What's Good for the Goose Is ... Ethics and Vaccinations

There appear to be many in our profession who are opposed to mandatory vaccination. A recent study conducted in the Canadian Province of Alberta found that 27.2% of the doctors of chiropractic who completed the survey encouraged/advised their patients against having themselves or their children immunized.¹ The authors of the study, Russell, et al., concluded that there is great heterogeneity among our profession's behaviors regarding immunization, similar to everything else in chiropractic. We believe that there are a variety of subtypes within the profession regarding immunizations. There are those that are driven by libertarian political philosophy, whose opposition is purely to government's control over our health. Some have a basic reluctance to use vaccines as part of their general reluctance to use any medication. This reluctance is consistent with our profession's philosophical belief in naturalism and therapeutic conservatism.² These chiropractors appear to us to be the least strident in their opposition to the use of vaccination, and we suspect, rarely suggest to patients that they should avoid vaccinations.

The final group is those that are zealously anti-vaccination (anti-vax). We believe that the level of fervor within this subset of the profession is extremely high. Some talks we have seen, given by leaders in this movement, are similar to the level of fanaticism one sees in some religious meetings. Typically, the basic contention of these doctors is that the risks are so profound that no one should submit to mandatory vaccination. Some of them push the concept that vaccinations are the major contributor to the increases in certain diseases (e.g., asthma, autism, juvenile diabetes, learning disabilities and attention deficit hyperactivity disorder [ADHD]). They suggest that chiropractors are ethically mandated to inform patients of the "harms" of vaccination. Chiropractic supposedly has this duty because no one else will stand up to the "lies" of the medical profession and the drug industry.

Our purpose in this article is to discuss the ethics of giving a patient a recommendation that they should not be immunized and that they refrain from having their children immunized.

First, we give a reminder about some ethical principles. There are benefits and hazards to both having and not having any procedure. Recommendations and actions that produce benefit for patients are done in compliance with our duty of beneficence. Beneficence is doing something that helps a patient. Conversely, recommendations and actions that prevent harm to patients are done in compliance with the duty of nonmaleficence. Nonmaleficence is familiar to us all in the Latin phrase primum non nocere - first do no harm.³

Informing a patient of a risk is consistent with the duty of nonmaleficence, but any explanation of risk needs to be conducted within the context of similar risks. Thus, a discussion of the risk of stroke from cervical manipulation should include a discussion of the risks of the alternatives (e.g., NSAIDs).⁴ Any discussion of the risk of a procedure must also talk about benefits and the risks of not having the procedure. For example, there are risks associated with the use of insulin in the diabetic (e.g., glaucoma); however, the risks of not taking insulin are far more serious (i.e., frequent infections, progressive renal insufficiency and failure necessitating hemodialysis, and death).

Clearly everyone acknowledges that vaccinations have risks associated with their usage. In Table 1, we have listed common immunizations and their associated rates of common serious side-effects that are often written about by anti-vax zealots. There is also a risk associated with not using them - the risk of contracting the disease the vaccination is intended to stimulate immunity against.

For example, let's compare the "old" (whole-cell) pertussis vaccine with the disease itself, head to head. If we were to take a day-care facility with 150 children in it, and none of those children were to receive vaccines against pertussis, approximately 135 children would contract clinical pertussis (the disease has a nearly 90% penetrance in a confined population). Forty-three of those children would likely require hospitalization (most for pneumonia). Two of those children would suffer seizures, and one child would acquire encephalitis every third year.^5,6

If, however, all 150 children were to receive four doses of the DPT vaccine (and again, this is the "old" vaccine, the whole-cell pertussis, which is no longer given in the United States), one child would suffer seizures every 78 years, and one child would suffer an encephalopathy every 667 years. These are numbers that anti-vax zealouts do not like to discuss.^5,6

Here are a few more numbers they don't like to discuss: Unvaccinated children are six times more likely to contract the disease than are unvaccinated children, and for every 1% increase in exemptors in a population (those not getting immunizations), the risk of an outbreak increases by 12%.⁷ Clearly, this also shows that the vaccine is imperfect. The most recent data suggest that the "old" whole vaccine gave a 70-90% response after three doses, leaving some children as nonresponders.

Recently, the World Chiropractic Alliance (WCA) issued a press release⁸ proclaiming that chiropractic adjustments have a positive impact on the immune system, implying that flu vaccines could be replaced by adjustments. To back up this claim, they cited a number of articles, including non-peer reviewed sources such as this paper (Dynamic Chiropractic), and The Chiropractic Journal. While there are some introductory data which might suggest that immune function, theoretically, could be altered by spinal manipulation, to date, the data reviewed do not validate this theory. In the end, we are not aware of a single well-controlled study which found that chiropractic care prevented any infectious disease or reduced the severity of such a disease. Anecdotes from the early 19^th century are far from compelling data. This is another example of crossing the line separating scientific facts from scientific misconduct, error or willful ignorance⁹ in suggesting chiropractic care can improve immune function and might work as a replacement for flu vaccines.

We find any suggestion that there is an ethical duty to inform patients and the public about the hazards of vaccination, and that getting adjusted is an alternative to vaccination, to be completely disingenuous, illogical and completely unethical coming from most chiropractors. The anti-vax chiropractors suggest that vaccines are so hazardous that they should be avoided at all costs, while at the same time, they typically recommend that there is a need for people to have their cervical spines adjusted regularly. This is a case of the pot calling the kettle black.

Although the exact rate of stroke is unknown, the literature shows estimates of stroke from manipulation of one in 1 million treatments, or one in 100,000 patients, if one assumes a case average of 10 visits per patient.¹⁰ Given the fact that most DCs who would recommend avoiding vaccination also recommend maintenance care, which can consist of monthly to weekly adjustments, it is obvious that the small risks of a manipulation are compounded by repeated use. In fact, the WCA specifically suggests adjusting as an alternative to vaccination.¹¹ Repeated cervical adjustments are worth that risk when the benefits are great, such as getting rid of neck pain¹² or headaches.¹³ However, right now, lacking compelling evidence that maintenance care is beneficial, the risk outweighs the benefit. So, if a chiropractor tells a patient that vaccination is too risky, then ethically, they must also tell them not to get adjusted. What's good for the goose is...

The chiropractic profession has long suffered from difficulties with honesty. Grod¹⁴ and Sikorski¹⁵ documented this well in their two articles about literature and Web sites from the largest chiropractic associations and colleges in the United States and Canada. Not that organized medicine has always been forthcoming, as reports from the Institute of Medicine have often pointed out. But as is so often said, two wrongs do not make a right. Being dishonest, in any area, calls our professional integrity into question. Therefore, we call upon the profession to be stringently honest when discussing risks and benefits. This should hold true whether we are discussing procedures that we clearly should be the authority on (such as spinal manipulation, active rehabilitation and adjunct therapies), or discussing topics that our training does not necessarily adequately prepare us to evaluate (such as the use of different medications, including vaccinations, and their relative risks and benefits).

So, what should chiropractors do regarding vaccinations? Obviously, we believe that it is unethical to recommend avoiding vaccinations while also recommending adjusting, because of the comparable level of risk. Likewise, we would agree that for a chiropractor who strongly believes that vaccinations are bad, and believes that adjusting is good, telling patients who ask about vaccinations that they should have them is also a significant ethical problem. While doctors need to respect their patients' autonomy rights, they also need to respect their own. The great problems in ethics occur when two rights or duties are in conflict. Thus, for the anti-vax chiropractor, we see a significant ethical distress. The solution, we believe, was developed by the College of Chiropractors of Ontario. Its Standard of Practice S-015 states: "Chiropractors may not, in their professional capacity, express views about immunization/vaccination as it is outside their scope of practice." It seems best, since there are questions as to the ethics of recommending avoidance of immunizations, to not say anything at all.

Chiropractic offers great benefits for mankind's sufferings, but overstating them violates our nonmaleficience duty. It harms people to tell them we can prevent or reduce the severity of a disease that we clearly have never shown we can. Likewise, teaching or preaching that vaccinations are bad without looking at their benefits, and then telling them that adjustments are good without stating their risks, is dishonest and again violates our nonmaleficience duty. It harms people by scaring them away from preventive treatments - vaccinations - that have been shown to be effective, with real but small risks comparable to chiropractic care itself. What is good for the goose is good for the gander.

References

1. Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M. Beliefs and behaviours: understanding chiropractors and immunization. Vaccine 2004;23(3):372-9.
2. Coulter ID. Chiropractic: A Philosophy for Alternative Health Care. Oxford, UK: Butterworth-Heinemann Medical; 1999.
3. Purtilo R. Ethical Dimensions in the Health Professions. 3rd ed. Philadelphia: W.B. Saunders; 1999.
4. Dabbs V, Lauretti W. A risk assessment of cervical manipulation vs. Nsaids for the treatment of neck pain. J Manipulative Physiol Ther 1995;18(8):530-6.
5. Atkinson WL, Pickering LK, Schwartz B, Weniger BG, Iskander JK, Watson JC. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Recomm Rep 2002;51(RR-2):1-35.
6. Update: Vaccine side effects, adverse reactions, contraindications, and precautions. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1996;45(RR-12):1-35.
7. Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 2000;284(24):3145-50.
8. World Chiropractic Alliance. Press release distributed by the World Chiropractic Alliance. The Chiropractic Journal December 2004.
9. Perle SM. Scientific misconduct, error or willful ignorance? Dynamic Chiropractic 2004;21(14):14, 26.
10. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;32(5):1054-60.
11. World Chiropractic Alliance. Can chiropractic strengthen immunity? The Chiropractic Journal December 2004.
12. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J 2004;4(3):335-56.
13. Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther 2001;24(7):457-66.
14. Grod JP, Sikorski D, Keating JC, Jr. Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manipulative Physiol Ther 2001;24(8):514-9.
15. Sikorski D, Grod JP, Keating JC, Jr. The unsubstantiated website claims of chiropractic colleges in Canada and the United States. J Chiropr Edu 2002;16(1):95-6.

Stephen Perle, DC, MS
Bridgeport, Connecticut

Randy Ferrance
Mechanicsville, Virginia