By Kelsey Berry
The conflict between a physician’s dual roles as an agent of population health and an agent of his or her patient is exemplified in the classical debate about ethical vaccination policy. Whereas studies have demonstrated the role of vaccination in protecting public health at negligible risk to individuals, “vaccine hesitancy” and non-acceptance among parents has increasingly contributed to vaccination delay and refusal. Recent domestic measles outbreaks and increased numbers of reported infections in 2011 and 2013 gesture to the public health impacts of even small decrements in uptake, especially in a globalized setting where the infection can travel easily.
The FORUM at Harvard School of Public Health recently hosted an event on vaccination, exploring through an expert panel the drivers of public perception about vaccination and ways of restoring public trust in vaccination. Panelists discussed the need for research into the values and concerns of those who exhibit vaccine hesitancy, and development of effective modes of communication, tailored to individuals’ concerns, that will allow trained physicians to effectively guide choice. Notably, the clinical encounter was brought up several times as fertile ground for both reestablishing trust and promoting vaccine uptake effectively.
Reestablishing public trust in public health interventions may be key to avoiding conflicts between physicians’ duties to both population health and patients/guardians. If the patient/guardian ultimately expresses support for vaccination, as a result of persuasive information supplied by the physician, the conflict seems to disappear. However, what about the case in which a patient expresses support for vaccination as a policy, but does not support the use of vaccination in the case of his or her own child (assuming for simplicity that there are no medical contraindications to vaccination in this child’s case)? This scenario brings out a possible duality in the held views of patient/guardians. There seem to be two competing views within one patient/guardian: first, the view that we as a society should promote population health through vaccination, and second the view that one’s own person/child should be exempt from vaccination.
Acknowledging the duality of views within such individuals might suggest two grounds for physicians to vaccinate these individuals’ children, even without their consent. First, the duality of views may signal an inconsistency in patient/guardian reasoning, suggesting that the patient/guardian’s capacity for autonomous, rational decision-making is flawed and another’s judgment must be substituted. This seems to be an unattractive ground for the physician to proceed with vaccination, especially because humans are capable of holding multiple opposing and apparently inconsistent views at once, while still functioning as agents. The second way to think about the duality of views expressed by a patient/guardian may be to presume that each view is held and willed simultaneously by a fully rational agent. In this case, the physician could conceivably act on behalf of the patient/guardian (in accordance with the patient/guardian’s support for the policy applied at a population level) while also acting as an agent of population health, without conflict.
This is a unique way of framing dual views held by one patient/guardian, and it is not clear that, even if each view was equally held and willed, the physician would be acting permissibly in aligning him or herself with one view over the other as grounds for vaccinating. However, the extent to which patients/guardians trust and agree with population health policies may inform the permissibility with which physicians act as agents of population health, even when the individual patient expresses aversion toward the policy’s application to him or herself. If this is the case, the next step is ascertaining how patients/guardians express support for population health policies, if not in the clinical encounter alone.
1. American Academy of Arts and Sciences, Public Trust in Vaccines: Defining a Research Agenda (Cambridge, Mass.: American Academy of Arts and Sciences, 2014).