“The risks are far greater to your child of not getting immunized than any kind of speculative potential relationship between the vaccine and the development of autism.”
– Irwin Redlener, MD
There is perhaps no greater illustration of the delicate balance between personal rights and the public health need for a collective response to disease than the hotly debated topic of vaccination. Different levels of government (federal, state, municipal) continue to evolve their regulations and guidance, meanwhile misinformation abounds on the Internet and elsewhere to the detriment of established scientific fact. In the context of applying to medical school, your own personal opinion can be a highly dangerous item to introduce into a medical school interview setting without the proper context. White Coat Checklist has framed a consistent approach to topical issues to help medical school applicants frame even highly contentious issues with both perspective and coherent respect:
- Historical Perspective & Implications
- Arguments In Favor
- Arguments Against
- Inclusive Response
The maturity and presence of self-control for a moment of thoughtful introspection will only grow in importance as health care systems and hospitals assume much more direct responsibility and financial risk for actual patient outcomes.
Historical Perspective & Implications
Appropriate factors for consideration include the following:
How long has vaccination existed as a historical practice?
What are the current public health guidelines in the United States regarding vaccination?
What rights does an individual have, if any, to refuse a vaccination?
What rights do parents have, if any, regarding stipulating or refusing vaccinations on behalf of their children?
What are the known clinical guidelines regarding vaccination?
What substantiated medical problems can be associated with vaccination?
How has pricing of vaccinations relative to public health value impacted vaccine schedules and policy recommendations?
Vaccination has existed as a medical practice option at least since the year 1000, and this technique was first documented in China, Turkey, and Africa before eventually reaching Western Europe more than 700 years later. Many early treatments revolved around the prevention of smallpox – a once-feared disease which now only resides in a handful of sealed vials in two countries, while the vast majority of people alive in the 21st century have no immunity against this nearly eradicated menace. This very achievement has been the source of some debate – is it prudent to actively seek to wipe out all smallpox stockpiles when unknown vials can unexpectedly come to light? Smallpox was one of the most responsive communicable diseases to vaccination – the parallel case study of polio provides an example of how the requirement of repeated vaccination administration and the challenge of more pervasive socio-political challenges can combine to forestall even billion-dollar global eradication efforts. As the CDC itself states, the consequences of not protecting against vaccine-preventable diseases can be tragic both for individuals and entire populations, because the phenomenon of herd immunity ultimately means that communities share the benefits of vaccination as well as the risks of not vaccinating. Even individuals who may have already been immunized can still contract the disease because very few vaccines are 100% effective. There is also the fact that some individuals, including very young infants and immuno-compromised patients, sometimes cannot receive vaccinations and therefore are forced solely to rely on herd immunity for their own individual protection. The U.S. Health Resources and Services Administration also maintains a very select list of legitimate rare complications which are eligible for compensation from vaccinated individuals, but rumors still abound on the Internet of supposed risks like thimerosal which have been conclusively refuted by repeated studies. Meanwhile, costs for newer vaccines are becoming increasingly disconnected from their public health benefit, to the point that some higher-cost vaccines are being restricted to certain populations rather than all prospective vaccine recipients and some physicians are choosing not to stock vaccines because of the significant up-front financial investment and cold storage costs required to stock highly perishable products. At least a handful of researchers aren’t sure vaccines are the best public health approach in all cases with some diseases like HPV that only rarely lead to actionable harm and where the long-term protective capability of a relatively new vaccine has not yet been established. As this map reflects, religious protections against vaccinations are nearly universal in the United States but California and Vermont have recently joined a majority of states in refusing to honor philosophical objections. It’s also worth noting that in the case of certain populations like private university students, those institutions can have stricter requirements than state law would otherwise allow because attending these institutions is elective, not required.
Arguments In Favor (‘Pro Vaccination’)
- Herd immunity is a powerful argument in favor of maximizing access to vaccination, under the theory of collective benefit to everyone from the respective actions of each individual and family in taking advantage of readily available public health resources
- Research has shown that physicians have a statistically significant ability to influence likelihood of vaccination based on how holistically they engage patients in staying on course through the process.
- Globalization has increased demonstrated that avian flu, Ebola, and other disease which emerge in remote corners of the globe have the ability to easily cross international borders in mere hours or days, well before any government effort could reasonably be in place to halt an outbreak
- One of the greatest vulnerabilities in our current public health system is that the proven infection of previously vaccinated individuals could trigger a ‘death spiral’ of fewer vaccinations based on a diminished sense of efficacy leading to more frequent and larger outbreaks
- States are acting to tighten vaccination refusal criteria in the best interests of their residents, both short-term and long-term
Arguments Against (‘Anti Vaccination’)
- New vaccines are increasingly being priced above their established public health benefit and of unknown long-term efficacy, which is forcing health insurers to limit vaccination ability thereby weakening the historical principle of herd immunity
- Some arguments against vaccination are clearly non-factual, including ‘spacing out vaccines’ and blaming vaccinations for other complex health challenges including the rise in autism diagnoses in recent years, but these are still rooted in sincere patient beliefs which require respect
- Many low-level implications of vaccine refusal may arguably be worse than the disease – for instance, should a provider refuse to see or treat families with non-vaccinated individuals out of fear that other, highly vulnerable patients could get sick or die from a transmitted microbe?
Inclusive Response Examples
It’s entirely possible to use the evidence above to support several responses in an interview setting. The examples below attempts to illustrate the effective combination of both halves of the available arguments in combination with the historical perspective to offer a thoughtful response which demonstrates both personal reflection and active external engagement regarding the issue at hand.
Appropriate Response: In Favor, With Balanced Discussion of Topic
“Vaccination has a long and effective history of improving the welfare of mankind, but the United States faces a pervasive divide on this issue despite the overwhelming balance of scientific evidence being almost wholly one-sided. All reasonable efforts need to be taken to engage individuals in learning and valuing the benefits of vaccines, and combating emergent myths, misinformation, and occasional hysteria with the single greatest weapon in any physician’s arsenal – calm, reasoned sincerity balanced which relies on previously established trust and credibility to nudge a hesitant patient toward the decision which protects all members of the community. As medical costs continue to rise, making preventative care including vaccines accessible to patients at little or no cost regardless of coverage plan type is perhaps the most straightforward weapon in the public health proponent’s arsenal. I certainly acknowledge that vaccines are a complex issue and I am prepared to do my part to uphold the proven benefits of herd immunity through patient engagement, education, and support for autism research to dispel such myths through the identification of alternative explanations.”
Appropriate Response: Personally Opposed, But Sensitive to Patients and Legally Compliant
“Vaccination stands on a nearly-unshakable foundation of scientific evidence, but the philosophical and business implications of a pro-vaccination stance are not nearly as clear-cut as they were even a few years ago. More and more recent vaccines are priced above their public health benefit, forcing payers to abandon the long-held principle of herd immunity in favor of protecting the most vulnerable patient subsets. As physicians increasingly shoulder the up-front and logistical burdens of storing highly perishable vaccines, providers may need to draw a boundary between investing increasing resources into one subset of clinical practice while many pervasive chronic health conditions such as diabetes go largely untreated. In fact, the AMA Journal of Ethics describes a hypothetical refusal of treatment for families who decline vaccination as ‘premature.’ Given these facts, I will certainly make vaccines readily available for my patients in line with CDC guidelines but I will not attempt to use a potential refusal of health care services in an attempt to force patients to act against their own perceived best interests. To do so would be a betrayal of my own principles of respect for human rights and ultimately undermine my mission to provide effective patient-centered care.”
White Coat Checklist’s Member Resources section includes the free AppTrackR medical school dashboard to allow applicants to track their target schools in real-time, question prompts for composing a compelling personal statement, and real-life secondaries essays to learn from the mistakes of prior applicants who have successfully matriculated. Members are also eligible to Contact WCC to ask questions or request 1:1 Advising or Remote Editing Sessions for individual targeted support.