Should childhood vaccination be mandatory? No
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2435 (Published 15 May 2012) Cite this as: BMJ 2012;344:e2435
All rapid responses
Sirs,
The definition of child abuse includes depriving children of adequate medical care, and exposing them to unnecessary dangers.
Surely this includes depriving a child of vaccination against a disease that could kill or permanently injure them?
It is about time we saw the first prosecution of parents in this country for child abuse for depriving their children of immunisation.
Paul Offit is correct: too much emphasis is given to the parents' rights, and not enough to the child's rights.
Competing interests: No competing interests
David M Salisbury argues against the introduction of mandatory vaccination in the UK and he suggests that compulsion is not necessary if the immunisation coverage is above a “sufficiently high” level.1
In 2008, the first author came to Scotland from Hungary hoping to learn lessons on communicable disease control to take back home, including undertaking a formal comparison of the two countries. In 2010 we published on the two countries' communicable disease control systems, including childhood vaccination.2 We showed that in 2007, vaccination coverage rates regarding MMR and DTPa were essentially 100% in Hungary, which was primarily due to the long-standing mandatory immunisation system there. In Scotland, the coverage rates of MMR and DTPa were 88.9-93.8% and 94.1-97.8% respectively. These rates can be considered reasonably high for a country with voluntary immunisation system, and surely above the “sufficiently high” level. Despite this relatively small gap in vaccination coverage, considerable differences in disease rates were seen between the two countries.
In 2007 the number of reported pertussis cases was 48 in Hungary and 98 in Scotland (0.5 vs 1.9 per 100,000 inhabitants). There were no notifications of rubella and measles, and only 16 cases of mumps in Hungary, whereas the Scottish numbers were 146 cases of rubella (incidence rate per 100,000: 2.8), 168 cases of measles (incidence rate: 3.3) and 2741 cases of mumps (incidence rate: 53.3). As the systems of notification, the collection of data, and the structures in place were very similar, we think it unlikely that these differences were merely statistical artefacts.
On this evidence, we believe that mandatory vaccination has significant advantages over the voluntary system, however, we also agree that its introduction in the UK would present serious challenges. Our comparison surprised us. There are lessons to be learnt from other countries, including on mandatory childhood vaccination.
References
1. Salisbury DM. Childhood vaccination: should it be mandatory? No. BMJ 2012;344:e2435
2. Stefler D, Bhopal R. Comparison of the Hungarian and Scottish communicable disease control systems: Lessons for a convergent European Community. Public Health 2010;124:167-173
Competing interests: No competing interests
Re: Should childhood vaccination be mandatory? No
Offit and Salisbury present the stereotypical (and opposing) opinions of US and UK vaccination policy. The US is a collection of 50 different states with very differing views and regulations about childhood vaccination, the main difference being how clearly the thresholds for “philosophical objection “ of parents are observed and enforced.
For decades, the UK approach has been one of mutual partnership and trust between parents and health professionals. Its undoubted success has relied heavily on parental education and ultimately professional respect for parental autonomy in making decisions in the Best Interest of children. However it remains an unresolved ethical question about whether parents have a duty to vaccinate their own children for the sake of others as well as themselves. (ref 1)
Once mutual trust and dialogue are lost, then children undoubtedly suffer. Children may be left unvaccinated due either to parents actively disagreeing with vaccinations (active refusers) or parents passively disenagaging from appropriate dialogue with health professionals (passive refusers). Whilst the damage done to public confidence by the MMR debacle is now slowly recovering, the issue of children left unvaccinated as part of neglectful care by their parents has not been fully addressed. (Ref 2).
The current UK childhood vaccination programme cannot differentiate between the two since it usually only records the dates and types of vaccination given, not reasons for delay or refusal. It is therefore suggested that the forthcoming NHS reforms are used as a vehicle for change from the current “Opt in” vaccination requirement to that of an “Opt out” requirement. Parents would be expected to vaccinate their children as and when appropriate. If they disagreed, there would be mechanisms for dialogue and recording of their refusal of vaccination. Parents who neither ensured that their children were vaccinated nor engaged in dialogue with health professionals would be regarded as neglectful. This would allow easier identification of children at risk of neglect whilst respecting the wishes and autonomy of parents actively opposed to vaccination. (ref 3). Coercion should not be part of this as it leads to ideological opposition and manipulation of information in a damaging, negative way. (Ref 4)
I thus agree with Salisbury in his final conclusions but feel that more should be done to protect unvaccinated and neglected children in the UK.
1. O’Neill O. “Some limits of informed consent”. Journal of ME 2003;29:4-7.
2. Nuffield Council for Bioethics. “Public health : Ethical issues”. November 2007.
3. NICE. “Reducing the differences in the uptake of vaccinations.” September 2009.
4. Beauchamp & Childress. Principles of Biomedical Ethics. 2006. 6th ed, OUP.
Competing interests: No competing interests