Advocate for vaccines, but not for candidates

Scenario: Mr. and Mrs. Matthews have decided that they do not want their 3-month-old son vaccinated. They know that vaccines are largely safe but don't want to take the risk of having him vaccinated since it is unlikely he would contract any of the diseases that childhood vaccinations prevent.

Reply: Pediatric vaccination programs have been one of the most important public health initiatives of the 20th century. Today, the United States has one of the highest rates of vaccination coverage in the world, which has led to the suppression and in some cases elimination of vaccine-preventable disease.

Though millions of children have been vaccinated safely, the climate of public discourse about vaccine risk has changed, with fear of adverse events eclipsing fear of disease.

Parents now aggressively question pediatricians about vaccine safety. In turn, pediatricians often feel unwilling or unprepared to respond to such scrutiny, especially when based on false or misleading information acquired from the media or the Internet. All of this can make effective vaccine risk communication a difficult challenge for health care professionals in the office setting.

Some parents, such as those in the case, refuse immunization because they perceive the risk of their child acquiring disease to be insignificant.

In fact, when rates of coverage for certain diseases reach a certain high level, a resistance of the community to disease attack might occur because a large portion of the population is immune. This is what is known as herd immunity and allows for limited numbers of individuals to avoid vaccination, yet take advantage of vaccine protection.

Therefore, the couple presented in the case pose a very common, logical question: why would a parent voluntarily accept even the extremely small risk of a vaccine-associated adverse event when the actual risk of serious disease is so low?

In general, parents are presumed to exercise surrogate decision-making appropriately to promote their child's best interests. States allow parents to exempt their children from vaccinations based on medical, religious or, in some cases, philosophical grounds.

But parent refusal of vaccination without personal exemption status poses serious moral and legal problems that put public health at risk. First, the risk of suffering or dying from a vaccine-preventable disease is far greater than the risk of a vaccine-associated adverse event. Second, there is sound evidence that significant numbers of parent refusals within a community create vulnerable points of disease transmission that put the entire population at risk. Finally, refusing vaccines without having exemption status poses a practical legal problem for parents when they try to enroll the child in day care or school. School immunization statutes exist in all states and have been upheld by the Supreme Court.

Parents with growing fears about vaccine risks look to pediatricians to ease those fears no matter how irrational. Engaging and educating parents, such as those presented in the case, is a significant challenge and can stir up emotions on the part of both physician and parent.

If parents continue to refuse after an initial attempt at education, many pediatricians suggest that the parents find another doctor.

This is problematic for two reasons. First, it doesn't place the child's best interests first. The child remains unvaccinated, and the parents may not seek further pediatric care. Second, by dismissing a family, an opportunity to educate, dispel myths and put good information into the parents' hands is lost.

Pediatricians can do several things to establish a dialogue with parents such as the Matthews:

Be proactive. When possible, try to have discussions about vaccines before the visit in which they are to be given.

Be resourceful. Have resources available for parents such as books, handouts and credible Internet sources such as the American Academy of Pediatrics and the Centers for Disease Control and Prevention Web sites. Bring parents back for follow-up visits in which vaccine concerns can be addressed specifically.

Be flexible. Pick your battles. Parents sometimes initially refuse certain vaccines but are willing to do others.

Be respectful. Parent fears, even when based on a misperception of vaccine risk, are real fears. Offering platitudes or making light of parent concerns without offering reassuring evidence will only serve to frustrate parents.

Be resolved. Establish yourself as a committed vaccine advocate and continue the vaccination dialogue at each visit. Make sure parents understand that while you may not agree with their position on vaccination, you will continue to care for their child during health and illness. Some pediatricians might have parents sign a waiver in which the parent acknowledges and accepts the risks associated with refusing vaccination.

The growing anti-vaccination movement, based on miscommunication and misperception of risk, may threaten the high vaccination rates that protect us all.

Physicians must find a way to enhance the quality of vaccine risk communication and forge partnerships with parents such as the Matthews about childhood vaccination in order to protect individual children and the entire population.

Erin Flanagan-Klygis, MD, assistant professor of pediatrics, Rush Medical College, Chicago; attending pediatrician in the Division of General Pediatrics at Rush Children's Hospital, Chicago

Scenario: Do politics and medicine mix in the medical office?

Is it appropriate for a physician to post signs in his or her office endorsing a candidate running for office?

Reply: Imagine a political or social position on which you feel strongly. Perhaps it is the war in Iraq, legalization of marijuana, criminalization of abortion, abolishing the death penalty, or favoring or opposing health care for illegal immigrants. Now visualize being ill and visiting your doctor, who indicates her predilection to vote for a candidate for president who is a poster child for the opposing point of view, someone whose views you find reprehensible.

Ask yourself the following questions. Will that information from your doctor make your illness better or worse? How will that affect your trust in that physician? Will that influence your judgment of that doctor's intellectual acumen, integrity or professionalism? Will you continue to respect that person's medical judgment?

Consider the goal that patients have when they initiate encounters with physicians. When we go to a lawyer for help with legal problems or to a psychotherapist for help with emotional problems, we do not expect or want the person consulted to step outside the role for which we chose them and suddenly tell us, for example, how we should vote. Similarly, when patients go to doctors, they want medical advice, care, and alleviation of suffering. The stimulus that initiates the patient-physician encounter is a health concern, not a desire to become politically embroiled.

The criteria each person uses for choosing a physician will vary, but it will rarely include political beliefs. When a physician offers a political opinion, whether verbally, by posting a sign or by leaving literature in the waiting room, he is blurring the boundaries between his responsibilities as a physician and other unrelated areas.

To bring up political opinions in a medical setting is to risk introducing tension into the therapeutic encounter, which may negatively affect patients. Regardless of the doctor's intent, advocating for a particular position or candidate may suggest to patients that their views are "wrong" and make them feel unwelcome.

Further, when patients consult physicians, they are often sick, making them vulnerable and creating a power imbalance. Patients may believe that the doctor has some special authority in nonmedical areas. To express political opinions in that context is to violate the patient's rights. The exposure of differences in political attitudes can jeopardize the foundations of the patient-doctor relationship: trust and the assumption that the doctor will be concerned only with patients' best interests.

Any attempt by the doctor to influence the patient's political choices puts physician needs ahead of patient best interests, creating a conflict of interests for the physician. The patient's welfare must come before any other agenda. It is not unreasonable for the patient to wonder whether the physician will feel a special kinship with the patient who shares his political views and act with indifference or distaste toward those who do not.

The well-being of patients depends upon an alliance between physician and patient in which doctors serve as their patients' advocates. Political disagreement, stated or not, can rupture that alliance. The end result will frequently be an upset patient, an upset physician or a situation in which the patient fears or imagines the physician's disapproval.

There are many gray areas. Some patients are anxious to know where their physician stands on issues, assuming that a physician they like will have similar views but wanting to be reassured that this is so.

One also must ask: Shouldn't doctors have the same rights to campaign for their favorite causes and candidates as other Americans? Is not such activity intrinsic to a democratic society? If a physician believes that some political action or piece of legislation promotes the greater good, and he is not acting for his personal benefit, is he not obligated as a responsible citizen to endorse such an agenda?

The problem is that political opinions are not facts, and they especially are not medical facts. No one is omniscient; no one knows what is "the greater good." The long-term consequences of a particular political act cannot be known. Therefore, outside of the role for which the patient hired us, we must assume complete humility. It is indeed appropriate for physicians to advocate for political positions, parties or candidates, and to fully exercise their political rights away from the office or hospital.

Lawrence W. White, MD, internist, Foster City, Calif.