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Head To Head

Should childhood vaccination be mandatory? Yes

BMJ 2012; 344 doi: (Published 15 May 2012) Cite this as: BMJ 2012;344:e2434
  1. Paul A Offit, chief of infectious diseases
  1. 1Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
  1. offit{at}

Paul Offit believes that mandatory vaccination is needed to protect vulnerable people from infection, but David Salisbury (doi:10.1136/bmj.e2435) argues that there are more workable ways to ensure high uptake

In a better world, vaccine mandates wouldn’t be necessary. Parents would educate themselves about the diseases that vaccines prevent and learn that measles causes pneumonia and brain damage, mumps causes deafness and sterility, rubella causes severe birth defects, pertussis causes suffocation, and human papillomavirus (HPV) causes cervical, oropharyngeal, and anal cancers. They would learn about the remarkable safety and effectiveness of vaccines. And they would learn that although vaccines are not free of risk, their benefits clearly outweigh their risks. Mostly, they would learn that vaccines stand on a mountain of scientific evidence. Well informed: the choice to vaccinate their children would be an easy one.

Unfortunately, we don’t live in that world. In our world, science based information is often obscured by false and misleading claims readily available in newspaper and magazine articles, on radio and television shows, and on the internet. Parents hear that the measles, mumps, and rubella (MMR) vaccine causes autism; that pertussis vaccine causes brain damage; and that HPV vaccine causes blood clots, strokes, heart attacks, epilepsy, mental retardation, and chronic fatigue syndrome. As a consequence, some parents make bad decisions based on bad information.

In 1977, Luther Bohanon, a federal judge in Oklahoma, ruled on the right of a man with a malignant intestinal polyp to use a bogus cancer remedy called Laetrile. “Freedom of choice,” he wrote, “necessarily includes freedom to make a wrong choice.”1 Children, however, are different; they don’t make their own medical choices, sometimes with tragic consequences. For example, children have died needlessly because their parents chose homeopathic asthma remedies instead of bronchodilators, bogus cancer cures instead of chemotherapy, or prayer instead of insulin or antibiotics.2 3 4 Parents are virtually never held accountable for these choices. When it comes to resolving the conflict between a parent’s right to make medical decisions and a state’s right to protect its children, parents’ rights always win.

Wider implications

Vaccines pose an additional problem. When parents choose not to vaccinate, they are also making a choice for those with whom their children come in contact. This includes people who can’t be vaccinated, such as children who are too young to receive vaccines and people receiving chemotherapy or immunosuppressive drugs. These people depend on those around them to be protected (that is, herd immunity); otherwise, they’re the ones most likely to suffer. Now the question changes. Is it a parent’s right to make decisions that affect the health of others? In 1991, the city of Philadelphia suffered a measles epidemic that centred on two fundamentalist churches that had chosen not to vaccinate their children. Hundreds, mostly churchgoers, were infected and six died.5 Was it the inalienable right of church members to catch and transmit a potentially fatal infection? Which is paramount: the freedom to make bad health decisions or the right of the community to protect itself from those decisions?

In the United States, mandatory vaccination clearly increases uptake; several studies showed that states or districts that allow philosophical exemptions to mandated vaccines have higher rates of vaccine preventable diseases.6 7 8 9 Further evidence for the value of mandates can be found in the events immediately after promotion of the false belief that the MMR vaccine caused autism. In 1998, the year the fear about autism was raised, there were 56 measles cases in the United Kingdom and no deaths; in 2008, there were 1348 cases and two confirmed deaths.10 Although concerns about MMR vaccine spread, the United States didn’t suffer a measles epidemic. False concerns about measles vaccine haven’t disappeared. From January to October 2011, the World Health Organization’s European region—containing countries that don’t mandate vaccines—suffered a measles epidemic that affected 26 000 citizens, causing more than 7000 hospital admissions and nine deaths; in 2009, the European region reported about 6000 cases.11 In the United States, on the other hand, only about 200 people were infected with measles and none died; most measles cases in the United States in 2011 were linked to European travel.12

Someday we may live in a world that doesn’t scare parents into making bad health decisions. Until then, vaccine mandates are the best way to ensure protection from illnesses that have caused so much needless suffering and death.


Cite this as: BMJ 2012;344:e2434


  • Competing interests: The author has completed the ICJME unified disclosure form at (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; PAO is the coinventor and copatent holder of the rotavirus vaccine, RotaTeq, licensed by the FDA in 2006 and recommended for universal use in children by the CDC and WHO, but no longer receives royalties from this vaccine.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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