While I’m on the subject of medical ethics, this article caught my eye the other day:
All males starting at age 11 should receive the HPV vaccine Gardasil to protect themselves against sexually transmitted forms of human papillomavirus, the cause of most cervical and anal cancers as well as most mouth and throat cancers, a Centers for Disease Control and Prevention advisory committee voted today.
Thirteen members of the committee voted in favor of extending the HPV vaccine recommendation to young boys, and one member abstained. The recommendation now goes to the director of the CDC and the secretary of the U.S. Department of Health and Human Services for final approval.
The CDC already recommends routinely immunizing girls with a three-dose vaccine beginning at age 11 or 12, before they become sexually active, although they can be vaccinated as young as age 9. The agency previously issued a so-called permissive recommendation giving boys and young men from ages 9 through 26 the option of receiving the vaccine.
I haven’t followed the discussion of vaccination of girls against HPV at all. Here’s the part that caught my eye:
But Dr. Lawrence Stanberry, chief pediatrician at New York Presbyterian Morgan Stanley Children’s Hospital, said parents support universal recommendations more recommendations targeting groups at higher risk.
“Recommending universal immunization for girls and making the recommendation for boys permissive sends parents mixed messages,” Stanberry said.
He offered a fairness argument for recommending vaccinations for both sexes.
“Girls acquire the infection from boys and it seems appropriate, even fair, for boys to share responsibility for maximizing community [herd] immunity,” he said.
It appears to me that’s on shaky ethical grounds. Let me lay out my thinking.
There’s a small but real risk of death from being vaccinated against HPV just as there is a small but real risk for contracting anal cancer (the estimate is about 50,000) deaths a year. That’s not where the ethical problem that I see is.
The professional’s primary ethical responsibility is to the patient or client not to a third party or “the herd”. If a physician performs a procedure on Person A that has real risk and little benefit to Person A but greater benefit to Person B who is not they physician’s patient, the physician may be acting for the greater good but I don’t see how it is ethically licit. I also don’t see how things like patient confidentiality can survive such a standard.
I don’t have particularly strong feelings one way or another on this subject. I’m just mulling it over. What do you think? You be the medical ethicist.
Megan McArdle wrote a pretty compelling post on good reasons to vaccinate boys.
As to the ethical question, vaccination is designed to protect the herd. Most people won’t get many of the diseases we vaccinate for yet they are still required to get vaccinated and risk potential complications. This mainly benefits vulnerable groups and not necessarily individuals. I don’t really have an ethical problem with that.
Dave Schuler: The professional’s primary ethical responsibility is to the patient or client not to a third party or “the herdâ€.
It is certainly a doctor’s first responsibility to quarantine someone with a highly infectious and dangerous disease.
Quarantine is not an ethical responsibility of the physician.
Dave Schuler: Quarantine is not an ethical responsibility of the physician.
AMA Code of Ethics: The Use of Quarantine and Isolation as Public Health Interventions: “The medical profession, in collaboration with public health colleagues, must take an active role in ensuring that those interventions are based on science and are applied according to certain ethical considerations.”
Perhaps I should have modified that to “solely”. The physician must always act in the best interests of the patient. The ethical consideration arises when the action threatens the welfare of the patient.
Yikes! Fascinating. I, too, must mull this over, but I’d be extremely interested in steve’s take.
I have a fiduciary duty to my investors, and not the “herd.” But what if my fiduciary duties conflict with…….the law. Well, that’s easy. I don’t have to break the law to maximize my duty to an investor. But what if my fiduciary duties conflict with other considerations…….let your mind wander.
In business, that’s why they have the legal protection of the “business judgment rule.” In short, “what would a reasonable group of people do?” With gardband surrounding the decison, in either direction.
Do you torture a prisoner to save thousands from a terrorist act?
Do you send men to war at risk of death or being maimed, and of the so-called “collateral damage” for the greater goal?
Do you subject an individual to vaccination risk for the benefit of a “herd?”
Ever wonder why Presidents go in with youthful look and dark hair……….and come out grey and haggard?
It ain’t easy when you are the “decider” and not just a clown on the sidelines.
I guess I could cop out by noting that HPV is associated with penile, anal and oral cancers. TBH, I am not sure how efficacious it will be against developing these cancers, but the risks are pretty darn low for the vaccine, so it is likely a positive.
However, the larger question is more difficult and interesting. I would advocate for policy that may still seem like a cop out, but it is what we should do IMO. I think physicians should retain primary responsibility to their patient. A doc should discuss a male child receiving this vaccine with parents noting the advantages and disadvantages for the child. I think it perfectly legit to mention the herd immunity and how it also protects women, but the doc should not pressure parents on that basis.
The decision to require immunizations to protect others is not something to be decided by physicians. That is a social/moral question which is too important to leave up to doctors. I dont think doctors are necessarily any better at these kinds of moral decisions than anyone else.
Steve
Thanks Drew and Steve for commenting and also for understanding the underlying issues in the question. Steve brings up the important issue of informed consent. As I’ve mulled the question over I’ve come more to the view that Steve suggests in his comment: the physician should present the vaccination as an alternative, advising the parents of the child on the risks and possible third party benefits.
I maintain my previous position on the ethical responsibilities of physicians: the physician’s primary responsibility is to the patient. My reading of the AMA ethical guidelines on quarantine is that the code of ethics’s position allows physicians to participate, as advocate for the health and welfare of his or her patient, in what would otherwise be a course of action in which it would be unethical for him or her to participate.
What alarmed me in the original article was the assertion that such vaccination should be undertaken in the interests of fairness. While such an assertion might be reasonable from a public health official, IMO for a physician it skates very close to a breach of ethics.
I think at the end of the day I feel the same as steve and Dave: the doctor patient relationship must be primary. But I’m still left with a level of uncertainty.
Don’t school officials require children to receive certain vaccinations so they won’t infect entire classes? They do here in Naperville.
On the opposite side of the argument (and I fly alot) I can’t imagine requiring everyone to get a flu shot so that they don’t infect passsengers on a flight. Although it probably would be in the interest of overall public helth.
Perhaps the risk reward tradeoffs in various cases are different.
Tough issue.
You always have informed consent. No one can force you to get you or your children vaccinated against measles, rubella, meningitis, etc. as long as you’re willing to homeschool. Your chances of getting one of those diseases is very small, but that is mainly thanks to herd immunity.
Is the threat of HPV big enough to justify mandatory vaccination for school children, to provide similar herd immunity? In other words, is this a public health problem? At this point, I think it is.
I haven’t been able to come to some resolution myself about required vaccination for HPV. Perry’s effort to push such a mandate through, though, has re-opened the conversation, and initially I took the side of being uncomfortable with such a mandate.
However, after doing more research I can’t help but come to the conclusion that there is sound reason for implementing a mass program of vaccinations for the following reasons:
1. Unlike curable bacterial STD’s such as syphitis and gonorrhea, which were the only 2 STDs in 1960 (now there are over 25 recognized), HPV has an incurable aspect to it’s management.
2. Condom protection does not work in preventing the disease, as it is spread by skin-to-skin contact, rather than bodily fluid exchange.
3. As of 2005 it was estimated 56 million were infected with HPV, with 33% of ALL woman having it. That’s huge, and that statistic is likely to be even greater and more worrisome in 2011.
4. HPV is a collection of a 100 types of viruses, 20 types of which are incurable. The worst part, though, is that only 1% present with visible symptoms (genital warts), while the rest are considered ‘subclinical’ and ‘asymptomatic’ with no visible symptoms at all. Now that is scary!
@Drew- I think that when you have a daughter, this hits home a bit harder. It’s a tough question to answer with no settling answer.
Steve
I think a lot of parents are somewhat annoyed by the number and proliferation of vaccines, the posterchild of which is for childhood chickenpox. Most of us have had it, and the justification for it appears to be almost purely economic (it saves mom/dad from taking time off work). And then the stories come out about whether it was being given at the right ages, whether the protection lasts as long as originally billed, and whether the vaccinations are increasing adult shingles. CDC comes off with a pro-vaccine bias.
I think any vaccine that is to be mandated by the state on the basis of herd immunity concerns should be paid for by the state. It seems to me that costs are big part of the problem, and I can’t tell how much CDC is influenced by the notion that its recommendations will increase the likelihood that states will force insurance companies to pay for their decisions.
As is the case for prostate exam or colonoscopy, the elderly person has little to gain and a lot to lose by such a vaccination, with the result that it would be unethical for a doc to perform it. The same should hold for sexually inactive young persons as well.
People continue to forget that our 14th Amendment protects liberty and property as well as life.