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June 21, 2019

Preserving Civility in Vaccine Policy Discourse: A Way Forward

Author Affiliations
  • 1Mayo Vaccine Research Group, Mayo Clinic, Rochester, Minnesota
  • 2Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
  • 3Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
  • 4Department of Pediatrics, University of Washington, Seattle
JAMA. 2019;322(3):209-210. doi:10.1001/jama.2019.7445

Vaccine policy-making meetings, advisory committees, and legislative hearings at the local, state, and national levels have become increasingly uncivil. Many who object to vaccines have resorted to shouting, threats, and other disruptive behaviors.1 These behaviors erode the premise of civil society and undermine the goals of most vaccine-hesitant persons, who are thoughtful and law abiding. Civil skepticism in public discussions about vaccine policy can lead to productive discussion. The science of vaccinology, like all science, has uncertainties; applying science in policy entails value judgments, and people can disagree on the implications of scientific evidence. Skepticism reminds all individuals that intellectual humility is important and reinforces the value of democratic debate and transparent procedure.

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    4 Comments for this article
    Speaking OF Values, But Not ABOUT Values.
    Bryan Kaufman, MD | Withheld due to likelihood of biased repercussions by zealots of one form or another.
    A glaringly absent point in the otherwise well-framed discussion is the topic of paternalism in medicine. There is always a patient's right of refusal-of-treatment to consider, regardless of whether the choice is wise. Thus we are brought head-long into the real unspoken difficulty of when does the society have the right, or even the obligation, to coerce an individual to comply with treatment against their wishes. In communist societies, this is not an issue. It is, however, a core issue, albeit not spoken aloud recently, in real democratic republics where individual rights are not merely paid lip service. These are the values that must be resolved across the spectrum. And I submit that there are few in politics, law, medicine or media who are equipped to wrestle with these core issues. I whole-heartedly agree with the authors that a real dialogue, absent the diatribes, ad hominems, obvious fixated beliefs, and one-sided agendas is sorely needed. But, until the real issues can be brought out on the table and reconciled in a coherent fashion, no progress will be made.
    Maybe Paternalism is a Necessary Evil
    Mark Pickin, MB ChB | Retired Physician, York, UK
    Paternalism in medicine is something we need to think about. "The doctor knows best" has become difficult in our correct and emancipated 21st century society and we instinctively back away and allow our patients the right to unscientific opinion.

    The problem is, the doctor should know best. The doctor has been to medical school, studied for endless postgraduate diplomas and a lifetime of CME. The patient has read one article online or, God forbid, in the Daily Mail. There is also the problem of disease beliefs. When a patient is trying to understand some disease, vaccination, or whatever, they
    do that on some form of personal construct of bodily function, and those constructs are rarely based on science or anything that a doctor might recognize and impossible to correct without a degree course in the medical sciences. But then, even some doctors have some very strange beliefs.

    We have eliminated smallpox and polio and, very nearly, measles but, due to a combination of acquiescence and cupidity, we are allowing them to return, to kill and to maim. I think we have a responsibility to say that, in this case, we do know best and the politicians need to have the guts to back us up. The herd needs to be protected: eliminate the disease completely and then immunization does cease to be necessary.
    Healthcare Reform
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. Retired
    Putting aside the Social Dilemma issues for each person regarding our nation's immunization policies, it is unlikely that the measles or influenza prevention issues for our nation are resolvable. As compared to the other OECD nations, the USA does not offer universal healthcare insurance to its citizens, and we have no strategy to assure that enhanced primary care is equitably available to each citizen within every community. Thus, even with a disaster-declared emergency, we have no means to manage the associated social dilemma issues related to real or predictable epidemics.

    Remember, disaster preparedness has a 4 to
    1, return on investment ratio. Just for reference, the ROI for early childhood education is 7:1 . Eleanor Roosevelt said: "It's better for every body when it gets better for everybody." And, a social dilemma may be defined as a situation involving a group of 2 more persons that occurs as a collective action situation for which each of the persons must make their own decision as to whether or not they will acquire a short-term benefit for themselves or  forego the short-term benefit for the long-term benefit of the entire group of persons participating in the situation. Further definitions for social capital and social cohesion would apply as well. I agree, a pervasive level of paradigm paralysis exists. Its eventual resolution will require new levels of trust, cooperation and reciprocity, community by community.
    Not Primarily a Question of Paternalism
    Dena Davis, JD, PhD | Lehigh University
    This is not primarily a question of paternalism. The main concern is that unvaccinated people will be a source of contagion to others. Therefore, requiring them to be vaccinated would not be primarily "for their own good," which is the core of paternalism.

    Even where children are concerned, the state would be requiring parents to do something to their children (have them vaccinated). Even if that were primarily for those children's own good, it would still not be paternalism, because it would be forcing parents to do something for their children's good, not for
    their own good.