I had a nightmare recently: in it my 10-year-old son showed me blistering sores covering his back. As I reassured him he already had chicken pox and was going to be fine, the sores grew into larger, more grotesque lesions. Then I awoke.
Reading the news of the spreading measles outbreak in the US, and more recently in Chicago’s suburbs, I realized that my conscious anger at parents who refuse to vaccinate their children had seeped into my unconscious.
There, it manifested as raw fear for my children’s health.
But rather than stoking my anger with the anti-vaxxer parents, the nightmare increased my empathy, offering a visceral reminder that parental motivations are complex, sincere, and largely rooted in concern for children’s welfare.
When I’m not being a dad, I do research to understand the experience of illness from the point of view of patients and families. I focus on how and why people make decisions about whether to take medications or follow other medical advice.
Although vaccine refusal gets a lot of attention, especially when it is linked to an outbreak of preventable infections, refusing or resisting medical advice is commonplace. It is more the norm than the exception. Across the spectrum of recommendations about diet, exercise, smoking, drinking, safe sex, and medication-taking, just over half of all people do as their doctors say.
From a biomedical perspective, ignoring medical advice seems irrational. But seen through the eyes of patients and families, it makes more sense.
The general skepticism and cynicism of anti-vaxxers is not wholly without merit. Vaccines have caused harm, the best known example being Guillain-Barre syndrome (an acute paralysis syndrome) following the swine flu vaccination program in the US in 1976 (though the harm is exaggerated). Medications are often harmful: thalidomide was a sedative and anti-nausea drug that caused serious birth defects in thousands of children; DES was a drug sold to pregnant women to reduce the risk of miscarriage that caused breast cancer in mothers and vaginal cancers in children exposed in utero; and Vioxx was an arthritis pain medicine that increased the risk of heart attack, stroke, and heart failure being the classic examples of a much more widespread problem.
Drug and medical device companies have repeatedly, and often fraudulently, exaggerated the benefits and minimized the risks of their products. Many diagnostic tests and medical treatments are unnecessary and harmful. Doctors themselves now urge parents to choose wisely which interventions to undergo.
These facts justify healthy skepticism and a conservative approach to prescribing. By encouraging such conservatism, physicians have even greater credibility when they eventually do recommend active treatment or prevention. Any credible argument in favor of vaccination must acknowledge the real and specific risks without making sweeping generalizations about all treatments being harmful.
Into this complicated mix has entered another cultural current: Patient autonomy (“freedom to choose”) has begun to surpass beneficence (“first do no harm”) as the dominant ethical imperative in medicine.
Patients’ concerns about the risks of medical care are in part well-founded—doctors themselves urge patients to be more skeptical, and patients are increasingly encouraged to assert their autonomy and to participate in shared medical decision-making.
As parents, we are allowed great autonomy in how we raise our children, but there are laws against abuse and neglect. Furthermore, I am not allowed to hurt your child, and you are not allowed to hurt mine.
With respect to medical care, courts can and do order life-saving treatment to be provided to children over their parents’ objections.
Most relevant to the anti-vaccine issue, when it comes to highly contagious diseases like tuberculosis, there are state laws that mandate screening, testing, reporting, investigation, forcible treatment, and even detention, quarantine, restriction of movement. And of course there are laws requiring proof of vaccination prior to registering for school. Even our most basic constitutional rights have limits (e.g., speech-related prohibitions on obscenity, child pornography, and inciting violence).
Given the cultural value placed on autonomy, the best possible scenario would be to persuade anti-vaxxer parents to vaccinate their children voluntarily. But evidence shows that once these views take hold, people are largely unresponsive to rational, evidence-based persuasion by means of listing pros and cons, risks and benefits.
Scare tactics don’t work either.
This is true outside the realm of vaccines, where many patients resist taking medicines that are objectively “good for them.” Interviews and focus groups with such patients reveal that many resist because the meaning of the medication is not consistent with their own identities or life stories.
People resist antidepressants because they do not want to accept the stigmatized identity that comes with mental illness. Others resist asthma medicines because they see asthmatics as weak and crippled. Still others, inclined to lead “organic” lifestyles reject medicines as “artificial” or containing “chemicals.”
To overcome this type of identity-based resistance, there are two logical possibilities.
First, we could try to reframe the meaning of the medication in a way that is consistent with the parent’s identity. That would mean encouraging people to see that the medication symbolizes love and concern and that vaccination is a loving, parental expression of the desire to protect your children. It also affirms a commitment to the common good.
Second, we can attempt to offer parents an alternative identity, presenting an identity of pro-vaccination that is desirable. More parents would want to assume this pose if they were convinced a pro-vaccination identity is optimal.
There is a limited scientific literature about this type of identity-based persuasion, especially in the realm of consumer products. Many can remember the “I want to be like Mike” Nike campaign years ago, and it may work in this application. But, yes, it is not the traditional approach for having parents sign on to vaccinations for their children.
There are certainly major roadblocks to those two approaches. Given that some continue to maintain anti-vaccination attitudes in the face of media and peer persuasion, and that we have a cultural preference for autonomy and a general discomfort with forceful compliance, it would be hugely valuable to have a better understanding of how to change such antisocial behaviors.
Can we convince the anti-vaxers to simply do the right thing? Until new methods of persuasion are developed, we have little choice but to compel compliance with vaccination requirements, eliminating all personal exemptions. But without trying, our dreams of a healthy future for our children turn to nightmares of death from preventable infectious diseases.