Viewpoint Expert opinions on trends and controversies in autism research.
IIlustration by Jun Cen
Opinion / Viewpoint

Vaccination: Costly clash between autonomy, public health

by ,  /  15 August 2017
The Experts:

Ruth Fischbach

Professor, Columbia University

John Loike

Adjunct professor, Columbia University

Listen to this story:

In the United States, 117 people from 13 states contracted measles between 1 January and 15 July of this year, according to the Centers for Disease Control and Prevention (CDC). In the same time period, 45 states and the District of Columbia reported 3,886 mumps infections. In 2015, there were 20,762 reported cases of pertussis, or whooping cough, in the country. Pertussis infections are on the rise in many states, prompting a call to vaccinate. For instance, pertussis cases doubled in Indiana from 2016 to 2017 and included one fatality.

Each of these numbers is alarming, because if all children were vaccinated, the number of cases of these infectious diseases would drop dramatically. Studies estimate that vaccines save about 42,000 lives each year in the U.S., and $13.5 billion in direct medical costs.

If vaccinations are so effective, why do thousands of parents refuse to vaccinate their children?

In a survey conducted in 2013, 87 percent of pediatricians in the U.S. said they encountered parents refusing to vaccinate their children. And about 6 percent of all kindergarteners in the U.S. have not received at least one essential vaccination. Equally important and worrisome is that although most physicians continue to provide care to families whose children are unvaccinated, physicians are increasingly choosing to dismiss these families from their practices.

The failure of parents to vaccinate themselves and especially their children jeopardizes the health of their children as well as other children and adults.

We propose that doctors and hospitals institute measures that protect people in their practices, rather than refusing to treat anyone. And we believe that all states should require that children be vaccinated before attending school.

Unfounded fears:

Many parents cling to multiple false claims and beliefs when deciding whether to vaccinate their children, and many are no longer willing to take the word of their physician.

For example, some parents fear that vaccinations increase the risk of autism, a belief that is based on false data and continues to spread through social media. Others believe that vaccines are ineffective or that they can cause attention deficit hyperactivity disorder, ear infections and allergies. Still others believe that unvaccinated children are healthier than vaccinated children.

In addition, in the 2013 survey, parents reported that vaccinations are unnecessary because the diseases they prevent have been wiped out in the U.S. When parents have not seen these diseases in many years, they become complacent.

Furthermore, some parents are calling for more long-term clinical studies to assess the health risks of vaccinations. Ethicists caution that such studies are unethical because half of the volunteers would receive the vaccine and half would receive no vaccination, placing half of the volunteers at risk.

Are there health risks associated with vaccinations? Yes. Children have had allergic reactions to vaccines — which is why all parents must sign a statement that, to the best of their knowledge, their child is not allergic to eggs or other products contained in the vaccine. These reactions are rare, however. The CDC reports that only about 1.3 percent of children and 0.2 percent of adults are allergic to eggs.

Importantly, no reported risks of vaccinations are associated with autism. (British researcher Andrew Wakefield’s original paper in The Lancet linking vaccinations to autism has been shown to be a complete fabrication. The paper was retracted and Wakefield’s medical license has been revoked.) Children whose mothers were infected with a flu virus or who received their flu shot while pregnant are also no more likely to develop autism than other children, according to a study published in January that looked at more than 196,000 children1. Many other studies support this finding.

Unethical exemptions:

All 50 states provide medical exemptions to vaccination for the few individuals who are at risk of an allergic reaction. What is ethically challenging, however, is that 47 states allow parents to use either religious exemptions or personal-belief exemptions to avoid vaccinating their children. These exemptions highlight three bioethical principles that are, in this case, in conflict.

The first principle, autonomy, allows parents, as the decision makers for their children, to exercise their autonomy or self-determination to accept or refuse medical intervention. Many parents believe vaccination is a private affair, not a public-health responsibility. The second principle, beneficence and its partner, non-maleficence, states that medical actions should provide good and not harmful outcomes. The third principle, justice, is seen when public-health experts look at the potential benefits for a whole population, whereas many parents focus only on what they think is good for their child.

Fortunately, there are dilemmas in bioethics, such as whether to vaccinate children, when the solution is absolutely clear.

Vaccination is particularly critical because of the ‘herd effect,’ also called ‘herd immunity,’ among other terms2. This is a form of indirect protection from infectious disease that occurs when a large percentage of a population has become immune to an infection, providing a measure of protection for individuals who are not immune. When enough people refuse to vaccinate, protection for the vulnerable is in jeopardy.

So it is imperative that state laws mandate that, except for medical reasons, all children have up-to-date vaccines before they are allowed to attend school. In the past year, at least seven states have tried to pass bills with a provision requiring children to be vaccinated before attending school. We propose that the remaining states follow suit.

Australia may serve as a model. In July, the state of South Australia proposed legislation that would ban unvaccinated children from preschool and childcare centers. The idea follows a federal law that punishes parents of unvaccinated children with fines and loss of government benefits.

Separate clinics:

The refusal of some pediatricians to accept unvaccinated children into their practice has some theoretical ethical merit. These doctors do not want to expose people in their waiting room to an unvaccinated child who harbors an infectious disease. We argue, however, that refusing to treat anyone violates the ethical code of doctors to care for all sick individuals.

Recognizing the health risks of caring for an unvaccinated child in an office setting, we propose that private physicians set up exclusive times to provide medical care for unvaccinated individuals. Further, we propose that hospitals set up special clinics with enhanced protections to provide healthcare to people who are not vaccinated. These protections might include heightened infection-control measures and staff who have been specially trained in containing infectious disease.

In both situations, professionals should be available to educate parents about the benefits of vaccination and the risks of not being vaccinated.

Vaccines are among the most effective methods to control, if not eliminate, serious infectious diseases. The almost complete eradication of polio and smallpox are examples of their incredible value. They also have a record of success in preventing chickenpox, measles and pertussis.

As bioethicists, we appreciate the need to institute laws and educational programs to ensure that all individuals at risk are vaccinated. We trust that the CDC and public-health authorities will continue to rebut the erroneous associations linking vaccination to autism and other health conditions, that regularly appear on social media and in movies such as “Vaxxed.” Science has shown that vaccinations not only protect our current generation but future generations as well.

Ruth Fischbach is co-founder and former director of the Center for Bioethics and professor of bioethics at Columbia University. John Loike is adjunct professor of pathology at Columbia University and professor of biology at Touro College in New York City.

  1. Zerbo O. et al. JAMA Pediatr. 171, e163609 (2017) PubMed
  2. Fine P. et al. Clin. Infect. Dis. 52, 911-916 (2011) PubMed
TAGS:   autism, community, ethics, policy

9 responses to “Vaccination: Costly clash between autonomy, public health”

  1. Ethyl says:

    Parents associate vaccinations with autism because so many autistic kids have had serious reactions to vaccines. Take for instance, children with Dravet’s syndrome. The WHO states that 1 in 4 (27%) are likely to have a serious reaction to vaccines which is thousands of times more likely than their typical peers. Children with Epilepsy are 6 times more likely…even family members are 3x’s more likely. Science would not have to work so hard to save the 99% who have no serious reaction to vaccines if they would just give a little attention to the 1% who do. Half of these kids already get medical dispensations because of Immune deficiencies. What about the other half whose sensitivity has not yet been determined?

    Yes, vaccines are medical miracles, and have saved millions of lives. But if your child is the one in 99% who have a severe reaction…it may be a coincidence, or it may not. We don’t really try to determine why kids have reactions. And we say there is no problem, when in all actuality, no long term studies have been done.

    Autistic parents have always been given the short stick by science before. The squeaky wheel is the one that gets the grease.

  2. Claire Cameron says:

    Hi there, thanks for taking the time to read this Viewpoint. We’d like to take this opportunity to remind everyone of our comments policy, which is accessible in full here:

    Briefly, they are:
    – Stay on-topic
    – Stick to the science
    – Be brief
    – Be polite

    Comments that contravene the policy will be moderated and may be deleted. We ask that you familiarize yourself with it before commenting.

    Thank you for your help in maintaining our comment forum as a safe and inclusive debate space. If you have questions about the comments policy, please feel free to email

  3. Beth Clarkson says:

    Mandating vaccination in order to attend school places the societal benefit of vaccinating that child above the societal benefit of educating that child. I think it’s more important to ensure that every child has access to education.

  4. Minority View says:

    Mumps. You left out the lawsuit by two former Merck employees, suing Merck for faking the efficacy of the mumps vaccine. Pertussis. You left out the fact that the vaccine doesn’t prevent carriage or transmission of the illness. You can’t get to herd immunity with a vaccine where vaccinated people can carry and transmit the illness. You just can’t.

    And the measles vaccine does work to some extent, but it is only available as the highly reactive MMR. There would be more people vaccinating against measles if they could access the single measles vaccine rather than the triple (or even the quadruple MMRV, even more reactive than the MMR), but no, it is all three or nothing.

    Who makes vaccine policy? What a mess!

  5. Vacunas Autismo says:

    Who writes these stupid, misinformed articles, anyway? I’m sick of them.

  6. Katie Wright says:

    These articles remind me of someone’s old grandfather complaining about rick music. @Spectrum u must listen more and lecture less. Instead of posting the same “anyone who doubts vaccination safety is a tinfoil hat wearing nut who threatens every American’s health,” article 10x, try talking wthe community you so often malign.

    Clearly people are not convinced of anything by these posts except that you are out of touch. There is no big “anti vac” movement. There IS a community of families who saw their infants and toddlers have severe adverse reactions. This is not a joke. Wishing these children away or hectoring their parents isn’t the solution. We want independent safety research and research into adverse reactions. No one should be threatened by that.

    • bpatient says:

      “There IS a community of families who saw their infants and toddlers have severe adverse reactions.”

      That “community of families” will someday understand that their childrens “severe adverse reactions” to postnatal vaccines were symptoms of their underlying pathology rather than the cause. Rapidly accumulating evidence strongly supports the idea that autism begins in the womb. The “vaccines caused an epidemic of autism” meme is still dead.

  7. Elizabeth Marling says:

    I had a very bad reaction to immunization as a child, specifically the rubella vaccine.

    I am now an adult with ASD.

    I still fully believe that the benefits far outweigh the risks of immunizing our children. The evidence that the two statements here reflect causation and not coincidence is purely anecdotal. Not one shred of scientific evidence supports the theory that vaccines cause autism.

    My reason for posting a comment at all is that I am a real person who has every justification to fall prey to pop culture paranoia given my own life history. Yet I choose to be reasonable and responsible for myself and my community. Children without immunizations against crippling diseases are being potentially endangered by their parents of physical disfigurement and permanent health damage. The disease which we immunize against was chosen because it is so debilitating to the affected person’s overall health for their entire life. These are not diseases that one simply recovers from; they cause anything from deformity to physical impairment/disability to death.

    This article is not outdated. it is needed more than ever. My life is happy and productive as a person on the Spectrum. I certainly would not be able to say the same had I been crippled by polio or smallpox. The assumption that autism is worse than the diseases one may contract if not immunized is in itself flawed and reflects a deep ignorance that is inappropriate for anyone claiming to be an advocate for affected individuals.

Leave a Reply

Your email address will not be published. Required fields are marked *