Ethical Issues Related to Vaccination of Children

The Treuman Katz Center for Pediatric Bioethics hosted its second conference on pediatric bioethics on July 14 and 15, 2006, in Seattle, Washington.

The conference attracted more than 200 attendees from the United States, Canada, Puerto Rico and Taiwan who gathered to explore the ethical issues related to childhood vaccination.

Conference Highlights

The following stories highlight two of the many vaccine-related issues debated during the two-day conference.

Contact Angel Latterell if you would like to receive a 2006 conference syllabus. We are accepting $25 donations.

The luxury of choice

"The decision not to vaccinate is a luxury that only those in the developed world have," contends Dr. Lainie Friedman Ross, public health pediatrician, professor of molecular pediatrics and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Using the United States as an example, she explains that high immunization rates of more than 80% act as a firewall against the spread of disease, offering the protection of "herd immunity" to those in the population who remain unvaccinated.

Yet the implications of not vaccinating a child go beyond any one individual, says Dr. Doug Diekema, medical ethicist from Children's and former director of the bioethics center. Parents must weigh their responsibility to their own child with their responsibility to the larger community, such as those with weakened immune systems and the elderly.

Diekema faced this dilemma in his own family. "The chickenpox vaccine was new when our daughter, Katie, was born, but we didn't feel she was at substantial risk, so we decided to wait until there was more data about it. But when she was 4, her best playmate developed leukemia. Factoring in her friend's fragile health changed our equation, and we decided to get Katie the immunization," recalls Diekema.

Parents should consider what is happening beyond their own community, too, says Diekema. "We live in a global world. Older children and young adults who travel may be exposed to preventable diseases. People from the developing world come to the United States. All of the diseases that are prevented by vaccine in this country are just a plane ride away," he says.

Are different standards OK?

Throughout the world, rotavirus is the single most important cause of severe diarrhea in young children. In 1998, the vaccine RotaShield was introduced in the United States. Within a year, 15 cases of intussusception (twisting of the intestine) were reported in children within one week of receiving RotaShield, and the Centers for Disease Control (CDC) recommended withdrawing it until more information could be gathered. About 1.5 million children had received the vaccine at the time it was withdrawn from the U.S. market.

On the basis of this decision, policy makers in developing nations chose not to introduce RotaShield in their countries, reasoning that if it was not good enough for children in the United States, it was not good enough for their children either.

That decision was a result of faulty ethical reasoning because the social and economic contexts were not factored into the equation, says Ross.

The burden of disease and the ability to effectively treat disease are two such factors. In the United States, rotavirus results in 500,000 visits to the doctor, 50,000 hospitalizations and 20 deaths each year. In the United States, the risk of the vaccine-related complication outweighed the burden of the disease.

In developing countries, the scenario is much different. Each year, there are 111 million episodes of rotavirus, 25 million clinic visits, 2 million hospitalizations and between 400,000 and 500,000 deaths in children under age 5. In such a situation, argued Ross and others, the virus's impact should have outweighed the risk of vaccine complication.

Earlier this year, two new vaccines for rotavirus were approved. But in the intervening seven years, more than 3 million children died throughout the world.

2006 Pediatric Bioethics Conference Presentations

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Day 1

Ensuring the Future Availability of New Vaccines to Developing Countries
Presented by Sarah Ewart, MSc

Ms. Ewart develops and manages PATH Malaria Vaccine Initiative (MVI) partnership projects and conducts targeted research, analyzes data and develops strategies for MVI on policy, advocacy and commercialization issues affecting malaria vaccine development.

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Prioritizing Vaccines for Disease-Endemic Countries: Immunization Policies of Industrialized Countries Are Not Necessarily the Best Policies for Developing Countries
Presented by Daniel Wikler, PhD

Dr. Wikler is Mary B. Saltonstall Professor of Population Ethics in the Department of Population and International Health at the Harvard School of Public Health.

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Ethical Issues in Conducting Trials of Novel Vaccines in Children in Africa
Presented by Tonya L. Villafana, PhD, MPH

Ms. Villafana manages the clinical aspects of PATH Malaria Vaccine Initiative (MVI) work, which includes overseeing the development of clinical trials and coordinating scientific and ethical review of protocols.

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The Rotazyme Story: When Are Double Standards Justified?
Presented by Lainie Friedman Ross, MD, PhD

Dr. Ross is an associate professor in the Department of Pediatrics and an associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, where she is the co-director of the ethics case consultation service.

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Making Choices About Who Should Get Vaccine in Shortage Situations: Ethical Considerations
Presented by Daniel Wikler, PhD

Dr. Wikler is Mary B. Saltonstall Professor of Population Ethics in the Department of Population and International Health at the Harvard School of Public Health.

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Developing Vaccines for Emerging and Global Infectious Diseases: The Need for New Research Infrastructure
Presented by Lawrence Corey, MD

Dr. Corey is head of the University of Washington's Virology Division and the Fred Hutchinson Cancer Research Center's Program in Infectious Diseases.

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Thimerosal and Vaccine Risks
Presented by Neal Halsey, MD

Dr. Halsey is the director of the Institute for Vaccine Safety and a professor in the Department of International Health for the Disease Prevention and Control Program in the Bloomberg School of Public Health, with a joint appointment in the Department of Pediatrics at The Johns Hopkins University School of Medicine.

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Day 2

Childhood Immunizations at the Crossroads: Opportunities and Challenges
Presented by Stephen L. Cochi, MD, MPH

Dr. Cochi currently serves as senior advisor for the Global Immunization Division (GID) in the National Immunization Program at the Centers for Disease Control and Prevention (CDC).

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The Case of Vaccine Refusal: Parent Conviction, Child Best-Interests and Community Good
Presented by Douglas S. Diekema, MD, MPH

Dr. Diekema is an associate professor of pediatrics at the University of Washington School of Medicine, with an adjunct appointment in the Department of Bioethics and Humanities.

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How Physicians View the Issue: Physician Response to the Parent Who Refuses to Vaccinate a Child
Presented by Joel Frader, MD, MA

Dr. Frader is professor of pediatrics and professor of medical humanities and bioethics at the Feinberg School of Medicine, Northwestern University, and Children's Memorial Hospital, Chicago, Illinois.

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Requiring Vaccines for Children: Are There Limits?
Presented by Lainie Friedman Ross, MD, PhD

Dr. Ross is an associate professor in the Department of Pediatrics and an associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, where she is the co-director of the ethics case consultation service.

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