Personal Belief Exemptions for Vaccines: What Is Just?

Abstract

Parental refusal or delay in vaccination of their children has become a vexing problem for many pediatric health care providers and has led to communicable disease outbreaks in the United States and Europe. Personal belief exemptions allow parents to opt out of having their children receive vaccinations required for school or child care entry. Personal belief exemptions can be based on religious beliefs or political ideology. There are also “self-interest maximizers” who choose for their child to benefit from herd immunity without incurring the risks of vaccination.Tension arises when parents, in the interest of preserving their individual freedom to decide what they believe to be best for their children, choose against the common good. Two groups of ethicists have recently weighed in on this issue.1,2Lantos, Jackson, and Harrison argue that personal belief exemptions should not be allowed on the basis that vaccines are very safe and have far fewer risks than the diseases they prevent.1 They assert that vaccination of individual children also has the benefit of promoting herd immunity. These authors affirm that personal belief exemptions put both the individual child and the public at increased risk. They recommend eliminating personal belief exemptions to vaccine mandates when a disease is potentially deadly, occurs during childhood, and there is a safe and effective vaccine.Opel and Diekema agree that vaccines are safe, efficient, protect the individual as well as the community, and that a link exists between exemptors and the transmission of disease.2 They argue, on the basis of both health policy and morality, that a just vaccine policy need not forbid parents from exercising their personal belief exemptions. The authors believe a ban would, perversely, make parents resist even more. Instead, they recommend making personal belief exceptions more difficult to obtain, by adding the additional step of requiring a conference with a child’s physician before an exemption is granted. Opel and Diekema also recommend financial incentives such as a decrease in insurance rates and/or state rebates for receiving vaccines and the removal of financial barriers by establishment of a publicly funded immunization program with no individual out-of-pocket cost.Society recognizes that parents are their children’s principal caretakers, responsible for their well-being, with a wide range of discretion as to what that well-being will include. In most cases, fully informed parents are the best decision-makers for their children. At the same time, parents are morally and legally obligated to observe certain standards in the decisions they make for their children.Must individual freedom be restricted? What is the just decision? The tenets of patient/family-centered care demand substantial and sometimes difficult effort by physicians to engage parents as partners in medical decision-making for their children. Complete and accurate information on the risks and benefits of vaccination to their child and for the community must be provided, with empathetic persuasion, cultural sensitivity, and an effort to reconcile with dissenting parents.The decision to vaccinate or not should not be made by parents in isolation; pediatricians and others providing health care to children must do their best to ensure that it is a fully informed decision. Society ought not supersede the authority of the fit parent. A ban on personal exemptions would be considered coercive by many. Financial incentives could be helpful, although they may not sway the decision of many parents. This is not a cost issue, but a battle fought best by earned trust and relationship, not legal mandates.