Case 6.  A parent who reject the vaccination for their children.


Community health nurse in my village told me there is one parent
who don't want their one year children's vaccination.
In Japan, BCG, Polio, DPT vaccination is recommended and done by
the government's financial help. Till 1994, Vaccination should be done
for all children except contra-indication and usually done by mass
injection by law, but now Vaccination was only recommended and
individual injection is recommended by new law.
The parents say vaccine has some side effects and they know one
children who was suffering from encephalitis by the influenza vaccine.
TB, Polio, Diphtheria, Pertussis, Tetanus are not so common in Japan.
I think their comment is half true, but we still have some TB or
Pertussis and vaccination is the only way to prevent these disease.

I want to tell them the risk and benefit of the vaccination concretely.
But the epidemiological data is very difficult to use.
The rate of the side effect is very low but for the person who is
suffering from severe damage side effect is 100%.
The risk of severe side effect of vaccination usually 1/1000000,
and the rate of severe infection case is 10 cases per year and the
rate is almost the same in Japan now.
I know in United states, Vaccination Document is needed to enter the
primary school. How do they treat these kind of unvaccinated children?



Stuart Sprague, PhD
Associate Professor of Family Medicine
AnMed Family Practice Center

Case 6-Vaccination
   The first important issue in this case is the distinction between
recommendation and legal requirement.  If it is only a recommendation, then
parents cannot be compelled to have children vaccinated.  This is a legal
issue.  Sometimes the law provides for exceptions.  In our country, each state
makes its own laws for exceptions, so the practice varies from state to state.
In South Carolina exemptions are granted for two reasons.  An exemption
from taking the vaccine will be granted for a child when the parent brings a
letter from a physician stating that the child is allergic to some component of
the vaccine.   An exemption will also be granted for religious reasons.  In
theory the objection to participation in a particular legal requirement should
be based on well founded and longstanding religious practice.   Authorities may
legitimately ask for some evidence that the person is a member of a particular
group whose public beliefs preclude participation and that the practice has
been over a long period of time rather than something which began only
recently.  In practice, there is not any questioning of a parent who says that
the objection is religious.  If they are willing to sign a statement of their
religious objection in the presence of a notary public, a minor official, the
health department will accept it without question.
   The moral issue is different.  Because whether children are vaccinated affects
not only their own health, but also the health of the other children, the
obligation to be vaccinated is a strong one.  Unless the parent can point to
an absolute principle of a religious, or similar nature, the moral issue can be
resolved by a utilitarian calculus of benefits and harms.  As you point out,
parents are not always able to understand and use the epidemiological data
in making a decision.  You can legitimately, I believe, point out the risks
which one person's choices pose for themselves and for all the other people
in the group. It is important not to degenerate into manipulating your patients,
but calling on their sympathy for others is not illegitimate.
   As in other cases, I believe the key moral ingredients are full disclosure of
the facts in as understandable a way as possible and the forging of a strong
physician-patient relationship in which the patients feel assured that they will
be supported and not abandoned.



Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the
Life Sciences,Michigan State University, East Lansing, MI USA.

The case described by Dr. Shirahama is fairly common in the U.S. There are three
basic reasons why parents refuse immunizations on behalf of their children:

 1. Religious or quasi-religious beliefs
 2. Philosophical belief systems that are not properly called religious,such as beliefs in
 "natural" remedies and rejection of "artificial" remedies
 3. Either a correct, or else a mistaken assessment of the level of risk posed to the child
(Obviously, parents could combine more than one reason.)

 In the U.S., I believe that there has been a greater tendency to allow children to enter
school without immunizations if the parents stipulate that they refuse these for religious
reasons.

 The ethical question might be viewed as a risk-benefit calculus: what is the risk to the
child and to the community of a child going unimmunized; vs. the damage done to the
family unit and the dignity of the parents by rejecting their beliefs. (The latter assumes
that one has corrected any misinformation and has offered educational materials about
immunizations.)

 I think one could make a case for the primacy of the parents' right of refusal so long as
only a small proportion of the community actually refuses. The children are then
protected by herd immunity and are less likely to get the infection even without having
been personally immunized. A more serious public health situation would arise if the total
immunization rate fell below the threshold for effective herd immunity.

 As Dr. Shirahama notes, it is often dangerous and disrespectful to label the parents'
beliefs as "irrational." There is definitely an element, in childhood immunization, of the
individual child being pout at risk at least in part for the benefit of other people.
 Well-meaning parents could legitimately object to this.



Yooseock Cheong M.D.
Department of Family Medicine
Dankook University, College of Medicine, Korea

In Korea, vaccinations for children are not legal obligation but only a
recommendation. So, if parent don't want vaccination for a specific reason,
physician can't compel to have child vaccinated. In this case, parent's
decision should be accepted because the parent had a bad memory about
vaccination.
In ethical idea, it's a conflict between personal autonomy and social harm.
Usually personal autonomy should be respected within social security.
So, several countries have a legal obligation to have their children vaccinated.
I'm not sure the reason for changing Japanese vaccination policy from legal
obligation to recommendation. But, maybe the government stresses the personal
autonomous decision more than social harm which is thought negligible.
In fact, I guess infectious diseases such as Tuberculosis, Polio, and so on are
not more serious problems in Japan as well as Korea.
So, although physicians could give good and bad points of vaccination in detail
and persuade for social reason, they can't compel some parents' autonomous
decision in Japan and Korea.



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