This headline comes from a story on Yahoo today by Jessica Ashley. Pediatricians in Chicago and NYC discuss their new policies on refusing to see patients whose parents have chosen not to vaccinate them. Since these markets are large enough that the parents have the option of finding another doctor, the pediatricians feel comfortable that their policies are not depriving anyone of medical care. It sounds like they would not have the rule if they were located in, say, a rural area where parents could only access one such doctor.
Personally, I think this is a good policy that will protect the health of other patients who are vulnerable or too young to have been fully vaccinated. It’s not fair for parents who decide not to vaccinate to expose and endanger other children whose parents don’t have the luxury of such a choice. I would be pleased if my own doctor’s office chose to adopt such a policy, as it would give extra protection to our kids who suffer from asthma and for whom vaccination is not complete protection against illness, and to our soon-to-be new baby who will be making all of those regular, early trips to the doctor before he or she is old enough to receive vaccines and boosters. Pertussis and mumps are both making a strong comeback in my area, thanks to the high numbers of unvaccinated children. I don’t need my newborn or asthmatic kids exposed to those germs in the doctor’s office, thanks!
As a followup to my earlier post on the proposed circumcision ban in San Francisco (and Santa Monica), one argument I’ve seen made in response is that I shouldn’t be so vehemently pro-vaccination if I want to preserve choices about circumcision on the grounds that the medical evidence is mixed. Three quick responses to this argument:
1. The medical evidence in favor of vaccinating children is far more powerful than the evidence about health benefits or risks on either side of the circumcision battle. For this reason alone, we shouldn’t demand that the two cases be treated in parallel.
2. I advocate mandatory vaccination, but not mandatory circumcision. I don’t think there’s even remotely near enough evidence of health benefits from circumcision that the state should mandate the procedure. My position is simply that there’s enough evidence for me personally to think it’s a good idea for my own child, but even then it was a close and difficult call. When the state is going to mandate something, as opposed to leaving it an open choice, the standards of evidence have to be very high.
3. Failure to circumcise could have small and indirect effects on the health of others: for example, female partners of circumcised males would lose the apparent benefit of being somewhat less likely to contract an STD. However, several other and better preventative measures exist. Failure to vaccinate, by contrast, has major and direct effects on the health of others. Diseases that should be eradicated or incredibly rare are making comebacks because of the spreading anti-vaccination sentiment. Vulnerable populations who cannot receive a vaccine or who remain susceptible even with vaccination are dependent on the “herd immunity” that is threatened when more people choose not to vaccinate. Because of the direct and life-threatening consequences for others, this case needs to be treated differently from the circumcision case.
I had doubts about giving my oldest child the chicken pox / varicella vaccine back when it first became available to her. My father had only a mild case of chicken pox as a child, and developed insufficient immunity so that he caught the illness again when I had it. As a child, I suffered from a few days of uncomfortable itching; as an adult with the disease, my dad became gravely ill, was hospitalized, and could have died or suffered severe complications. I was worried that if children didn’t develop sufficient immunity from the vaccine–since there was talk that immunity might wear off over time, or that more shots would be required later–they would be more vulnerable to the kind of serious case my dad suffered. However, it turns out that the best way of preventing those cases is simply to reduce the number of kids who have chicken pox, thereby reducing exposure for adults or other vulnerable patients. Needing a booster shot later isn’t a problem if most children in the community aren’t contracting the illness in the first place. If people don’t choose to vaccinate, though, we won’t achieve this kind of group effect, and more people will suffer from an easily preventable problem.
In San Francisco, supporters of an initiative that would ban circumcision of males under 18 say they have enough signatures to place the measure on the November ballot. I find it rather rude for some to suggest that the state should prevent parents from making this decision for their own children. I would find it equally unpleasant if the state were to mandate that boys be circumcised. I am not aware of any evidence about health benefits or drawbacks that is strong enough to compel only one decision about this issue. When reasonable people have legitimate disagreements about how to weigh uncertain evidence on both sides, it seems wrong for the state to mandate one approach or the other.
Though the proposed San Francisco measure would not offer a religious exception, my reasons for considering circumcision always had to do with health rather than religion or culture. According to the CDC, circumcision may reduce the chances of acquiring or transmitting diseases like HPV or HIV. A reduced incidence of penile cancer is also reported. I understand that some men end up seeking circumcision later life due to phimosis or other physical difficulties in older age, but by then the procedure is more likely to have complications or a difficult recovery. Thus, if circumcision is chosen for potential health benefits, it seems better to have it done during infancy.
Though the above reasoning led me to conclude that I would probably circumcise a newborn son, I certainly appreciate the gravity of the opposing arguments, and I understand why parents might come to a different conclusion even from the same evidence. Any time a parent makes a decision for a child that has permanent effects and could cause suffering, it should be undertaken with great caution after investigating the available evidence. The mild hysteria about this issue in recent years can make it more challenging to find quality evidence. For all I know, the medical evidence may someday change, and my decision along with it. However, based on what we know today, the state needs to allow parents to weigh and decide this question for themselves.
Now that the circumcision ban is in the news, one argument I often hear is that medical organizations like the AAP do not recommend routine infant circumcision. However, this does not mean that they recommend against it, as some people misleadingly allege. Rather, there is insufficient evidence of health benefits to support recommending that the procedure be done routinely. The AAP, like other medical organizations, acknowledges evidence of both risks and benefits of circumcision. This is why I think parents who choose not to circumcise are perfectly justified in that choice and should be free to make it. Similarly, parents who choose to circumcise should be afforded the same freedom under the law.