In 2002, the BBC’s Panorama series included an edition entitled MMR: Every Parent’s Choice which investigated the origins of the controversy over measles, mumps and rubella (MMR) vaccination in the UK. In particular, the programme focussed on the role of Dr Andrew Wakefield and his, now refuted, claims concerning the link between the use of ‘triple-jab’ MMR vaccine and childhood autism and bowel disease. Although the public controversy surrounding this vaccination has now largely been settled, MMR uptake still remains below the level required to ensure population (or ‘herd’) immunity (see MMR uptake still short of target, BBC News, September 28th 2007 or watch video Warning over low MMR uptake, BBC News). The 2006-07 NHS immunisation statistics in England for example report it to be 85% by the age of two (NHS Immunisation Statistics, England, 2006-07), a figure which highlights that even today, 10 years after the controversy first ignited, immunisation rates have not yet returned to their previous levels of over 90% (NHS Immunisation Statistics, England, 1997-8).
|MMR controversy makes the Telegraph headlines on February 27th 1998 (from Panorama, BBC2, February 3rd 2002, 22.15)|
The MMR controversy also remains a particularly rich source of material for discussing the ethical issues implicit in mass vaccination programmes. The MMR: Every Parent’s Choice episode of Panorama is a good example of this as it explicitly explores key issues, including:
- the tension between the rights of individual parents to choose whether or not to have their children vaccinated and the aims and objectives of state endorsed vaccination policy
- the factors influencing parents decision-making about vaccination, and variable influence of health professionals, the media, and science in shaping these
- the proper role for doctors as both scientific and social actors
Rights and responsibilities
As it is represented in MMR: Every Parent’s Choice, the tension between individual rights and collective/social responsibilities was an important source of controversy. In the case of the MMR vaccination, this can be expressed in the conflict between individual parent’s right to choose whether or not to have their child vaccinated against measles, mumps and rubella, and their responsibility towards the community they live in to help prevent outbreaks of disease. Measles, for example, can have devastating consequences, such as subacute sclerosing panencephalitis (SSPE) – a condition illustrated in the opening scenes of the programme, and may also result in death.
While, in the case of childhood immunisations which are not controversial, there appears little conflict between an individual’s right to choose and his/her responsibility towards the community they live in (that is, in vaccinating their child, parents are both exercising their individual rights and fulfilling their responsibilities towards the community), in the case of MMR the choice for many parents was not unproblematic. In this situation, which is the greater moral duty? To protect one’s own child, or to protect the wider community of children of which that child is a part? This incorporates a wide range of ethical concepts including: the notion of rights, duties, the best-interests of the child and the community, and a consequentialist assessment of risks and benefits to all concerned.
|Vaccination policy in action (from MMR: Every Parent’s Choice, Panorama, BBC2, February 3rd 2002, 22.15)|
These concepts and issues are explored both in relation to the state and health professionals involvement in public information campaigns (see screenshot, left) and parents decision-making processes (discussed below)
To vaccinate or not to vaccinate: the parents perspective
As the title of this programme suggests, one of its major concerns is how various factors combine when parents make a choice over MMR (and other) vaccinations. Put simply, in 2002 when this episode of Panorama first aired, many parents felt this choice was either to expose their child to the risk of autism (via vaccinating), or to the risk of measles (via not vaccinating). This may seem an ‘irrational’ formulation of the choice from a scientific point of view, given that any link between MMR and autism had not been established to be a causal one, however, as presenter Sarah Barlay states “though unproved scientifically, that observation provides [a parent] with a plausible explanation” (00:19:33) for his/her child’s symptoms.
In their discussion of this controversy Collins and Pinch (2005) highlight how parents causal understanding of Wakefield’s research developed in the context of the media reporting of the MMR controversy. They suggest that in attempting to offer a balanced view of the controversy media reports often gave equal weight to the views of parents who believed that MMR had caused their child’s autism, and the scientific and policy representatives who maintained that there was no causal link between MMR and that parents should continue to vaccinate their children in order to assure measles immunity at the community level. This pattern of reporting dominated the controversy despite a continuing lack of evidence of a causal link between MMR and autism, such that the experience of concerned parents was “given salience and concreteness by the press” (Collins and Pinch, 2005: 185).
However, media coverage and public opinion were not the only factors that may have influenced parents decisions regarding MMR vaccination (particularly the decision not to vaccinate). Another potential contributor was the government’s “poor track-record in respect of science” (Collins and Pinch, 2005: 189) as exemplifed by their handling of the BSE crisis in the late 80s-early 90s. One parent comments “I think there is a greater questioning of authority and I think affairs such as the BSE fiasco has certainly had an effect on people’s perception of what they’re being told” (00:12:05).
The role of personal experience with autism and measles is also identified as a factor influencing parents perceptions of the risks associated with vaccination and non-vaccination. Community Paediatrician, Dr Anne Nesbitt suggests that “parents’ anxieties have been fuelled by the fact that many of them now know a child who has autism, but relatively few parents these days know a child who’s had measles, and I think you worry about things you know about, but it’s harder to worry about things that you haven’t experienced” (00:35:44).
|Dr Andrew Wakefield on MMR: Every Parent’s Choice (Panorama, BBC2, February 3rd 2002, 22.15)
The role of the doctor
Until shortly before this episode of Panorama was filmed, Dr Andrew Wakefield worked at the Royal Free Hospital in London. In 1998 he (along with a number of co-authors) published a paper entitled “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children” in the peer-reviewed medical journal The Lancet. This scientific paper was one of the key starting points for the MMR controversy and, as MMR: Every Parent’s Choice highlights, embodies the conflict between his role as a doctor (with a responsibility to take seriously and investigate the concerns of his patients, and to protect them from harm via medical intervention) and as a scientist (with a duty to evidential standards, peer-reviewed reporting and the scientific community). This tension is highlighted particularly well in a section of the programme which includes an interview with Andrew Wakefield (00:31:08 to 00:32:35). Barclay asks him “Obviously you have to do your duty as a doctor, obviously you have to listen to the parents and observe and investigate. But isn’t your duty as a scientist different? Doesn’t it require more rigorous proof?” (00:32:13).
Wakefield apparently applied different standards of proof, stating that “the proof was there that the questions that the parents had raised were valid” (00:32:01). While this may have justified his public statements regarding MMR vaccine at one level, other members of the scientific and medical community express different views. For example, a former colleague of Wakefield’s, Dr Simon Murch, regards the connection between MMR and autism as “quite an improper area for any of us to pronounce on without hard evidence” (00:30:53). Others raise questions about his methodology and the reproducability and validity of his results (see statement by Prof Brent Taylor at 00:31:18). The role of the peer-review process is alluded to in this respect: Barclay reports that “one prestigious medical journal turned down the paper Andrew Wakefield and his colleagues were working on because it failed to prove that the measles virus came from the vaccine” (00:21:35).
In 2004, a number of the co-authors of Wakefield’s 1998 paper retracted the interpretation it contained (see Murch SH, Anthony A, Casson DH, et al. (2004) “Retraction of an interpretation”, Lancet, 363 (9411): 750) and in the same year the General Medical Council (GMC) launched an investigation of Dr Wakefield’s research practice in this area (see MMR doctor to ‘face GMC charges’, BBC News, June 12th 2006).
While MMR: Every Parent’s Choice presents little scientific detail regarding how the MMR jab works or the mechanism for Wakefield’s suggested link between MMR and autism, it offers an excellent resource for teaching about the social and ethical aspects of vaccination covering the majority of key points in both UK GCSE science/biology and GCE A/A2 level biology/human biology curricula. Further, it could also be used more broadly, as a basis for any discussion of the tension between individual rights and social responsibilities in biomedical care (as manifested, for example, in the case of Herceptin licensing – see the BioethicsBytes post Herceptin: Wanting the wonder drug).
MMR: Every Parent’s Choice was first broadcast on BBC1 on 3rd February 2002 at 10.15pm. Members of the BUFVC may obtain copies for educational use (TRILT identifier: 00170398). All timings contained in this post are approximate and may vary by up to a minute.