Strategy to Address Vaccine Refusal Must Include Research, Training, and Advocacy

Daniel J. Hurst, PhD

Fam Med. 2019;51(9):786-786.

DOI: 10.22454/FamMed.2019.138424

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To the Editor

Dr Seehusen’s call for family physicians to be involved in advocating for states to pass laws mandating childhood vaccinations against diseases seems prudent in the face of the risks posed to public health, and I have no qualm with it.1 Indeed, advocacy is increasingly being viewed as a core component of what a family physician must do. However, what merits further attention are the ethical and philosophical underpinnings behind the state compelling parents to vaccinate their children (barring exemptions for genuine medical concern) in order for such a program not to be viewed as unjustifiably paternalistic.

While Seehusen notes examples where individual freedoms have been restricted to protected populations—such as with drunk driving laws—I would find it helpful to also explicate the ethical underpinning of such a notion. In his “harm principle,” John Stuart Mill took the position that “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”2 Mill’s harm principle is often cited in public health ethics and public health intervention strategies as justification for policies that interfere with or abrogate individual liberty.3 To me, it seems that further parsing this out for family physicians could be helpful in garnering further advocacy to the cause.

Nonetheless, we also need to be cognizant of the challenges that persist—legal, social, and psychological—with mandatory interventions for childhood vaccinations, that Seehusen does not mention. New York City Mayor Bill de Blasio issued an order this spring requiring unvaccinated persons in certain areas of Brooklyn to receive the measles vaccine or face a $1,000 fine.4 This was challenged in the courts but was ultimately upheld. Yet, the social and psychological dimensions of mandatory vaccination, especially of children, are largely unknown. In West Virginia, though the state has achieved high levels of childhood vaccination,5 the law is only for children enrolled in public school.6 Logistical problems are also apparent. Were a parent to continue refusal for vaccination of their child, would the child be forcibly vaccinated, or face a significant fine, as in New York City, or simply not allowed to attend public school? Such a practice is not risk-neutral, as emotional harm to both the parent and the child could ensue from being forcibly vaccinated, and/or not being allowed to attend public school, placing the child’s education and future at risk. Further, while a physician or nurse may, in theory, believe that all children should be vaccinated, vaccinating a child whose parent is compliant versus one who is adamantly opposed to the vaccination could also produce harm to the provider in the form of moral distress.

While I agree with the general premise of family physicians advocating for solutions to the childhood vaccination crisis, additional work seems to be needed in order to prepare family physicians for this and to ensure that children and providers are not harmed by the practice. Research into the social and psychological dimensions of mandatory vaccinations—from both a provider and patient perspective—seems prudent. This could be analyzed in West Virginia or in a community that has very recently been mandated to receive vaccinations, such as areas of Brooklyn. Furthermore, if mandatory vaccinations are to continue—and family physicians are to be part of the advocacy and vaccination effort—then training on what exactly advocacy may look like, as well as risks that may ensue, is needed. As mentioned, one of the risks of mandatory vaccinations in a patient who is opposed to such vaccinations is that it may produce moral distress in providers, as the provider is aware they are doing something that is counter the wishes of the patient and/or family. The awareness of this potential risk is an essential first step.

Hence, as Seehusen noted, there is enormous opportunity for family physicians to be involved in advocating for mandatory vaccination laws. However, additional research and training should coincide with this call for advocacy.


  1. Seehusen DA. Time for Family Physicians to Change Strategy Against Vaccine Refusal. Fam Med. 2019;51(6):468-470. https://doi.org/10.22454/FamMed.2019.248359
  2. Mill JS. On Liberty and Other Essays. Gray J, ed. 2nd ed. New York: Oxford University Press; 1998.
  3. Faden R, Shebaya S. "Public Health Ethics" in:  The Stanford Encyclopedia of Philosophy. Winter 2016 ed. Edward N. Zalta ed. https://plato.stanford.edu/archives/win2016/entries/publichealth-ethics/. Published April 12, 2010. Accessed September 3, 2019.
  4. Madani, D. NYC measles vaccination order prevails in court. NBC News. April 18, 2019. https://www.nbcnews.com/news/us-news/challenge-nyc-measles-vaccination-order-dismissed-judge-n996186. Accessed 13 Jul. 2019.
  5. Holdren W. West Virginia has highest child vaccination rates in nation, but some parents want more choice. The Register-Herald. March 4, 2018. https://www.register-herald.com/news/west-virginia-has-highest-child-vaccination-rates-in-nation-but/article_c6fb222b-905c-552a-84a3-5bef92763b29.html. Accessed 8 Jun. 2019.
  6. West Virginia Code. Chapter 16: Public Health. Article 3: Prevention and Control of Communicable and Other Infectious Diseases. http://www.wvlegislature.gov/wvcode/chapterentire.cfm?chap=16&art=3&section=4. Accessed June 8, 2019.

Lead Author

Daniel J. Hurst, PhD

Affiliations: Cahaba-UAB Family Medicine Residency, Centreville, AL

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Seehusen DA. Time for Family Physicians to Change Strategy Against Vaccine Refusal. Fam Med. 2019;51(6):468-470. https://doi.org/10.22454/FamMed.2019.248359.


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