Who is responsible?

While perhaps underappreciated, vaccines are perhaps the greatest advance in modern medicine. Diseases that killed thousands and devastated millions of lives are simply prevented. It’s not perfect – no science is – but from a historical perspective, the change is beyond dramatic.

And it seems that we have become victims of our own success. It’s hard to imagine that during the worldwide influenza epidemic of 1917 that anybody would argue against vaccinations. It’s just as hard to imagine parents of a child with polio refusing to vaccinate their other children when it became available on principled grounds.

The argument that “it’s not necessary to vaccinate since these diseases don’t really exist anymore” is actually quite common. The fallacy is that most people don’t know anybody with these diseases is precisely because of vaccinations. In fact, when a patient came in to Bellevue Hospital with the measles, it took quite some while to accurately diagnose him because most of the staff had never actually seen a real case.

Leaving aside any “scientific” argument against vaccinations (since the “science” it was based on has been proven to not only be wrong, but completely fabricated), a larger public policy debate still looms as to responsibility for vaccination.

As a liberal democracy, we tend to let each person live their own life and make their own decisions, until those decisions start to adversely affect others. So while we will tolerate smoking and drinking, we limit smoking and public areas and prohibit drinking and driving.

When it comes to vaccinations, it’s more complicated.

In theory, an unvaccinated person (leaving aside for the moment that often it’s parents that are deciding for their kids) is taking a risk for themselves. Generally speaking, we as a society allow risk taking (within limits) in allowing [and usually encouraging] personal autonomy. However, when it comes to vaccines, there are others who are put at risk as well.

There are a whole class of individuals who cannot receive some or all vaccines because of medical reasons. These include otherwise immuno-compromised individuals and those allergic to some component of a given vaccine, among others. When an unvaccinated person becomes infected, they can spread that infection to such people, who often are otherwise not so healthy to begin with.

Additionally, since vaccines are not 100% effective at preventing disease (no medical treatment is), it means that even among the vaccinated population, there will be people are who not completely protected against infection. They too can become infected from an infected non-vaccinated person.

Both of these groups of people want to be protected, they are simply unable to do so, either knowingly or not.

Does the unvaccinated person bear any responsibility?

Art Caplan makes the case that when a direct causal connection can be made, there is ample ethical and legal room to hold the non-vaccinator accountable for the ‘damage’ she inflicted. Whether it’s civil or criminal accountability will be a matter for the courts to adjudicate, every personal decision carries with it concurrent responsibilities. And even while an infected non-vaccinated person didn’t purposely or intentionally infect somebody else, it doesn’t necessarily exempt him or her from culpability and liability.

A recent study shows the larger societal liability caused when a group of people choose not to vaccinate. In 2013, a measles epidemic broke out in Brooklyn, NY.

58 people were infected, needing treatment and they collectively exposed another 3,351 to the disease, all who needed to be screened. A full 78% of those infected were unvaccinated because of refusal or intentional delay (includes only age-eligible cases, to exclude those too young to receive the vaccine).

Total direct costs to the Department of Health and Mental Hygiene were $394 448, and 10 054 personnel hours were consumed responding to and controlling the outbreak.

Aside from the moral issues involved, the MMR vaccine (measles, mumps, and rubella) costs $70.92. Meaning, that vaccinating those 78% would have cost $188,577 (plus labor) – a staggering amount, but almost 50% less than dealing with the epidemic once it spread.

That, and saving many people from hospitalizations, one miscarriage, one case of congenital measles, and tons of discomfort and feeling sick.

While not all moral issues can or should be adjudicated in terms of dollars and cents, count this as just one more reason that vaccination is one of the greatest social goods our society has to offer.