Thursday, December 17, 2009

Should Immunization Decisions be Internal to the Family

I heard a woman interviews on a PBS program on the H1N1 flu pandemic state as if obvious that the decision to immunize a child should be made by the family. That strikes me as simply wrong. First, few families have the knowledge of the risks of immunization versus the risks of the disease; those families need expert advice so the trained practitioner should be fully involved in the decision.

More fundamentally, immunization is a communal decision. If a high level of immunity can be obtained for a total population, then a communicable disease will not spread -- each immunization benefits others, each unimmunized child represents a threat to others. Moreover, the risks and benefits are non-linear, because the threat of the epidemic/pandemic is highly nonlinear around the point where one victim is on the average likely to infect more or less than one other person. If it benefits a community to have a high level of herd immunity, then the community as well as the family has an interest in the immunization decision. Indeed, modern network theory has pointed out that the threat posed by one unimmunized person depends greatly on who that person is and the way he/she is connected with others. While it may be OK to leave the decision on immunization to a family that lives in isolation in rural Alaska, it is clearly not OK to have public health nurses dealing with large numbers of immuno-compromised patients unimmunized.

Similarly, it a family expects that a child who becomes seriously ill with flu will be hospitalized and provided with intensive medical care, and if the family expects that the costs of that care will be shared with the community (by public health services or some form of health insurance) then the immunization decision has economic implications for the others who might help pay for the care of the sick. In this case too, the public has a right to participate in the decision.

Of course, in our society we allow for families to play a key role in such decisions. It is the family that bears the greatest risks if a member falls ill, and it is a family that will know if there are medical reasons why a member should not be immunized. Moreover, a family might have religious reasons to avoid immunization. However, the family rights do not trump the community rights to participate in the decision.

No comments: