Vaccination against mumps, measles, and rubella: is there a case for deepening the debate?How safe is MMR vaccine?Validity of the evidenceDealing with uncertaintyGP's response
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7317.838 (Published 13 October 2001) Cite this as: BMJ 2001;323:838
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Sir
Government appears to be using several pieces of research cynically
to exclude MMR from consideration as a cause of autism - and has managed
to convince professionals and public alike. Taylor 2002 (1), Gillberg 1998
(2), Kaye 2001 (3) are fine examples of this; they focus on MMR to the
exclusion of the single antigen vaccines which were used for decades prior
to MMR, such that the media and parents may have developed a false faith
in these. The evidence for measles vaccines in any form causing autism is
mounting and at least one study - as yet unpublished so one must ask why -
Singh 1998 (4) found significant MMR antibody relationships with the
brains of autistics and not controls! His previous study, Singh 1998 (5),
found a strong relationship between measles antibodies and autistics'
brains compared to controls, this was published. Is his second study (4)
too hot to handle?
Wakefield 1998(6) Singh 1998 (4 and 5)lead us towards understanding
the role of measles vaccines, and MMR vaccines, in autism via the gut and
brain; is Government not at least suspicious of these vaccines?
Autism may have increased in frequency and quantity of diagnosis this
past 30 years (3); one cannot be completely sure how much enhanced
diagnosis (7), coupled with medical and political will, is responsible for
this. If there has been a genuine rise in autism since the British Cohort
Study of 1970 (BSC70) which showed a rate of 0.45/1000 children, measles
vaccine alone cannot explain this, although measles vaccines were
introduced into the UK in 1968 and, without a survey of autism prior to
this date measles vaccines (and therefore MMR) CANNOT be excluded as
causes of autism.
If, as Huessler et al (7) suggests, the incidence of autism is about
the same now as in 1970, measles vaccine (and hence MMR) remains a
probable cause of autism when one also considers the findings of Wakefield
and Singh; and this fact can only be refuted by studies with a time line
way before the introduction of single measles antigen vaccines to look at
any impact those vaccines had on autism. It would also demolish the impact
of studies such as those of the Kaye, Gillberg, Taylor and Peltola teams
whoso protocols (conveniently?) excluded consideration of the impact of
single measles vaccines.
A rather sinister consequence of this Government stance is that many
parents now put their trust in single antigens and/or MMR, where neither
may be safe.
I tend to believe that autism has risen exponentially this past 30
years, partly as a result of changes in the diagnosis processes but also
partly from measles vaccination in its various forms. I do not exclude
other causes, from which one or a combination may be particularly related
to the dramatic rise.
A few years ago I carried out a small parental anecdote study via
Communication, the journal of the National Autistic Society, of parents
who believed that vaccinations had caused their childrens' autism. 30%
blamed MMR but 36% blamed DTP. DTP has undergone changes during the last
20 years, between whole cell and acellular, and carries the adjuvant
Thimerosal (a toxic mercury derivative) which is suspected of causing at
least one variety of autism due to neurotoxicity. It is currently being
tried in US courts of law. The poison is found in D, DT and T vaccines
also. Furthermore, DTP has long been linked to Infantile spasms, a rare
form of childhood epilepsy - which is common in autism.
Congenital rubella is as a cause of autism, is this risk passed via
through rubella vaccines? We do not know.Thalidomide was associated with
autism yet this fact was obscured by the other handicaps (8). About a
third of autistic persons develop epilepsy; valproic acid, an anti-
convulsant, has been associated with inducing autism (9).
Pitocin-induced labour is suspected of causing autism and is under
investigation in the USA (10).
Smallpox vaccine was linked to causing autism in a paper (12) that
stated "vaccination is recognised as having a starter function for the
onset of autism" as far back as 1976 - have we such short memories?
Whatever the role of MMR in the onset of autism, scientists are
closing in on this despite limited funding, even more limited political
will most of which has spent the last few years trying to spin its way out
of the issue using public funds and supporting scientific studies that
must confuse, rather than clarify, this serious issue of child morbidity
and mortality.
We are bombarded with meaningless statistics about the dangers of
wild organisms and safety of live attenuated ones, despite the former
having been categorised as innocuous diseases of childhood in the past;
some of the present dangers have more to do with population shifts in
disease patterns induced my mass vaccination than by the wild diseases
themselves.
The poor uptake of the single measles vaccines here and abroad during
the early 70s was acknowledged then by researchers as due to "people not
fearing wild measles". These diseases had already lost their impact on the
mrobidity and mortality of European populations before vaccines were
introduced; by 1968 the mean annual death rate from wild measles in
England and Wales had fallen steadily since 1900 from about 1000 per
million to almost zero - due perhaps to improved sanitation and
medication!
However, the US Vaccination Adverse Events Reporting System collected
5799 adverse events reports of MMR vaccine between July 1990 and April
1994, including 3063 cases requiring emergency medical treatment, 616
hospitalisations, 309 who did not recover, 54 children left disabled and
30 deaths (12). The US National Vaccine Information Centre estimated that
underreporting may be 10-15% so total ADRs to MMR could have been as much
as 60,000 in those 4 years. One study described 80 cases of neurological
disorders starting within 30 days after measles vaccination (JAMA 1973;
223 (13): 1459-62) and also reported cases of SSPE after vaccination.
MMR is probably as unsafe as measles vaccines, and has the added
potential dangers of mumps menigitis and rubella arthritis plus many other
well-documented serious ADRs. All haste should be made to effect
scientific research funded by Government with independent scientists to
develop Wakefield and Singhs works; and to set in motion, across the
vaccination board, investigations into their impact on the rising
incidence of all types of childhood diseases from diabetes and IBD,
through leukaemias and cancers, to arthritis, MS and ME, all of which have
increased exponentially along with autism since live vaccines were
introduced into an unsuspecting medical and non-medical public several
decades ago.
Regards
John H.
References
1. Taylor et al BMJ 2002 24 Jan;324 "MMR vaccination and bowel
problems or developmental regression in children with autism: population
study"
2. Gillberg et al The Int Jnl of Res. and Pract. 1998;2(4):423-4 "MMR and
autism. Autism"
3. Kaye et al BMJ 2000 24 Feb;322:460-3 "MMR vaccine and the incidence of
autism recorded by GPs: a time trend analysis"
4. Singh et al 1998; Univ of Michigan, College of Pharmacy, Ann Arbor MI
48109, "Positive Titres of Measles and MMR antibody are related to myelin
basic protein autoantibody in autism".
5. Singh et al, Clin Immun and Immunopath Oct 1998;89(1): 105-108
"Serological association of measles virus & HHV-6 with brain
autoantibodies in autism"
6. Wakefield et al Lancet 1998;351:637-41 "Illeal-lymphoid-nodular
hyperplasia, non-specific colitis, and pervasive developmental disorder in
children"
7. Huessler et al, Letters, BMJ 2001;322:633 15 September "Prevalence of
Autsim in early 19702 may have been underestimated"
8. K Stromland, K et al "Autism in thalidomide embryopathy. A population
study" Develop. Medicine and Child Neurol. 1994; 36: 351-6
9. and 10. The Scientist, Research, 14 May 2001; 15(10):16.
"Rodier (Patricia, Prof. of Obstetrics and Gynaecology at the
University of Rochester) has found that valproic acid, a common anti-
seizure drug known to induce autism, causes brain damage in rodents, and
precisely in the places expected, based on what's known about this
disease".
"Eric Hollander, Professor of Psychiatry at the Mt. Sinai School of
Medicine and Clinical Director of the Seaver Autsim Research Centre, New
York City.....noting that an unusually large number of women at his clinic
had pitocin-induced labour, is currently conducting a survey of some
58,000 births...for a common connection between that drug and autism".
11. Eggers C, Klin Pediatr 1976 Mar;188(2):172-80 "Autistic Syndrome
(kanner) and vaccination Against Smallpox".
12. What Doctors Don't Tell You, Sept 1994, Vol 5, No.6, page 2.
"Measles Vaccine. Knee-jerk and jab-happy".
Competing interests: No competing interests
Responses to the MMR debate in the BMJ
Key points
Publication of an ethical debate about MMR vaccination in the BMJ
produced responses both through the electronic response option and
directly to the authors by e-mail
Those who responded to the authors were likely to have had a relevant
personal experience, to be opposed to the use of MMR and to express
gratitude that concerns about the vaccine had been aired in public
Examining the views of those who respond in different ways to journal
articles may offer insights into health controversies
The BMJ published an ethical debate on MMR vaccination [1], which was
followed by a number of responses to the authors individually (individual)
and to the electronic response option (public) in the BMJ itself. The
authors of the debate were interested in the extent of the response and
the differences in the characteristics and motivation of those who
responded personally or publicly. This report attempts to characterise the
responses. We subsequently sent a request to all respondents asking if
they had responded previously to a BMJ paper, what had been their
motivation to send a response and why had they chosen the personal or
public response mode.
We received 14 individual responses by e-mail (as well as a further
four responses by journalists which we have not considered further) and
there were 17 electronic responses in the BMJ. Nine of the 14 individual
respondents and 10 of the 17 public respondents replied to our request for
further information.
The Table attempts to characterise the respondents and the content of
their responses.
The characteristics of the respondents varied in that the personal
respondents were less likely to be health professionals than the public
respondents. Nine of the personal respondents mentioned an experience of
MMR or autism in their family and 7 declared an anti-MMR stance. A number
made positive comments about the courage of the authors (in particular the
first author). “There are too few people who are prepared to speak out and
I thought you should know that there are others out there who feel deeply
about the issue” “Thank you for voicing your concerns about MMR!! It is
refreshing to see a member of the medical profession voice a valid
concern” “I hope that your refreshing (moderate and balanced) honesty on
the subject may prove a kind of vaccination in the medical profession to
what often looks like a blanket surface denial to any potential dissenters
on the subject” “But you make important points and please don’t stop
making them…with appreciations for your courage”.
Among the 9 personal respondents who sent further information, 4 had
previously responded to BMJ articles (compared with 7 of the 10 public
respondents) and 6 stated that a personal or professional interest had
motivated their response (compared with 4 of the public respondents).
Reasons for sending a personal response to the authors included a feeling
of a greater likelihood of getting a reply (4) and a preference for
private, direct discussion (3). The majority of the public respondents
wanted to join the debate and to seek a wider audience for this. None of
the personal respondents made the point that ‘herd’ immunity is important
and that ethics discussions should balance individual with public
responsibility [2].
There do appear to be differences in the characteristics of those who
responded personally and those who responded in public. Those who
responded personally included a number with a personal family interest in
the issue and those who stated their opposition to MMR vaccination. A
number wrote to thank the authors (particularly the first author) for
having the courage to air views that would be unpopular amongst medical
colleagues. Of note is the lack of any comment amongst personal responders
of the ethical responsibility to the community as a whole. While the
electronic response option in the BMJ offers the opportunity to join
debate over contentious issues such as MMR vaccination, it does not
capture the responses of a small but important readership of the original
publication. Those who responded to the authors appeared to share many of
the concerns of the public as reflected in a focus group study on parents’
perspectives on MMR vaccination [3,4]. It may be useful to widen the
debate to gain insights of those who have a different view on evidence and
to capture these views. Examining the views of those who respond in
different ways to journal articles may offer insights into health
controversies. Medical journals might wish to explore the methods of doing
this, as might health policy makers who could thus be informed about the
concerns of members of the public which may influence the uptake of
important health policies.
Table. Characteristics of the respondents and their responses Personal (response to authors) N=14 Public (electronic response to BMJ) N=17 Health professional 5 14 Personal experience of MMR or autism in family 9 - Professional experience of MMR or autism - 3 Declared anti-MMR stance 7 - Personal positive comments on authors 5 - Comment on science 2 5 Comment on responsibility to whole community (‘herd’ immunity) - 4 Comment on concerns over ‘official’ cover-up of adverse evidence 3 2
Heller RF
Professor of Public Health
Evidence for Population Health Unit, School of Epidemiology and Health
Sciences, Medical School, University of Manchester, Oxford Road,
Manchester M13 9PT
Heller TD
General practitioner in Sheffield, UK and Senior Lecturer at the School of
Health and Social Welfare at the Open University, Walton Hall, Milton
Keynes, MK7 6AA
Pattison S
Professor and Head of Department of Religious and Theological Studies,
Cardiff University, Humanities Building, Colum Drive, Cardiff CF10 3EU.
Wales, UK
References.
1. Heller T, Heller D, Pattison S. Ethical debate: Vaccination against
mumps, measles and rubella: is there a case for widening the debate? BMJ
2001;323:838-840.
2. http://www.ephu.man.ac.uk/GrandRounds/2001_11/MMRPressRelease.htm
3. Jewell D. MMR and the age of unreason. Br J Gen Pract 2001;51:875-876.
4. Evans M, Stoddart H, Condon L, Freeman E, Gizzell M, Mullen R. Parents’
perspectives on the MMR immunisation: a focus group study. Br J Gen Pract
2001;51:904-910.
Competing interests: Table. Characteristics of the respondents and their responsesPersonal (response to authors) N=14 Public (electronic response to BMJ) N=17Health professional 5 14Personal experience of MMR or autism in family 9 -Professional experience of MMR or autism - 3Declared anti-MMR stance 7 -Personal positive comments on authors 5 -Comment on science 2 5Comment on responsibility to whole community (‘herd’ immunity) - 4Comment on concerns over ‘official’ cover-up of adverse evidence 3 2
MMR-no room for lingering doubts
Editor
We write to commend and complain.
Firstly, we refer to the recently published debate on the safety of
MMR vaccine from a primary care perspective.[1] Ethical debate is a
central part of the jigsaw of developing patient care and may undoubtedly
serve as the patient's (in)visible advocate. However, we question the
wisdom of the BMJ not in commissiong the debate, but in publishing the
anecdotal response of Dr.T.Heller, whose 'lingering doubts remain' as to
the safety of this vaccine. Such a reply risks some parents becoming
indoctrinated by it as the final word on the subject.
In paediatrics and primary care the uphill battle to increase vaccine
uptake rate feels ever steeper. Countless, perhaps excessive man-hours are
currently expended in both primary and secondary care counselling parents
anxious about the safety of the vaccine. This is not because they are
awkward,ignorant or ambiguous, more that they are becoming ever more
'informed'.Some of their information comes from the popular press, or on-
line, including the well-known flawed research by Wakefield et al[2].
Furthermore, the BMJ is one of the most frequently quoted in the popular
press, and available to all on-line.
The list of professional groups that endorse the vaccine is
exhaustive [3]. Why then publish alongside it at best anecdotal evidence
from one GP 'and many others' that he has lingering doubts as to the
safety of the vaccine? This adds nothing constructive in the way of
ethical debate and only serves to scaremonger. We agree that 'informed
refusal must remain an acceptable choice' but the overwhelming evidence
currently available is that the vaccine is safe. To this end, until there
is evidence to the contrary we in the medical profession must unite and
encourage vaccine uptake. It is not a case of 'keeping one's head down',
simply good practice. The Children Act 1989 highlights parental
responsibility. We as health care providers would do well to follow this
dogma in the setting of MMR vaccination. We have a responsibility to
emphatically endorse it; any less is a failure, and a breach of our terms
of service, visible or invisble.
To finish on a positive note, the personal view by Lesley Morris
tucked away towards the back of the same edition [4] was commendably
honest and painted the darker side of measles in the context of SSPE.
Honest yes, scaremongering not. In the setting of MMR, more of this and
less of the lingering doubt.
Nick Barnes
specialist paediatric registrar
Royal Berkshire Hospital, Reading
Elizabeth James
general practitioner
Didcot Health Centre, Didcot
1 Heller T,Heller D,Pattison S. Ethical debate:Vaccination against
mumps,measles and rubella:is there a case for deepening the debate? BMJ
2001;323:838-840 (13 October)
2 Wakefield A, Murch S, Anthony A, Linnell J, Casson D, Malik M, et
al. Ileal-lymphoid nodular hyperplasia, non-specific colitis, and
pervasive developmental disease in children. Lancet 1998;351:1327-1328
3 CSM/MCA Current Problems in Pharmacovigilance 2001;27:3
4 Morrison L.Measles-a minor childhood illness? BMJ 2001;323:875(13
October)
Competing interests: No competing interests
Sir,
Like Heller1 I am often asked for advice regarding the combined
mumps, measles and rubella vaccine (MMR). These inquiries come from
different directions including the wives of university friends shortly
before the first birthday of their child.
Most concerned parents have a vague notion that the MMR will "hurt
little immune systems" leading to a deluge of toxins that will leave their
child autistic or dependent on an ileostomy.
Parents are confused and a little frightened partly because the media
run stories about the issue in a naive and unscientific way. An MMR piece
invariably starts with a sensationally tragic story involving the home
life of a disabled child whose symptoms appeared days after the fateful
jab. This 'trial of one' is then expanded and used to add weight to the
hypothesis put forward by Wakefield and colleagues and published in the
Lancet2 3.
My response to questions about the MMR varies little. I explain that
based on the scientific evidence I have read4 there is no causal
association between the MMR vaccine and inflammatory bowel disease or
autism. I emphasise that mumps, measles and rubella are serious illnesses
with potentially nasty complications including death in the case of
measles. I stress that if sufficient children are not vaccinated then we
can expect epidemics of these illnesses to which unprotected children will
be vulnerable.
I conclude my advice by swearing that doctors are not colluding with
the State to hide the truth, I point out that the MMR is recommended by
the litigation sensitive Americans5 and disclose that my son has had both
doses of the MMR.
References
1. Heller T, Heller D, Pattison S. Vaccination against mumps,
measles, and rubella: is there a case for deepening the debate? BMJ
2001;323:838-40.
2. Thompson NP, Montgomery SM, Pounder RE, Wakefield AJ. Is measles
vaccination a risk factor for inflammatory bowel disease. Lancet
1995;345:1071-74.
3. Wakefield AJ, Murch SH, Linnel AJ, et al. Ileal-lymphoid-nodular
hyperplasia, non specific colitis and pervasive developmental disorder in
children. Lancet 1998:351:637-41.
4. Elliman DAC, Bedford HE, Miller E. MMR vaccine-worries are not
justified. Arch Dis Child 2001;85:271-74.
5. American Academy of Paediatrics. Evidence doesn't support
autism/vaccine link. New report adds to mounting studies. 2001.
http://www.aap.org/advocacy/washing/23apr01.htm
Dr Ieuan Davies
SpR Paediatrics
University Hospital of Wales
Cardiff
CF4 4XN
y.tarw@virgin.net
Competing interests: No competing interests
BMJ 323:838 sqq
I was dismayed to see your "ethical debate" on this important
subject. The
expert debate is over, and I can't understand why you feel you must
publish
the ramblings of a woolly-headed GP and even a theologist. If Dr Heller is
"uncomfortable" with the vaccine he should become an expert: review the
literature, learn the skills of statistical analysis, and then tell us
where
we have gone wrong. It seems to me that his discomfort is simply a measure
of the power of the popular press: from whence else does his uncertainty
stem?
Considering what he would do if his own family were involved seems to
be a
novelty for Dr Heller: I would hope that my own GP would always bring this
into the equation when faced with a difficult decision.
He reminds us that GPs are paid extra for vaccinating children. I
sometimes
feel that a hospital doctor could be forgiven for thinking that GPs have
to
be bribed to do almost anything. But what does Dr Heller think is the
motivation behind the bribe?
When he says "It is not easy to question authority these days", what
on
earth is he talking about?
It seems to me that the only moral issue is of a senior professional
with
responsibilities for the care of children undermining public confidence in
an important health measure which has a huge evidence basis and which is
unequivocally endorsed by every relevant expert body.
Competing interests: No competing interests
Stephen Pattison is incorrect in attributing the golden rule to
Singer.1 The original source is Jesus Christ’s Sermon on the Mount,2 a
fact which Pattison, as the head of the Cardiff University Department of
Religious and Theological Studies, must have known. I wonder why he felt
he couldn’t say it.
Christ’s golden rule, that we should treat others as we would want them to
treat us, was unique to him. Other moral teachers had put it negatively:
‘you should not do to others what you would not want them to do to you’,
but to live one’s life by that ethic would simply lead to being remembered
for ‘never doing anyone any harm’ - a far cry from the imaginative, costly
love that Jesus Christ demonstrated and taught.3
Jesus Christ’s dynamic entry into first century Palestine was marked by
eyewitness accounts of miraculous healing of many illnesses for which even
today there are no known treatments. Together with the quality of his
moral teaching these powerful acts of compassion were the ‘evidence-base’
for his claim to be the ‘Son of God’. Along with his compassion to restore
health he brought a message of healing of broken relationships - between
human beings, between human beings and the planet and most crucially
between human beings and God.
Doctors motivated by Christ’s teaching and example have been profoundly
influential in shaping medical history. Pare, Pasteur, Lister, Hodgkin,
Paget, Barnardo, Jenner, Simpson, Sydenham, Osler, Skudder and Livingstone
are just a few examples of medical pioneers who were also professing
Christians.4,5
Christians remain active in all fields of medicine today but particularly
in AIDS care and education, drug rehabilitation, child health, palliative
care, relief of poverty and in service to the developing world. The
Christian Medical Fellowship has almost 5,000 medically qualified members
in the UK alone and is affiliated to over 50 other similar national bodies
through the International Christian Medical and Dental Association
(ICMDA).
Many of Christ’s values have been so absorbed by civilised nations that we
take them for granted. Pattison’s misquote is a further example of
ethicists stealing their best ideas from the Judeo-Christian tradition,
without acknowledging the true source.
Peter Saunders
general secretary
Christian Medical Fellowship, 157 Waterloo Road,
London SE1 8XN
peter.saunders@cmf.org.uk
1. Pattison S. Dealing with Uncertainty. BMJ 2001; 323:840 (13
October)
2. Matthew 7:12
3. May, P. Jesus - the pivot of history and medical care. Triple Helix
2000; 11:5-7 (April)
4. Beal-Preston, R. The Christian Contribution to Medicine. Triple Helix
2000; 11:9-14 (April)
5. Graves D. Doctors who followed Christ. Grand Rapids:Kregel, 1999.
Competing interests: No competing interests
As a GP who remembers a daily visiting list of 30 or more during a
June measles epidemic, I am impressed with the results of routine
immunisation: but we must recognise the need for every parent to weigh
risks before submitting their infant to a recommended prophyllactic
programme. How can they accept advice if they know that the adviser has a
financial incentive to promote the programme?
More important, this seems to be a classical example of the conflict
between individual and community concerns. If the perception that the risk
to the individual of contracting measles (and polio in the UK) is now
negligible, ANY risk of ill-effect from immunisation is unacceptable to
that individual. But the need to maintain "herd immunity" requires that
each submit to the "common good". How often do we enter this debate with
our patients?
David Rands, general practitioner (retired)
Competing interests: none
Competing interests: No competing interests
Like Dr Heller I am a GP, however my children are young, and still due for
their second MMR dose. I have an interest in communicable disease issues,
and in fact teach a course at the University of
Newcastle NSW on communicable disease epidemiology. I have seen the
evidence in support of a link between MMR and Autism, and feel compelled
to say how I view it:
To my trained eye, I feel the evidence for a link is weak, and the
evidence for no link is moderatly strong. My children will be having their
second MMR. If there is a causal link between MMR and Autism it is at a
very low incidence, and a risk I am prepared to take because I know the
risk of measles is significant. I have seen measles epidemics, and they
can be terrible. In the future world who knows if current public health
efforts will be maintained. I would not want my child to grow up
susceptible to measles and then contact it either while travelling abroad,
or in Australia when measles re establishes in response to declining
immunisation.
This decison does not come from blind enthusiasm for immunisation,
and I have serious doubts about the introduction of varicella vaccine to
the routine schedule. Chicken pox is a minor childhood illness that causes
exremely rare fatalities, half of which are in immunocompromised children.
The risk from immunisation is a shift to older age groups if coverage is
not adequate to block transmission, and possibly the creation of
susceptible adults if vaccine produced immunity wanes over many years. As
disease severity is greater in adults the disease burden may in fact be
increased by immunisation.
On questions such as these the bottom line is a truly informed
personal decision, but as the information is complex there are few parents
in the lucky position to be fully indformed.
Competing interests: No competing interests
I remember having measles at the age of 5 in 1966; it was pretty
horrible but it wasn't even that bad as measles goes. Later my wife worked
on a paediatric unit where a child died of measles and was pretty
horrified by it. I've seen the many thousands of words from the various
studies and frankly the statistics pass over my head. When I see however,
reports from the Dublin and Dutch outbreaks with 5 children dead out of
4300 infected, think about all the morbidities that go with that, and read
Lesley Morrison's account of SSPE in this issue, my beliefs about measles
vaccine are pretty easy to come by. Its not so easy to convince the
concerned middle class parent.
The difference is that to vaccinate is an act of commission; to leave the
vaccination undone is an act of omission and a justification can be found
for putting it off. Like-as-not nothing will happen as a result, unless
everyone else in your community puts it off....
Change the act of omitting the vaccination into the same act of commision
by asking parents to sign a disclaimer after explaining the facts and
there is balance once more. Preferably both consent and disclaimer forms
should be in the Parent Held Child Health Record. Change the target
payments to payments for consultations about vaccinations rather than
vaccinations given and we will never have this argument again.
Competing interests: No competing interests
Reply to previous correspondence
Editor-There are 2 issues under discussion here. Firstly that of
parental right, secondly that of the relative safety and efficacy of MMR.
Society has decreed (rightly in my opinion) that parents do not have
absolute rights over their children. We have systems in place to protect
children from parental violence, sexual abuse and exploitation. Parents do
not have the right to deny education to their children, nor should they
have the right to deny their children the best possible medical care, as
that could lead to death. The role of doctors, medical scientists and
government should be to provide the best medical cover possible to the
population. This includes children, and in rare, but difficult cases,
protection against their own parents.
What would Dr Carey offer to an unvaccinated child with a known
hypersensitivity to one component of 'the best available' MMR? At present
the NHS offers NOTHING AT ALL...
That is a case for single vaccines, but that is not the issue under
discussion. For that child, the MMR is second best, and the doctor’s
responsibility is to make that decision and give advice, in consultation
with the parents.
Would you allow a doctor to inject your child against your judgement?
If the doctor were proposing to give an injection/treatment which was
against established medical practice and current guidelines, I would want
to know the reasons for his/her doing so. If such reasons were
unforthcoming, or were unsatisfactory, I would not allow that doctor to
proceed. If his /her reasons were woefully inadequate, I might consider
reporting him/her to the GMC. If she/he proceeded without my permission, I
would consider suing him/her and reporting him/her to the GMC which would
have to take action since both medical guidelines and parental authority
had been breached. If significant harm to my child resulted, I would
definitely take such action. But this is likely to be academic as
generally doctors do follow established practice and guidelines.
Would you inject a child against a parent's valid and sound
judgement?
Strictly, no. But this question begs the question as to what constitutes
valid and sound judgment. In the MMR context, is it valid and sound
judgment to request a vaccine which is currently believed to be inferior
to MMR? How can the decision of a layperson be as sound and valid as
thousands of virologists, immunologists, doctors with thousands of years
of training and experience between them? If it is as valid and sound, why
do we bother training? Thus, I would inject if I considered the parent’s
judgment to be invalid and unsound (see below).
A more relevant and practical alternative question is:
Would you ever treat a child against a parent's consent?
Yes, I would. If a child is sliding into a diabetic ketoacidotic coma, I
would inject with insulin even if the parents opposed it in spite of my
trying to persuade them otherwise. If time allowed, I would speak with the
MDU and try and get a court order, but if time were short, I would inject
anyway. Children have to be protected, sometimes even against their
parents. Would Dr Lewis not inject under such circumstances, knowing that
the child would otherwise die? We currently are witnessing the case of the
child with Goldenhar Syndrome at the Newcastle Royal Infirmary. How can a
distraught non-medical parent make a decision about the need for a
tracheotomy? The child’s interests have to be protected (I am, of course,
assuming that the tracheotomy is the best medical option).
The point here is that we are professionals, which, in this context,
means that we sometimes have to make decisions drawing on our experience
and training which override other considerations, which might include
parental consent. But we have to then justify our action. We do not
blindly follow rules, we do not blindly do what parents tell us to do no
matter how stupid. Like a parent, a doctor cannot be loved all the time,
and limits have to be set.
The pertussis example is not appropriate as it is another example of
the MMR dilemma and my question still stands, and applies to both cases.
Currently the evidence is that the MMR will save more lives than the
single vaccines, which in turn will save more lives than no vaccination.
At present, there is no evidence of medical advantage to the single
vaccines compared to MMR (except with specific exceptions as above). I
think that the government and the medical establishment must continue to
tough this out. However, if the uptake of MMR continues to slide, we might
have to compromise, but if we are to do that, then those parents
requesting the single vaccine must be made to understand that they are
going against the opinion of medical experts. Therefore the BNF should
state that single vaccines are currently considered to be not as good as
MMR, and doctors must get parents to sign a declaimer to protect the
doctor and NHS from future litigation from the parent should the child die
or be seriously disabled, or from the child when she/he grows up. In
future, we might have people suing doctors for failing to give them MMR
when they were children. Doctors would be covered (though perhaps not
definitely) by the disclaimer, and that person could sue their parents.
After all, there have already been cases of people suing their mothers for
her smoking when pregnant with that child.
In this context, where a doctor should not overrule a parent is if,
for example, it was medically established that there was a 0.1% chance of
MMR causing autism, and a 0.05% chance of the 3 single vaccines leading to
the death of the child because of the delay in getting full immunity. Here
there is a balance to be struck, and there is no right answer and the
choice would depend on one’s own perspective of risk and consequences.
Here, the responsibility of the doctor is to explain the situation and
discuss the options. For the adult, it is their decision (though often the
patient will ask of the doctor: What would you do?) For the child, it is
clearly the decision for the parent who has the responsibility for that
child and the doctor must abide by the parent’s decision.
One further point: What happens if we have a scare about the single
vaccine? If large numbers of parents then refuse all vaccines (not
inconceivable, since if MMR causes autism and bowel disease, so perhaps
could the measles single vaccine, until proven otherwise), do doctors and
the government agree not to vaccinate at all? There are circumstances,
surely, in which vaccination, for example, is made to be a legal
requirement. For example, if we have the vaccine and bioterrorists release
smallpox, surely the government has to enforce vaccination to prevent
massive loss of life.
I am all in favour of doctors not being treated as all knowing gods,
but it seems that the pendulum has swung and now some patients think that
they know just as much as doctors and that their medical opinion is just
as valid. If this results in detrimental treatment for themselves, so be
it, they were warned, but children must be protected.
Yours faithfully
Dr William D H Carey
Competing interests: None.
Competing interests: No competing interests