Fluent Essays

Assignment Your assignment is to write a four-to-five-page double spaced paper that uses the readings assigned for the course to develop and argue a thesis explaining why the controversy about vaccination still exists despite the fact that the science has ruled out links between vaccination and autism. Your goal for this paper is to situate this heated debate (as presented in Vaccine Wars and the personal essays from Narrative Inquiry in Bioethics) within a larger social context, drawing support for your argument from the analysis of the debate presented in Vaccine Wars and your own analysis of the topic based on the readings assigned on the syllabus. In your paper you are required to use the following: · at least one of the analytical articles (“Public Health Strategy” and “Medical Ethics for Children”)  · at least two of the personal narratives from the assigned readings from Narrative Inquiry in Bioethics. · You may choose to include other readings from the syllabus, but please make sure that you do not include so many that you are unable to focus your paper with a unifying thesis. Please remember that the goal for this paper is analysis. You ARE NOT being asked to take sides on the vaccine debate. Additional requirements · Your paper must include a clear thesis that presents a debatable argument. In other words, your conclusion must be something that another reasonable person might use the same evidence yet reach a different conclusion. ·  The paper should be structured so that each paragraph works to develop your thesis. · Paragraphs should be coherent with a clear topic sentence and conclusion at the end of the paragraph. · All quotations and references must be properly cited both in-text and on a works cited page using MLA formatting. Make sure you incorporate quotations into your sentences (no dropped quotes) and discuss their significance. · Your paper must run at least four FULL pages of text. Your font can be no bigger than 12-point Times New Roman and margins should be no bigger than one inch. Spaces between paragraphs should be no larger than the double spacing used between lines (if it is the default setting on your computer to insert an extra space after paragraphs please turn it off). Do not use overly large headers or footers—this includes the first page of your paper if you use this as a title page. The page count is based on the text of the body of your paper and nothing else. · Papers should be submitted on paper to me in class and on Canvas on time to receive full credit. However, I recognize that we are living in unusual times and this may not always be possible. If you are unable to meet this deadline but wish to receive full credit, please contact me about receiving an extension. You must contact me by the beginning of class time on the day the paper is due in order to receive full credit on a late paper.       Andrew Jack MARCH 18 2011 In a crowded room in central London in January last year, I jostled with other reporters for a copy of the General Medical Council’s longest awaited and most expensive verdict. The subject of scrutiny was Andrew Wakefield, a British doctor who in 1998 had notoriously claimed a link between autism and MMR, the combined measles, mumps and rubella vaccine, in children. The judgment was damning. Wakefield had brought the medical profession into disrepute through a series of ethical violations and undisclosed conflicts of interest. His original paper – initially published in the Lancet and since retracted by the medical journal – contained manipulated data that in January this year was labelled “fraudulent” by the British Medical Journal. But the GMC’s ruling was irrelevant to the dozens of parents gathered on the pavement outside. To them, Wakefield was a misunderstood hero, victimised by a cynical scientific and medical establishment that had provided them scant solace for their autistic children. He, by contrast, offered empathy, hope – and an explanation. This tension has provided yet more fuel for an increasingly fierce, international debate about vaccinations, from swine flu to HPV for cervical cancer, highlighted in four very different new books. Scientist Paul Offit, author of Deadly Choices, and Seth Mnookin, journalist and writer of The Panic Virus, both offer excellent overviews of the rise of the anti-vaccine movement in recent decades in the US and the UK. After Bill Gates pledged $10bn in 2010 for “the decade of vaccines”, Svea Closser, an anthropologist, explores the practical difficulties of polio eradication in Chasing Polio in Pakistan. Vaccine Epidemic, by contrast, provides a more disturbing and slanted view in a collection of papers co-ordinated by the US-based Center for Personal Rights, advocate for “the right to vaccination choice”. Oprah Winfrey Going viral Going viral | Financial Times https://www.ft.com/content/a2f9f1a6-50e3-11e0-8931-00144feab49a 1 of 6 1/17/21, 10:27 PM Offit, chief of the division of infectious diseases at the Children’s Hospital of Philadelphia, is a rare combination of scientist, doctor, communicator and advocate. In Deadly Choices, he powerfully lays out the history of vaccinations and their net benefit to society today. He warns of “a quiet, deadly war” between a growing number of parents who refuse immunisation for their children (the number has doubled in the US since 1991), and doctors who, in response, refuse to even see them in their surgeries for fear of spreading unnecessary infection among other patients. “Caught in the middle are children,” Offit writes. “Left vulnerable, they’re suffering the diseases of their grandparents.” Resistance to vaccines is nothing new. Offit relates that within half a century of the English doctor Edward Jenner’s pioneering use of modern vaccination in 1796 for smallpox – inspired by milkmaids’ resistance to the related cowpox (“vaccination” derives from the Latin word for cow) – that the British parliament introduced legislation to make its use compulsory. But, as with subsequent vaccines, the method to tackle a greatly feared disease quickly became a victim of its own success. The smallpox immunisation ended a scourge that had scarred and killed millions but the threat of that disease soon faded from popular memory. Meanwhile, healthy individuals suffered temporary pain from the vaccine, as well as occasional side effects and even had irrational fears they would turn into cows. An aggressive anti-smallpox movement was swiftly born in the UK, replete with rallies, pamphlets and even a mock hanging of Jenner’s effigy. Many of its arguments – from false claims of harm and conspiracy to the venality of doctors – sound familiar today. Offit is far from blind to the risks of vaccination. He highlights tragic flaws with certain vaccines, from the insufficiently weakened tuberculosis strains in BCG in the 1920s, to serum-transmitted hepatitis in yellow fever vaccines in the 1940s, and contamination in poorly made polio vaccines in the 1950s, all of which caused unnecessary infection and death. He might have lingered more on the issue of weak side effect detection: the vaccine hastily administered to protect against a feared swine flu epidemic that failed to materialise in 1976, which itself caused at least 25 deaths and hundreds of cases of Guillain-Barré syndrome; or the claims that an anthrax vaccine given to soldiers in 1991 triggered Gulf war syndrome. Going viral | Financial Times https://www.ft.com/content/a2f9f1a6-50e3-11e0-8931-00144feab49a 2 of 6 1/17/21, 10:27 PM While praising those who constructively analysed such problems and lobbied for necessary improvements, Offit scorns others who have conflated such concerns into a generalised critique of vaccines. He is scathing about celebrity interviewers who have given free rein to doubters in the name of entertainment, from Oprah Winfrey to Larry King. Nevertheless, the personal stories and passionate hunches of parents seeking causes for their children’s ailments come over so much more powerfully and convincingly on television than the arid language of often inarticulate scientists defending vaccines with intellectual arguments and abstract statistics. Offit is a rare exception. Offit also singles out for criticism doctors who propose delaying a series of childhood vaccines, contradicting official US advice for their rapid use. This approach leaves babies unnecessarily exposed to infection and permits free-riding on the “herd immunity” of others, who have been vaccinated and limit the spread of infection. But he also points an accusatory finger at trial lawyers and medical “experts” who have won significant legal settlements for people claiming vaccine-related injuries. The Vaccine Injury Compensation Program, where most such cases are played out in the US, was established in 1986 partly to shield manufacturers from escalating lawsuits that threatened to destroy the entire vaccine industry. Its authority was freshly upheld in the Supreme Court last month. The problem, Offit points out, is that the programme, which has paid out $2bn to 2,500 cases in the past quarter of a century, often gives plaintiffs the benefit of the doubt rather than scientifically scrutinising and validating every anti-vaccine claim. Yet its rulings are seized upon as proof of vaccine-driven harm. Seth Mnookin covers similar ground and beliefs in The Panic Virus, compensating for lesser scientific insight than Offit with greater journalistic skill, to tease out personal stories in a highly readable narrative about the rise in vaccine scepticism. He describes the agonies of families whose unvaccinated children have fallen ill or died, but also the desperation of exhausted parents with autistic children seeking explanations and online support from each other. “We can’t leave our homes and the only time you have to seriously do research or discuss this is the middle of the night,” one mother tells him. Going viral | Financial Times https://www.ft.com/content/a2f9f1a6-50e3-11e0-8931-00144feab49a 3 of 6 1/17/21, 10:27 PM A child’s crying after vaccination, and the subsequent onset of autism or other deeply traumatising developmental problems, which appear to have been on the rise in recent decades, makes the connection of the two events tempting. Yet correlation is not explanation, and the author stresses that visible signs of autism are often emerging spontaneously just at the age when vaccines are administered. Furthermore, as he digs, he finds inconsistencies in parents’ stories, with symptoms in their children already present long before, or emerging long after, jabs took place. He highlights that while doctors and drug companies may make money from one-off vaccines, there is a lucrative counter-trade consisting of anti-vaccine lawyers, medical expert witnesses and alternative therapists. This cottage industry offers treatments for children with allegedly vaccine-induced autism that are not subject to the ultra high scientific bar or continued scrutiny that the critics demand for vaccines. One supposed cure involves painful daily injections of Lupron (also used for the chemical castration of sex offenders) costing $70,000 a year. Mnookin criticises the pseudo-balanced “for” and “against” media coverage of the vaccine debate. He attributes this to a decline in specialist science journalism and a shift from more independent network news programmes towards openly prejudiced cable TV, and an inclination for sensationalism and controversy. Perhaps juries that grant awards to journalists for sensationalist reporting on vaccines later shown to be inaccurate should subsequently withdraw their honours. Both authors are at times overly reverential towards scientists and occasionally indulge in irrelevant snipes at critics of vaccination. Neither explores the nuances of practice and belief outside the US and the UK. MMR is much less controversial in France, for instance, where by contrast Hepatitis B campaigns were cancelled over fears of a link to multiple sclerosis. A more systematic collation of the number of lives saved and serious illnesses averted from vaccine-preventable diseases, counterbalanced by the number of serious side effects linked to vaccines, would also have been useful. So would a discussion of current topics such as whether the HPV vaccine, which primarily protects girls against a sexually transmitted virus that triggers cervical cancer, should also be given to boys. Going viral | Financial Times https://www.ft.com/content/a2f9f1a6-50e3-11e0-8931-00144feab49a 4 of 6 1/17/21, 10:27 PM Above all, neither author goes far enough in proposing ways to tackle the current rise in scepticism. But such omissions are minor compared with those in another recent book. The Center for Personal Rights’ Vaccine Epidemic portrays itself as a balanced collection of essays. Yet the sub-title, How Corporate Greed, Biased Science, and Coercive Government Threaten Our Human Rights, Our Health, and Our Children the references to “vaccine injury denialism”, and the categorisation of the two sides in the debate as “pro-vaccine” and “pro-choice”, hints at what is to come. Throughout, the phrase “I believe” crops up rather too often, as do anecdotal case histories in chapters written by, among others, lawyers, dieticians, natural healers, osteopaths and nurses. The pivotal argument is the primacy of individual rights. All very well, but what about when they compromise those of others? Andrew Wakefield himself contributes a chapter and there is also one written by a lawyer in his defence, brushing aside rather than seriously analysing the charges against him. Was ordering painful spinal taps in children against the express orders of other doctors justified, as he pursued clinical investigations while working on an undisclosed patent for an alternative vaccine to MMR? His defence is taken at face value and he is compared to Galileo, Andrei Sakharov and Nelson Mandela. US academic Svea Closser cites very different reasons for a shortage of vaccinations in Chasing Polio in Pakistan. She describes – colourfully if somewhat repetitively and theoretically – the barriers to the elimination of polio in the developing world, a disease all but forgotten in the west. Poverty, poor sanitation and scant resources are all impediments to universal vaccination. Closser observes that international priorities about vaccination are not shared by top Pakistani government officials, despite the disease being rife. “How long will we have to do this?” asks one polio programme worker. “As long as they keep sending money from abroad,” replies another. Co-opted by her fellow vaccination advocates and implementers, and the undeniable excitement of their vision, Closser is reluctant to call for the abandonment of eradication while citing others who do and point to repeatedly missed targets. She describes examples of forced vaccination among people in the developing world who wanted to refuse the smallpox jab, including some witnessed or supervised by US staff. The ethical trade-off was the world’s single successful eradication programme to date, completed in 1980. Going viral | Financial Times https://www.ft.com/content/a2f9f1a6-50e3-11e0-8931-00144feab49a 5 of 6 1/17/21, 10:27 PM Copyright The Financial Times Limited 2021. All rights reserved. The hurdles to polio eradication should not blunt efforts to extend the benefits of existing vaccines as widely and quickly as possible to the poor, when accompanied by necessary scientific scrutiny, safety monitoring and ethical discussion. In the rich west, meanwhile, one of the biggest challenges remains what Mnookin dubs the “hyper-democratisation of data” on the internet, with free-floating facts recombining “more according to the preferences of intuition than the rules of cognition”. What is needed is more people like him and Offit willing to engage the sceptics in a debate that just will not go away. Andrew Jack is the FT’s pharmaceuticals correspondent Going viral | Financial Times https://www.ft.com/content/a2f9f1a6-50e3-11e0-8931-00144feab49a 6 of 6 1/17/21, 10:27 PM Book Reviews doi: 10.1377/hlthaff.2011.0472 Vaccination: Facts Alone Do Not Policy Make BY ARTHUR CAPLAN Deadly Choices: How The Anti-Vaccine Movement Threatens Us All by Paul A. Offit New York (NY): Basic Books, 2011 288 pp., $27.50 The Panic Virus: A True Story Of Medicine, Science, And Fear by Seth Mnookin New York (NY): Simon and Schuster, 2011 488 pp.; $26.99 If biomedical scientists, physicians, or experts in health policy were asked what they base their clini- cal or policy recommen- dations on, one would probably hear references to facts, data, evidence, and confirmed findings. Little would be said about values—but they must be at the center of any dis- cussion. These two books make this point clearly. Evidence-based medi- cine began as an effort to identify and examine regional variations in clinical practice with the goal of increasing safety and efficacy. The field has evolved into a full-fledged ideological movement that demands that clinical practice and policies rest on solid, objective evidence for their warrant and reimbursement.1 Evidence surely is necessary and desir- able in trying to decide what to do about health care at the bedside, in the legis- lature, or in the boardroom. But it is not sufficient.2 Nowhere is this more in evi- dence than in the running battle about vaccination in the United States. Two recent books lay out the facts about vaccine efficacy and safety. One, Deadly Choices: How the Anti-Vaccine Movement Threatens Us All, is by Paul A. Offit, a physician and infectious dis- ease expert at the Children’s Hospital of Philadelphia. The other, by writer and editor Seth Mnookin, is The Panic Virus: A True Story of Medicine, Science, and Fear. Offit does yeoman’s duty in showing that worries about vaccine safety rest firmly on a vast pile of nonsense, duplic- ity, hype, and deeply flawed science. He tracks the history of vaccine opposition from its start among the conscientious objectors to smallpox vaccine in Britain in the nineteenth century down to the gaggle of celebrities and media lights who lead the movement today. If you want a solid grasp of the worries, fears, misunderstandings, and ideology that have inspired a small minority of people to vocally oppose vaccination for more than 100 years, Offit’s is the book to read. Both Offit and Mnookin spend a good deal of time reviewing the importance of vaccination for saving lives and prevent- ing disability. The facts areincontrovert- ibly on their side. However, Mnookin sets himself a somewhat different task than Offit’s. Although he is aware of and acknowledges the history that Offit uses to impale today’s vaccine opponents, Mnookin seeks to understand why so many well-educated middle- and upper- class families are drawn to the anti- vaccinators’ messages. Mnookin tells the story of Kelly Lacek to illustrate how vaccine hesitancy grows into vaccine rejection: “Matthew had been born in March 2003, several years after rumors of a connection between autism and vac- cines had begun to gain traction in sub- urban enclaves around the country. That May, Kelly’s chiropractor warned her about the dangers of vaccines. ‘He asked if we were going to get [Matthew] vacci- nated and I said yes,’ Kelly says. ‘And then he told me about mercury. He said, “There’s mercury in there.”’ Kelly had already heard rumors that the combined measles-mumps-rubella (MMR) vaccine was dangerous, but this was something new. ‘He was really vocal about it caus- ing autism. He said there was this big report over in Europe and blah blah blah. And I thought, Well, I’m sur- rounded by people who have autistic children. What if this happened to Matthew?’” Later, when she took Matthew to the pediatrician, Kelly asked her doctor “‘if she couldgive me a labelthat saysthere’s no mercury and she said, “No.” She said she wouldn’t give it to me.’ It was as if...[the] pediatrician was hiding some- thing.” Matthew got no vaccines. Mnookin describes how Matthew wound up near death in a medically in- duced coma at the University of Pitts- burgh, stricken with Haemophilus influ- enzae type b, a vaccine-preventable disease. He recovered. He and his sib- lings have now had all of their vacci- nations. Telling these stories is very effective, because the main puzzle Mnookin sets out to solve is why reasonably intelligent parents would not want to get their chil- dren vaccinated, both for their own sake and for the sake of others. How can it be that, as the journal Pediatrics reported last year,3 25 percent of parents believe that vaccines can cause developmental disorders such as autism in healthy chil- dren? It cannot be on the basis of the facts, because the facts about the posi- tive effects of vaccination on human health are as well confirmed and estab- lished as anything pertaining to health care. June 2011 30:6 Health Affairs 1205 Downloaded from HealthAffairs.org on January 31, 2021. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. Let’s review: Smallpox caused a mini- mum of 300 million deaths in the twen- tieth century. It was a major cause of blindness. It was completely eliminated in 1979, thanks to vaccination. In the United States, beginning in the early 1900s, annual epidemics of polio occurred with frightening regularity. In 1952, 57,628 cases of polio were re- ported. That year 3,145 people died, and 21,269 were left with mild to dis- abling paralysis. In 1955 the first polio vaccine was introduced in the United States. The last case of endemic paralytic polio in the country occurred in 1979.4 Who could possibly be against vacci- nation, given this kind of solidly verified track record? Offit and Mnookin point toward a motley assemblage of suspects: a few fringe doctors, an odd lot of promi- nent talk-show hosts, a few outspoken celebrities, and thus, probably, a few of your neighbors. In the fringe-doctor category, Andrew J. Wakefield figures most prominently. He is one reason why the facts seem not to matter to some people. Wakefield did a “study” that claimed to show a link between the measles- mumps-rubella shot and autism. Offit notes that Wakefield’s 1998 paper, in which the supposed autism link ap- peared, has since been renounced by ten of its thirteen coauthors and that it has been retracted as fraudulent by the Lancet, the medical journal that originally publishedit. A British journal- ist, Brian Deer, who has devoted himself to tracking down the harm that Wakefield did with this fraudulent re- port, found that—according to Offit— despite Wakefield’s claim in his paper that the twelve children reported on were normal until they had the mea- sles-mumps-rubella shot, five had had previously documented developmental problems. When Deer compared infor- mation from the children’s parents and from medical records, he also con- cluded that all of the data in the Lancet paper had been altered. The disgraced Wakefield—no longer a doctor—is the author of Callous Disre- gard: Autism and Vaccines—The Truth be- hind a Tragedy, published last year. The “callous disregard” part of the title is extremely apt, as he continues to prattle on about the dangers of vaccines. And he continues to leave misery in his wake. Wakefield, who is now in the United States, spent time over the past year in Minnesota. He was invited there to meet with members of the newly migrated So- mali community, who believe they have experienced a growth in autism among their children. Wakefield told them vac- cines were likely to be the cause.5 As a result, vaccination rates in Min- nesota’s Somali community have been falling. And as a result of that, in 2011 there was a measles outbreak in Minne- sota, with eleven cases reported. The pa- tients ranged from a four-month-old to a thirty-five-year-old. Three of the cases were in unvaccinated Somali children.6 The state epidemiologist believes that the root cause of the Minnesota out- break is an unvaccinated Somali child who recently traveled to Kenya, was in- fected there, and returned to Min- nesota.6 In another troubling development throughout the United States, whoop- ing cough (pertussis) is making a rapid and deadly comeback. The first vaccine against whooping cough was developed in the 1930s, and a safer vaccine ap- peared in 1991. Infants under two months old are too young to be immu- nized. Children under age six require multiple shots to be fully protected, and after that a booster is needed roughly every ten years. The effective- ness of the vaccine is about 85 percent.7 There might be diminishing efficacy in older children, but the vaccine is very effective.8 Yet last year California expe- rienced the worst whooping cough out- break in sixty years. At least ten infants died.9 Why? An analysis of the most current state data on vaccination for whooping cough shows that a little more than half of all people diagnosed with whooping cough in 2010 in California had been immu- nized.8 The data also showed that more than half of all cases were in children age ten and under, with infants less than a year old accounting for 17 percent of cases. Of all children ages 7–10 diag- nosed with whooping cough, only slightly more than half were up to date with their immunizations. In San Diego the percentage of kindergarten children entering school whose parents chose not to have them vaccinated increased from 2.3 percent in 2009 to 3.1 percent in 2010.10 Those who choose not to vaccinate themselves or their children are part of the cause of the resurgence of mea- sles, mumps, rubella, whooping cough, and other infectious diseases in the United States, the United Kingdom, Canada, Japan, and the Netherlands. They are also partly responsible for con- tinuing outbreaks of polio in Africa. The facts support vaccination. The price of nonvaccination can readily be seen in hospitals and morgues all around this country.Why don’t the facts suffice? In his book, Offit looks to the media as a prime culprit. By giving equal airtime on television shows such as Oprah to the likes of actress Jenny McCarthy and other celebrities to inveigh against vac- cination, and by treating the facts about vaccine safety as if they were still in dis- pute, the media foster fear and confu- sion. Mnookin fingers the media, too. But he also suggests, and I think rightly, that parents—bombarded with mixed messages about the dangers of technol- ogy—are more likely to listen to emo- tional narratives and charged stories than to reasoned evidence about what is right for our children. Both Offit and Mnookin are partially right in explaining why evidence has not won the day in the vaccination wars. The media, technophobia, irresponsible doctors, and an increasingly risk-averse middle and upper class have all played key roles. There are, however, other rea- sons why the facts have not commanded the vaccine battlefield, which neither book discusses. One reason is that the media are not alone in having an interest in promoting fringe and fraudulent views about the dangers of vaccines. Mainstream voices and institutions have been doing a very nice job of undermining the facts, too. Wakefield’s bizarre report about a link between autism and a measles-mumps- rubella shot did not appear on the Inter- net. It ran in the Lancet. The paper just might be the flimsiest, most underpow- ered study supporting a conclusion of monumental importance to appear in a leading peer-reviewed journal in the past fifty years. Physician Bernadine Healy, former director of the National Institutes of Health, is quoted repeat- edly and accurately by anti-vaccinators as having serious qualms about vaccine 1206 Health Affairs June 2011 30:6 Book Reviews Downloaded from HealthAffairs.org on January 31, 2021. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. safety. And when was the last time any medical school devoted a serious amount of time to explaining how to engage worries about vaccine safety, much less the good that vaccines have done? The prestigious British MedicalJournal (BMJ), which doggedly stayed on the Wakefield case until the Lancet cried uncle and retracted the bilious article, recently engaged in some highly dubi- ous fear-mongering. In 2010 it played a key role in fostering fears about the H1N1 (swine influenza) vaccine.11 The idea put forward in BMJ was that the World Health Organization pro- moted vaccination against H1N1 be- cause it was under the Svengali-like in- fluence of scientific advisers on the take from the vaccine manufacturing indus- try, which was eager to sell its wares. This is preposterous on its face. When H1N1 was deemed very dangerous early on—by all manner of experts all around the world—the only responsible course was to promote vaccine development and vaccination. Yet this major medical journal ran with a tale worthy of the most paranoid denizens of the Web. Anti-vaccine groups gleefully received all of this very mainstream conspiracy theorizing and trumpeted it far and wide. Public health agencies do not pull their weight in the vaccine wars. Those in charge do not speak out forcefully and vehemently in support of vaccines. In a very odd article in the Journal of Immu- notoxicology, Helen Ratajczak, a former senior scientist at a drug company, claims to have found a scientific ration- ale for vaccines’ causing autism: genetic defects linked to hypersensitivity, pre- sumably to vaccine components.12 When the Centers for Disease Control (CDC) was asked by a journalist if it wished to challenge Ratajczak’s review, the reply was that a “comprehensive review by CDC…would take quite a bit of time.”13 That is not the sort of response that bol- sters public confidence in the safety of vaccines, particularly as Ratajczak’s claims were all over the Internet in a matter of hours. Another reason is that we have ceded the ethical high ground to the critics. This is in addition to many mainstream voices’ abandonment of the good of vac- cines and the feeble efforts on the part of mainstream medicine to engage vaccine critics. Vaccine hesitators are said to ignore the facts. They fret over the possibility of remote harm or tell one another anec- dotal stories that show the dangers of vaccine. Then they invoke their right to choose not to vaccinate.14 But chastis- ing parents for making poor risk-benefit assessments is not an effective way of motivating them to do otherwise. Parents try to do the right thing by their kids. Exposing your child to risk is hardly that. What worried parents need to hear is that, as with all things in life, they need to countenance tiny risks to help their children and other children to flourish. A mom who lets her baby kiss the dog or be driven to visit grandma or try new foods that might trigger allergies takes small risks to achieve the goods of having a pet, bond- ing with family members, and having the joy of gobbling almonds. The moral message that those who favor vaccina- tion need to pair with the evidence is that vaccines are another form of taking a tiny risk to do a world of good. And for those who see personal choice as the foundation for nonvaccination, choice has its limits—big limits.You can- not kill helpless babies by your choice. You should not end the lives of the frail, elderly, and immunologically vulner- able by your choice. Instead, you should feel a strong duty to protect your neigh- bors and your community. If the only moral framework allowed for thinking about vaccines is individual choice combined with avoiding all risk, then the facts about vaccines are doomed. The facts make sense only when set in a context that demands responsible choice in light of the risks you and your family choose to face every day; accountability for choice in terms of the harm your choice does to others; the duty not to be a free rider when so-called herd immunity is a goal; the obligation to act as a moral member of a commu- nity; and the requirement that citizens who choose to live among others and to use public facilities have duties not to spread contagion. It is against this broad values frame- work that the facts about vaccines gain their power. It is a values framework of prudent choice, responsibility for the consequences of choice, and taking du- ties to others seriously—all of which needs to be the message of mainstream medicine. It also needs to be at the heart of the response to those who invoke their personal right to choose and self- ishly act on fear rather than on sound morals and the facts. Offit’s and Mnookin’s books get the factual basis absolutely right. Had they gone on to address this values framework, they would have contributed even more to the fight against vaccine ignorance and denial. ▪ Arthur Caplan ([email protected]) is the Emanuel and Robert Hart Director of the Center for Bioethics and the Sidney D. Caplan Professor of Medical Ethics at the University of Pennsylvania, in Philadelphia. NOTES 1 McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Nor- way. N Engl J Med. 1982;307:1310–4. 2 Caplan AL. Will evidence ever be sufficient to resolve the challenge of cost containment? J Clin Oncol. 2011;29:1946–8. 3 Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental vaccine safety concerns in 2009. Pediatrics. 2010;125:654–9. 4 College of Physicians of Philadelphia. The history of vaccines [Internet]. Philadelphia (PA): The College; 2011 [cited 2011 May 12]. Available from: http://www.historyofvaccines.org/content/ timelines/diseases-and-vaccines#EVT_100309 5 Shenoy R. Controversial autism researcher tells local Somalis disease is solvable. MPR News [serial on the Internet]. 2010 Dec 17 [cited 2011 May 12]. Available from: http://minnesota .publicradio.org/display/web/2010/12/17/ somali-autism/ 6 Perry S. Current Minnesota measles outbreak linked to misplaced vaccination-autism fears. MinnPost.com [blog on the Internet]. 2011 Mar 21 [cited 2011 May 12]. Available from: http://www.minnpost.com/healthblog/2011/03/ 21/26775/current_minnesota_measles_ outbreak_linked_to_misplaced_vaccination- autism_fears 7 Immunization Action Coalition. Pertussis vaccine: questions and answers [Internet]. St. Paul (MN): The Coalition; [cited 2011 May 12]. Available from: http://www.vaccineinformation.org/pertuss/ qandavax.asp 8 Crowe K, Williams B, Watchdog Institute. More questions about whooping cough vaccine in kids 8 to 10. KPBS [serial on the Internet]. 2011 Mar 29 [cited 2011 May 12]. Available from: http://www .kpbs.org/news/2011/mar/29/cdc-says- whooping-cough-vaccine-effective/ 9 Clinton L. Doctor explains rising infant whooping cough death toll. CNN American Morning [blog on the Internet]. 2010 Oct 22 [cited 2011 May 12]. Available from: http://amfix.blogs.cnn.com/ 2010/10/22/doctor-explains-rising-infant- whooping-cough-death-toll/ 10 Crowe K. CDC to announce preliminary findings on California whooping cough epidemic [Inter- June 2011 30:6 Health Affairs 1207 Downloaded from HealthAffairs.org on January 31, 2021. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org. net]. San Diego (CA): Watchdog Institute; 2011 Mar 27 [cited 2011 May 12]. Available from: http://www.watchdoginstitute.org/2011/03/27/ preliminary-findings-on-california-whooping- cough-epidemic/ 11 Cohen D, Carter P. WHO and the pandemic flu “conspiracies.” BMJ. 2010;340:c2912. 12 Ratajczak HV. Theoretical aspects of autism: causes—a review. J Immunotoxicol. 2011;8(1): 68–79. 13 Attkisson S. Vaccines and autism: a new scientific review. CBS News Investigates [serial on the In- ternet]. 2011 Mar 31 [cited 2011 May 12]. Avail- able from: http://www.cbsnews.com/8301- 31727_162-20049118-10391695.html 14 Habakus LK, Holland M, editors. Vaccine epi- demic: how corporate greed, biased science, and coercive government threaten our human rights, our health, and our children. New York (NY): Skyhorse Publishing; 2011. 1208 Health Affairs June 2011 30:6 Book Reviews Downloaded from HealthAffairs.org on January 31, 2021. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.