 25, 2000

Effects and Ethics of Sanctions on Childhood Immunization Rates

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorPhil B.FontanarosaMD, Executive Deputy EditorIndividualAuthor

JAMA. 2000;284(16):2056-2057. doi:10.1001/jama.284.16.2053

To the Editor: In their Commentary, Drs Davis and Lantos1 make a common mistake when they state that, "the PIP improved immunization rates" may have produced "untoward effects." They attribute these effects and "ethical problems involved in policy evaluation" to the evaluation rather than to the policy itself. In Georgia, it was the coercive statewide policy that improved immunization rates and may have had adverse effects. By adding a small temporarily exempt control group, the PIP2 merely increased the ethical quality of an otherwise uncontrolled, potentially unethical statewide policy experiment. When an agency laudably uses a randomized delayed control group to make a policy's effectiveness (or ineffectiveness) more measurable, it also makes other aspects of the policy, such as coercion and adverse effects, more evident. The challenge for ethicists, researchers, clinicians, and policy makers is to find ways to increase the linkage of policies to evidence, including ethics-related evidence. This can be better achieved by praising randomized policy trials for increasing visibility of ethical issues than by criticizing them for ethical aspects of the policies they are evaluating.

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