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'Often Wrong, Never in Doubt'

MANAGED CARE March 2004. © MediMedia USA
Ethics

'Often Wrong, Never in Doubt'

It's easy to blame the uninformed, and sometimes fair, but are the ignorant the only ones at fault? Medical professionals need to be able to explain, not just order and direct.
Michael S. Victoroff, MD
MANAGED CARE March 2004. ©MediMedia USA

It's easy to blame the uninformed, and sometimes fair, but are the ignorant the only ones at fault? Medical professionals need to be able to explain, not just order and direct.

Michael S. Victoroff, MD

OK, evil "medical establishment" people, we have failed again. Here is another of those awful he-said/she-said disputes where we are the bad guys. Like many, this one makes a child's care the prize of a contest between two adults. In this case, they are a mother and a pediatrician.

A syndicated columnist, who is also a mother, described the battle she fought against "the strong-arm tactics of the medical establishment" over her child's immunizations. The drama culminated in her refusing hepatitis B vaccine and changing physicians. Her selfcongratulatory conclusion was, "When it comes to protecting our children's health, skepticism is the best medicine."

As many victims know, she is dead wrong. Actually, the best medicine, proven millions of times over, is prevention.

Unprepared?

However, the question that started the ruckus was totally reasonable: "Why on earth should we vaccinate our newborn baby against hepatitis B virus that is contracted mostly through intravenous drug use and sexual contact?" Pediatricians and family practitioners, as well as hospital nurses, run into this frequently and should be prepared for it.

Apparently, nobody could give this mom a satisfactory answer. Her objections were met with defensiveness. She felt threatened: "Get the vaccines or get out of our practice." But, she won the contest — and taught a lesson to those loser doctors and their nasty nurses — by refusing her baby the vaccine. (Of course, if the kid ends up with hepatitis B, I am sure she will sue somebody.)

What happened here? The mother felt pushed, and she is obviously a person who pushes back. But her providers should have been able to give a better answer than, "Because!" Of course, who knows what either party really said? Still, I'm going to take the mother's side for the sake of argument, because I believe medical professionals are obliged to be prepared for all foreseeable questions — even from skeptical patients. And, I know how "informed consent" works in the real world; sometimes it leaves a lot to be desired.

To be fair, this mom, an experienced journalist, could have found an infectious disease specialist or public health nurse who could easily have explained why HB vaccine is good for infants.

If she had sought other authorities (or called me, or many people I know), she might not have concluded that the "medical establishment" was so belligerent, as she caricatures it.

But, we're dealing with a journalist, probably imprinted by temperament and environment with a distrust of authority. (I object, Doctor. Just who do you think you are? — Editor) She uses the word "coercion" only as a pejorative. Moreover, she just gave birth, with the dementia inevitably associated.

So, she acted out the paranoia that sometimes infects parents. Sadly, a lot of people see "the medical establishment" as merely some kind of nebulous political entity with no foundation in objective science. This is our fault, collectively.

Vaccine refusal is common in primary care. Often it is rooted in religious foolishness, character disorders, or superstition. But, her column shows none of the hallmarks of these disabilities. She comes across as just another one of those people who are "often wrong but never in doubt," with a strong indignation quotient. (Let's call this the "I-Factor." I don't have space here to explain my coining of this term to represent the "I" of narcissism, with overtones of "indignation" and "impatience," among others. You know it when you see it.).

There is no ethical problem here, only psychology. There is no dilemma about rights and duties, or comparative risk and benefit, or any other of the legitimate moral questions that arise in the context of parental authority. Sure, we could find those themes — and completely miss the point of the case. What alienated this woman from appropriate health advice wasn't some goofy philosophy or cultural belief. The failure here was not one of moral judgment, but simple human interaction.

Carpe diem

Let's suppose that she really did ask sincerely, "Why is it reasonable to immunize infants against hepatitis B?" The truest answer is, "Because babies can't object."

Since sex and IV drugs are the commonest ways to get hepatitis B, it's totally reasonable to ask why an infant needs this protection. The answer involves a little practical wisdom.

Immunization rates drop off the older children get. There are a hundred reasons, from economics to denial to laziness. Yet, without coercion, in the form of school requirements and such, immunization rates would be far lower than they are now. In matters of public safety, coercion is often good. Even though infants may not be at risk in the immediate future for hepatitis B, the vaccine's protection lasts into the years when that risk can become real. Unlike pertussis and Hib, which do attack infants, the HB strategy is simply that, since the kids are already lined up for lots of shots, it's convenient to toss in three more. They'll hardly notice. It's practical.

A responsible mother who guarantees that no surprises will ever occur in her family could be sent home with the understanding that, when sex and drugs do become potential issues, she will bring the child back. Right?

It's a fool's bet. On one hand, as a public health strategy, this would leave a lot of children exposed. Some would end up with HB-related liver failure or cancers that were totally preventable. Of course anyone can say, "Our family is different." Sure.

Plus, there are risks besides sex and drugs to which even infants are exposed. The one that I am sensitized to is a contaminated needle or razor blade that has fallen out of somebody's trash. What about the sweet lady next door who watches the kids sometimes, and is an HB-positive diabetic? What about the sleepover with the playmate who had a blood transfusion overseas, whose toothbrush is used by mistake? What about the 3-year-old kid in my own practice who stuck her hand in the "sharps" container when Mom and I were distracted? These are all low probability, and absolutely real stories.

Grim as it is to bring up, no matter how firmly you imagine your child is safe from sex and IVs and tattoos and wounds and transfusions by their own hand, what about the occasional third-party villainy that children are subject to? Finally, don't forget ear piercing....

Risk/reward

The point is that, no matter how low the likelihood a child catches hepatitis B, it's still vastly more probable than any risk from the vaccine. And that's the trump. While only an idiot ever says there is no risk of harm, the literature on HB vaccine is wonderfully reassuring. Simple math shows that, for this disease, the shot is the better choice. (The only misgiving with any objective merit is the very real problem of "too many needles for babies." But, this doesn't trump liver cancer.)

The trade-offs are all in favor of giving it early, when kids don't object or remember. Then you have the luxury of forgetting about HB for the rest of childhood. How many risks can we eliminate for our children this easily? Why did the indignant editorial writer not receive this information? Did somebody present it, and the mother not follow? We'll never know. Those involved may never know. But, we can see this case as a failure in the way somebody informed, persuaded, and reassured. These are procedural skills more important than suturing.

As a result, we have a baby at increased risk for disease. Worst, we have an editorial that encourages others to imitate this poor thought process. Houston, we have a problem....

Michael S. Victoroff, MD, is a family practitioner in Denver who has also been an HMO medical director.

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