There is a phenomenon that people don’t pay much attention
to and certainly don’t base public policy on. This is unfortunate in that the
public would be better off if they did pay slightly more attention to it, and
public policy would advance rather than atrophy from inattention. The
phenomenon: Knowledge does not persist from one generation to the next;
knowledge must be communicated and learned or it is lost. We all know it’s true
that knowledge must be learned, but we are perfectly willing to ignore what has
been learned or not.
The 2015 US measles outbreak is a symptom of neglecting such
knowledge. And we can add negligence to the mix by a weakening of public’s
healthcare policy by widening the exemption/waiver policy as if there were no
consequences to permitting non-inoculations. As the measles cases increase and
spread to multiple states, we can anticipate the public reaction. There will be
those who cry for the government to do something, this will be particularly
prevalent among politicians. Another response will be to demand an
investigation on how this (and irrationally for by whom this) was ‘allowed’ to
happen. There will be the segment of the public that advocates a personal
rights / individual freedom position that no one should be forced to inoculate
their children (and they will have their politicians who support them).
But where is leadership on this issue? What besides the
obvious has any leaders or pretender to the throne stated, declared or
proposed? Where is the analysis, the debate or the proposed policy to address
the demonstrated problem that the measles event has projected onto the national
scene?
Don’t expect any satisfaction on this front. Leadership has
apparently spent its load on what they can bring to the issue. If you missed
it, it basically: “I think people should get vaccinated to protect the public.”
Some add: “But I also believe individuals should have a role in this decision
for their family.” These two items cover
all bases as long as you don’t think about the statements, attempt to develop a
sound and reasoned policy from the statements, or consider whether the
statements represent the problem space that this issue needs to cover.
What is the issue? Is it really as simple as whether
everyone should be vaccinated or whether there are legitimate exemptions to be
allowed under the law? I contend that that is only a part
of the issue. The whole issue encompasses the scientific and medical understanding,
the public health policy, individual’s right to medical decisions, the social
cost/benefits for a pro- or con- position, and the responsibility of individual
members of a society to other members.
The scientific and medical side of the issue should come
down to what the ‘best’ scientific and medical expertise indicates we should
do. In the current world, the answer is that vaccinations are the correct
actions to take. This view acknowledges that there are medical conditions which
will require an exemption but those conditions are not because of being afraid
that vaccinations will cause autism. The view of medical and scientific
communities is the public should vaccinate. This position is appropriately
apolitical, it does not and should not be weighing in on the philosophy of
government dimension.
The public health policy side of this issue presents the
government’s (local, state and federal) involvement and responsibility in
establishing the requirements for citizens, businesses, organizations and government
agencies to follow in protecting the public and the nation from threats originating
from diseases or situations that impact citizens’ health. The policy
unfortunately varies at and across the various levels of government which makes
for an unreliable situation in terms of the cause and effect consequences of one
variation relative to another. While
there is a general consensus on the measles vaccination position within the
nation, there are widely different exemption criteria and rules which make it
much easier for an individual or parent to opt-out of being vaccinated. This
opt-out allowance is a particularly relevant aspect of the current measles
outbreak. So the public health policy supports
vaccinations but the instances where exemption rules are looser it is weakened
and thus less effective in confronting the risks to the public from diseases.
The individual right to make personal choices in medical
treatment that has come into prominent display with the measles outbreak is a
dimension of the issue that most readily comes into conflict with the public
policy, scientific, medical and other dimension of the issue. The reason for
this is that the individual rights principle is almost understood to be at odds
with a public / societal rights concept. I don’t believe that this conflict is
as real, necessary or sufficient as it is treated but that doesn’t prevent it
from creating a conflict that must be addressed. The fact that this conflict
has been addressed in the past and will have to be dealt with again and again
in the future is just part of the transmission of knowledge from the past into
the future.
The most salient element of the individual rights position
that must be considered with respect to a medical decision is whether the
decision is truly a decision about the individual (or their family) or whether
the decision involves the health of other individuals in the society. I don’t believe
there is any dispute as to who should be able to make a medical decision about a
wide range of medical conditions. Who else but you should decide if you go to a
dentist for a filling; should you get glasses or contacts for correcting vision
problems; should you get cholesterol pills, blood-pressure pills, erectile dysfunction
pills, or other treatments for various health conditions that are
non-contagious.
On the other hand, does our social contract for a free
democratic society allow individuals to choose to make individual decisions
about highly contagious and deadly diseases? If you have a highly contagious
disease, our laws allow for the public-good to override your right to act
indiscriminately and risk the health of others. You can be quarantined, you can
be forced to take medication and you can be held to be accountable for negligence.
Now these overrides of your right are narrowly defined in terms of the science,
medicine, public health policy and level of risks presented; but they clearly
demonstrate that like all things in our social contract there are limits,
conditions and obligations that go hand in hand with the right. So where does
this leave the individual right view on vaccinations? At best it seems to
depend on the risk to whom question, and it has to acknowledge that it does not
consistently trump the other factors irrespective of other interests.
Now I realize that people don’t like to consider or worry
about the trade-offs that have to be accounted for on such topics as
healthcare, but that doesn’t make the financial considerations unimportant or
even critical to the decision. From a Cost/Benefits view, the vaccination issue
presents a whole range of factors that are relevant to how the vaccination
policy position for a particular disease should be calibrated. There are some
diseases that while highly contagious are not highly injurious to anyone who
catches it from another, and of course at the other extreme there are those
diseases that have very high mortality rates and thus are significant risks to
anyone. In cases where there are vaccines for the low risk outcome diseases the
importance of a non-compulsive public policy position is rational, this would be
especially true if the dollar cost to vaccinate were high. For diseases on the
high mortality side, a policy to not require high-level vaccination compliance
is equally warranted. In fact if the dollar cost was high and it isn’t
feasible to protect every citizen the other-side of an individual’s right to
choose would surface. The element of the
cost/benefit assessment on a disease, like measles, is how to determine some of
the cost areas that come into play. How much does it cost to treat individuals
who are not vaccinated and who come down with the disease? To what degree are
long-term costs for someone that suffers a chronic consequence from being
infected? Are there costs to individuals who are vaccinated beyond the
vaccination, and if so what? On this dimension the answer is disease specific
the costs/benefits trade-off decision will need to be made with an eye to what
is the best policy for the public as a whole. This view presents the individual
choice right under the notion of being able to choose for yourself without
forcing a risky consequence onto someone else’s right to life.
