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Should we force parents to vaccinate their children? No: let’s just scare them instead

by Rebecca Roache

The BBC recently reported that some homeopaths are offering their patients homeopathic remedies designed to replace the MMR vaccine.  Given that the efficacy of homeopathic remedies is notoriously unproven, this points to the worrying conclusion that some parents who have chosen a homeopathic alternative to the MMR vaccine believe that their children are immune to measles, mumps, and rubella, when in fact they are unprotected against these diseases.

This development marks another blow for the ongoing campaign to ensure that children receive the recommended vaccinations.  Sir Sandy Macara, ex-chairman of the British Medical Association, has claimed that the UK has lower immunisation rates than some developing countries in which people have poor access to healthcare.  The percentage of the UK population currently vaccinated against MMR falls well below the level needed to achieve ‘herd immunity’ – where the number of immune individuals in the population prevents the spread of disease, thereby protecting those who are not immune – and recent outbreaks of measles in Wales has led the Welsh Assembly to consider making the MMR vaccine compulsory.  Such a move would be highly controversial, but is this a price worth paying to protect public health?

Making childhood vaccination compulsory would be heavy-handed, in my view.  There may be less coercive means of improving vaccination rates.  To see this, consider the way in which people commonly assess risks.

Deciding whether to have one’s children vaccinated involves comparing the risks and benefits of doing so with the risks and benefits of not doing so.  One way of carrying out this sort of risk assessment involves making a comprehensive review of all the available and relevant scientific literature relating to the vaccine in question and the disease(s) it immunises against – but few parents do this.  Instead, when assessing risks, we make use of a variety of shortcuts.  One of these, identified by the psychologists Tversky and Kahneman, is the availability heuristic.  Using this heuristic, we estimate the probability of a given type of event based on how many examples of it we can bring to mind.  So, for example, following this year’s Icelandic volcanic eruption, people are likely to view major volcanic eruptions as more likely than they would have done previously, because – as a result of news reports about the Icelandic eruption – an example of such an eruption can easily be brought to mind.  Whilst the availability heuristic can be a useful tool, however, it can mislead us.  It can result in our estimating rare but high-profile events (like major volcanic eruptions) as more likely than common but little-known events. 

How does all of this relate to childhood vaccinations?  Well, at least in the case of the MMR vaccine, risks of having the vaccine are likely to weigh more heavily in people’s minds than risks of not having the vaccine.  This is because, in recent years, there has been a lot more media coverage of MMR vaccine risks than of the risks of not being vaccinated.  The MMR vaccine has been controversial ever since a 1998 study in the Lancet linked it to autism.  Despite the fact that the study has since been discredited, many people are still distrustful of the vaccine (see, for example, the comments on this article).  Whilst concerns about the MMR vaccine are common, however, concerns about the effects of the diseases it immunises against are much less common.  In developed countries like the UK, measles, mumps, and rubella are generally experienced only in a mild form, and most of us would struggle to bring to mind an instance of someone suffering serious complications from any of these diseases.  As a result, parents who are considering whether or not to allow their children to have the MMR vaccine, and who rely on the availability heuristic to assess the risks involved, may well end up deciding that the risks of having the vaccination (autism) outweigh the risks of not having it (a few spells of mild and brief illness).  Based on this assessment, parents may decide against the vaccine.

However, this is a case of the availability heuristic leading to inaccurate risk assessment.  The risks of not being vaccinated against measles, mumps, and rubella are not confined to short, mild illness.  In underdeveloped countries, the fatality rate from measles has been as high as 28%, and in people with compromised immune systems – such as those with AIDS – the fatality rate is about 30% (see the references here).  Because such serious outcomes are unpublicised, however, they do not figure in people’s availability-based risk assessments. 

Increasing the profile of real cases in which people have suffered serious illness, disability, or death as a result of measles, mumps, or rubella could help address this problem.  To date, efforts to encourage uptake of the MMR vaccine have mainly focused on playing down the risks of the vaccine and mentioning that the diseases can be very serious.  These kinds of reassurances and warnings are unlikely to make much impact on risk assessments based on the availability heuristic, where it is real cases that count.

By drawing parents’ attention to serious, real cases of measles, mumps, and rubella as part of an NHS campaign, the government could be accused of using ‘scare tactics’ to encourage uptake of the MMR vaccine.  Scare tactics, however, are far less objectionable than coercion.  If this approach could improve vaccination rates without infringing parents’ freedom to choose whether or not to have their children vaccinated, it is worth considering.

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13 Comment on this post

  1. In favor of making it mandatory, I would suggest this analogy: We certaintly don’t think (I mean this as an invitation not a report, of course) people have the right to drive cars that are not properly kept up, lest they malfunction on the highway and cause a deadly accident. In the same way, getting the MMR vaccine is like keeping one’s body in order so as to not endanger others. The analogy isn’t perfect, of course.

    Question: does anyone know to what extent in the UK or US (or anywhere else, for that matter) the literature on heuristics and biases is taken seriously in the formation of public policy by governments and quangos?

  2. This argument would be fine if MMR was 100% effective and herd effects weren’t important. But because herd effects are important and MMR isn’t 100% effective, unvaccinated children are a hazard to a fraction of children whose parents don’t try to duck their responsibilities and vaccinate their children. Potential harm to others is a perfectly acceptable basis for mandatory vaccination.

  3. Exactly what is the great harm that people experience when they are forcibly coerced to give their children the vaccination? We prevent a good amount of disease and future suffering with it.

    We often times force people via laws to do things that they might not want to do. Speed limits and mandatory seat belts are examples of this.

    Parents don’t have a right, for example, to endanger their children, even if they sincerely believe that it would not harm them. Why should vaccinations suddenly get a pass?

    It seems like the only argument against mandatory vaccination is the fear of paternalism in general. But is that really a good justification for not implementing a law with benefits to the entire population?

  4. Thanks for your comments. They all make roughly the same point – i.e. that making the MMR vaccination mandatory would be acceptable – so I’ll address them all at once.

    I think there might be a case for making the vaccination mandatory if that were the only way to raise the vaccination rate to an acceptable level. My point in this post, however, is that there may well be a way to achieve the same end without coercion. In liberalised societies (like the UK), people do not expect their liberty to be restricted without good reason. If an end can be achieved without restricting people’s liberty, then there is no good reason to restrict it in order to achieve the same end. Unless the strategy I have suggested (or any alternative non-coercive strategy) is untenable, making the vaccination mandatory would be unjustified.

  5. Thanks for responding to the responses!

    So there’s a factual question: would the strategy you propose work?

    I have misgivings about it, even if it would. Above I asked how much use the heuristics and biases literature is being put to use in the formulation of policy. I am not sure that the sort of “nudges,” which I think is the popular term now, have been subject to very much critical ethical reflection yet. We seem to be comfortable because they do not resemble standard, prototypical cases of coercion, e.g., vaccinate or be fined. But why are we so interested in those sorts of cases, when so much of the psychological literature shows how easily we can be “nudged”?
    My view is not exactly that parent should be coerced into getting the vaccine for their children, but about the way in which these sorts of tactics of governance have begun to work their way into policy making. The power of the state and its proxies does not have to be understood solely in terms of legitimacy/illegitimacy and coercion/liberty to be deemed ethically problematic. (Obviously, I’m leaning on Foucault here.)
    Shorter: Perhaps it would just be more honest and respectful to coerce people under democratically established laws, rather than scare and manipulate them.

  6. Eric, I don’t think that ‘nudges’ are objectionable in cases where the person or organisation doing the nudging is open about what they are doing and why. The strategy I have in mind is the sort of ‘liberal paternalism’ that Cass Sunstein describes in his Laws of Fear. If nudges were deliberately used in a clandestine way – in an attempt to influence people’s choices without their realisation – then I would share your ethical concerns, and I would also agree that open coercion would be preferable.

    The sort of strategy I have suggested is not particularly novel, and some similar cases have not been viewed as objectionable, to my knowledge. For example, fairly recently there was a televised health campaign in the UK that focused on the sorts of minor injuries and mishaps that people often suffer as a result of getting drunk. As an attempt to persuade people to drink sensibly by drawing attention to some unwanted results of alcohol consumption (as opposed to the fun aspects that many people presumably focus on), it is similar to the strategy I have suggested for vaccination. I don’t know how successful it was at getting people to drink less alcohol, but I suspect that few would prefer the government to try to cut alcohol consumption by coercion.

  7. Okay, so it might be a viable alternative…. But if your viable alternative fails to work, then we have children dying of illnesses that could have been prevented. Is this an acceptable risk to take, or would the infringement of people’s liberty, be worth the lives lost? I think there are prudential reasons for us to choose the coercive method, than the “nudging” method.

  8. Okay, so it might be a viable alternative…. But if your viable alternative fails to work, then we have children dying of illnesses that could have been prevented. Is this an acceptable risk to take, or would the infringement of people’s liberty, be worth the lives lost? I think there are prudential reasons for us to choose the coercive method, than the “nudging” method.

  9. Consider an analogous case: The Health Agency (in democratically elected government) has decided that it will place in the water supply a drug that will cause many people to have the motivation, overrideable but real, to get the MMA vaccine for their children. (I don’t now how they childless are affected by the drug or the children themselves, but please play along.) The drug has no side-effects.

    Is this case morally equivalent to the cases of nudging helpfully explained upthread?

    A different point: I am not sure that we are getting at the more interesting ethical layer when we look at nudges in terms of concealment and transparency or legitimacy and illegitmacy (though they’re important). When I present material on heuristics and biases to my critical thinking class, I don’t tell them what I am about to show them about their thinking processes (e.g., that they are prone to the conjunction fallacy) when I ask them whether or not it is more likely that Linda is a bankteller or Linda is a bankteller and a feminist activist, in the famous, but I bet if I asked them to compute the probability of the truth of those two statements, making the underlying structure explicit, I would get many more right answers. This is an exercise in framing in which I have a real effect on their use of their cognitive abilities without deceiving them in any normal sense. Sunstein himself says that people often just don’t have clear preferences (or that it is unclear what it would mean to say that they have preferences) due to framing effects and that this fact can be leveraged to improve persons welfare without robbing them of the freedom to choose. Both of these are exactly the kind of cognitive technologies of power relations (in Foucault’s sense) that, while in the case of the MMR vaccine campaign are relatively innocuous, point to forms of governmentality and subjectification with more ominous overtones. (How are/might “nudges” be constructed to increase military enlistment despite the immorality/unpopularity of some war? How would those micro-level interventions interact with the disasterous consequences the macro-interventions of some-or-other economic policy? Or: more generallly, what sorts of things are we treating persons as when we use power/knowledge in this way–what sorts of subjects are we “making” them into? I think questions like these are not going to be answered especially well in the register of liberal/juridical concepts like legitimacy/illegimacy and related notions such as transparency, coercion.

    Thanks again!

  10. Wayne, you assume that coercion is likely to be significantly more successful than the method I have suggested – but we have no guarantee of that. Parents may not respond to legislation requiring them to get their children vaccinated with quiet obedience. One of the articles I linked to in my blog reports that, when childhood vaccinations were made mandatory in the US, there was uproar and many parents were arrested for non-compliance. I imagine something similar would happen in the UK, given that it is roughly as liberalised as the US. If the UK government is seriously to consider a significant infringement of its citizens’ liberty – and legally requiring people to vaccinate their children would be a significant infringement of their liberty – it had better have good reason to believe that doing so stands a good chance of achieving an end good enough to outweigh the badness of the infringement of liberty. However, we have little reason to believe that making the MMR vaccination mandatory would achieve results that are any better than using a non-coercive strategy.

    Eric, let me address your points in reverse order. I completely agree that the prospect of those in power exploiting cognitive bias for unscrupulous ends is worrying. But this doesn’t entail that exploiting it for ethical ends is suspect. All sorts of tools available to a government can be used either for good or ill – taxation and education, to name just two examples – but we don’t usually take the potential for abuse to be a good reason not to use those tools at all. Instead, we expect measures to be put in place to ensure that they are used only (or at least mainly) for good. Similar measures could be put in place to ensure that the exploitation of cognitive bias is used only for good. Admittedly, this is likely to be tricky, and perhaps even impossible in practice – it would, for a start, be difficult to prove that a given piece of information is being presented with the intention of deliberately influencing choices in an undesirable direction – but this does not entail that we should not try. We currently try to regulate all sorts of things that are likely to be, in practice, impossible to regulate effectively (for example, we try to catch all terrorists before they attack); and our legal system deals regularly with the problem of trying to prove things that are difficult to prove (for example, that someone killed someone else deliberately rather than accidentally).

    I don’t accept that influencing choices about vaccines by adding a drug to the water supply is morally equivalent to influencing choices by nudging. We all, presumably, accept that if parents are to be encouraged to have their children vaccinated, they should be provided with information about the vaccine. My suggested strategy is simply a suggestion that this information is presented one way rather than another. My strategy is intended to influence choices in a particular direction; but it is not the case that, if this strategy is not implemented, then choices will not be influenced in any particular direction. Currently, I have argued, parents are being influenced in such a way as to overestimated vaccine risks compared to disease risks. What my suggestion amounts to is this: given that parents must be provided with information about childhood vaccines, and given that this information will end up influencing their choices in some way, let’s ensure that these choices are influenced in such a way as to safeguard the best interests of the children concerned. Unlike providing information about vaccines, however, adding drugs to the water supply is a choice-influencing tool that can be avoided.

  11. Wow, I am shocked. How about the fact that vaccines are not 100% safe and carry very real risks themselves for a small number of recipients. Who decides then what the acceptable sacrificial number of children is for the good of the collective? There are contraindications to different vaccines, as well as allergies to vaccines that parents are not always able to assess by the age at which the vaccine is recommended. While I don’t promote the idea that people should not vaccinate their children, to imply that parents who don’t vaccinate are “ducking their responsibility” is absurd. Parents want whats best for their children and should be given some credit for being skeptical. After all, vaccines have been recalled and made safer on multiple occasions after being found contaminated or harmful by the FDA. Letting the collective make health decisions for all individuals is a dangerous and slippery slope.

  12. I had a family member pass out and go into seizures right after getting a vaccine. You people are twisted if you would force parents to expose their children to that kind of danger. The CDC itself admits that vaccines cause fevers, swelling, brain damage, seizures, deafness, paralysis, coma, Guillain-Barr Syndrome, and DEATH. YES, the all-knowing CDC says it on its website.

    Also I have seen ZERO evidence of vaccines actually working. I have known numerous cases of people contracting the disease they were vaccinated for, either because of the vaccine or in spite of it. Either way I see vaccines as a huge failure. People get the flu vaccine and then spend the following 2 weeks with the worst flu of their lives. I know a lady who spent a year with pneumonia after being forced to take the vaccine in the military. My sister took the HPV vaccine Gardasil and then contracted HPV, from the shot. What a CROCK!!!!

    Also you need to read the 4th Amendment of the US constitution. People have a right to be secure in their persons, meaning free from government molestation of any kind. What you are advocating is incredible violation of people’s rights and destruction of the constitution. People will not take kindly to your heavy-handed Nanny State solutions.

    I suggest you have your Living Will written before you plan to force that poison into my family. I speak for a large percentage of the population. American freedoms are already practically extinct. Send some government thugs after us with a needles full of mercury & carcinogens and WE WILL RESIST.

    This blog SICKENS me. “Ethics”, WHAT ETHICS???

  13. R.I.P. LIBERTY, I have – both in this blog post and in my responses to other commenters – argued against making vaccinations compulsory. You might at least take the trouble to read the blog before deciding to be ‘sickened’ by it.

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