Misled and Confused? Telling the Public about MMR Vaccine Safety

This article, published in the Journal of Medical Ethics 2003, No: 29, examines the ethical issues surrounding various groups and individuals who have legitimate roles in informing the public about vaccine safety. The article examines the United Kingdom (UK) debate surrounding the measles, mumps, and rubella (MMR) vaccine. Specifically, it discusses the ethics surrounding provision of the right information to enable the public to make the choice about whether their children should receive vaccines.

The authors argue that because the media have reported a mixture of scientific evidence, theories, views, opinions, etc., caregivers of young children are not convinced that vaccines are safe. They are not sure who to listen to and trust. Hence, they are reverting to the belief that it is safer to have the disease than have their children vaccinated. To support its observation that vaccine and immunisation communication to the public is challenging, the article cites various other public health issues on which the public feels misled or feels that information given through a variety of channels is incomplete.

In addition, the public, as stated here, is a challenging audience which can "detect flaws or inconsistencies of argument, analyse the risk benefit ratios, or identify omissions in evidence presented to them. The public may focus more on the presence or absence of risk rather than the relative risk of a situation. Because of these and other potential problems in communicating with the public, professionals somehow need to draw them into a participatory process in any risk communication efforts."

The article poses this question on informing the public: "Exactly who is responsible for informing them? Certainly governments (politicians) and their appropriate health agencies must take the vanguard in this task, and, of course, individual health care workers at the vaccination visit. But there are many other actors on the stage. Independent scientists may undertake research or possess specialist knowledge that the public may need to know about. The medical press is a valuable source of reference for informing both the professions and the public in this area. Independent authoritative bodies such as the World Health Organization (WHO) may contribute technical information and advice at a global level. For instance, WHO has access to the world's top experts in the area of public health and is able to distil their wisdom into useful, independent guidelines for member nations.

Finally there are independent individuals and organisations who make their voices heard about the safety of vaccines, especially when they differ from the official view on some aspect of safety. This heterogeneous group of individuals has become known as the antivaccine lobby and encompasses parent groups, individuals, and even congressmen. They operate through a number of methods, including an extensive number of internet sites. The antivaccine lobby is not, however, mandated with responsibility to inform. Instead they form an invaluable, if at times uncomfortable, voice of dissent, a capacity highly valued in Western civilisation."

The authors discuss information dissemination by various parties and challenges to the ethics of interested parties, as well as contingencies affecting disinterested parties. For example, health care workers may be judged for performance based on low immunisation levels, or medical correspondents may be encumbered by the media's need for profit through sales and advertising. Governments generally use information packages to promote public health policies. In the UK, immunisation is promoted through printed material, television slots, and other public service announcements. In this way, as stated here, the government controls the content, providing as much information for and against the policy as they consider appropriate to the situation. Reporters often present two differing points of view in which the results of medical research involving a large population study may be presented alongside the opinion of an individual who be advocating a position based on a single experience. The internet is an additional information source where seemingly plausible websites may present biased information from pressure groups, activists, or special interests.

The authors discuss the two sides of partial disclosure. On the pro-vaccine side, there may be an aversion to discuss the minor part of the population that has mild reactions to immunisation and the even smaller number that has serious reactions. On the anti-vaccine side, there may be an aversion to admitting that if a low number of children go unvaccinated, they are often protected by the "herd immunity" of those who are vaccinated, while if large numbers are unvaccinated, deaths due to the disease may soon outnumber those from vaccination reactions. The authors then outline the ethical implications of the responses of the following actors regarding complete or incomplete disclosure on vaccine information:

• Politicians - The authors suggest that there can be a difference in the vaccine message based on the politician's audience: Based on literacy and personal experience with disease prevalence, the audience in industrialised countries need to know the percentage of cases of serious and mild reactions, while the illiterate mother in a high disease risk area may need to hear only about the protection offered by the vaccine.
• Health Care Workers - Though honesty in health professionals is a quality sought by patients, the article recommends emphasising the safety of vaccines and their proven ability to reduce health risks through disease prevention and does not recommend what it characterises as "truth dumping" of side effect information.
• Researchers - "The first ethical principle of the researcher is to be honest in both the conduct of the research and its reporting. He must also understand and communicate the limitations of his study. The write up must be of a standard that will allow the experiment to be repeated exactly by another researcher seeking to validate the work. The results and conclusions must be limited to what has been shown by the study, and personal views should only be expressed if they are clearly identified as such, and not given the same weight in the report as the scientific observations."
• The Medical Press - "The common practice for most journals is to call on a panel of experts to undertake a peer review of an article before its acceptance." However, when the occasional article is published and later found to be inaccurate, the public seeks admissions of responsibility on the part of the press and the authors.
• General Media - Key principles of the press include accuracy, impartiality, and freedom to publish. The authors suggest that if inaccurate information appears, a correction or retraction appear with the same prominence as the error.

The article concludes that "[w]hether the public understands and accepts important information in the debate will depend on both the communication skills, and the credibility, of the source." It states that ultimately individuals must decide whether to follow public policy or the lead of an anti-vaccine lobby, but those who present information must take responsibility for the consequences of immunisation-related decisions.