Thursday, February 19, 2015

I used to fear mad scientists. Now I fear mad anti-scientists.

This is how I titled my guest blog post for the Philadelphia Inquirer, on how the proclivity of many Americans to deny science is endangering the rest of us, whether it is parents refusing to vaccinate their kids, or the more than one out of four Americans who deny that the earth is warming and/or that humans have anything to do with it.  Here is my entire post, as it appeared in the Philadelphia Inquirer:

“When, as a teenager, I first watched the groundbreaking Stanley Kubrick satire Dr. Strangelove, it scared the heck out of me. The final scene, when Dr. Strangelove’s Doomsday Machine sets off worldwide nuclear (brilliantly set to the pop tune “We’ll meet again” . . . some sunny day), captured the anxiety of a generation that grew up fearing that mad scientists and their complicit politicians, would end up getting us all killed.

Today, I fear that it’s the mad anti-scientists, and their complicit politicians, who may end up getting us killed. Because of science-denying people who refuse to vaccinate their children and themselves, the United States is experiencing a measles outbreak that so far has infected at least 121 people, mostly children, in 17 states, including Pennsylvania and Delaware. As the Philadelphia Inquirer’s editorial board observed in a February 8 editorial, Vaccinate Your Child, Pennsylvania “is particularly susceptible to” measles, mumps, and rubella (MMR), because only 87% of its kindergarten-age children are vaccinated against these diseases, among the lowest in the country. In New Jersey, 97% of kindergarteners are vaccinated.

Make no mistake about it: measles not only is highly infectious, it kills.  In the late 1950s, before the first licensure of a measles vaccine in 1961, “an average of 150,000 patients had respiratory complications and 4000 patients had encephalitis each year; the latter was associated with a high risk of neurological sequelae [harm] and death. These complications and others resulted in an estimated 48,000 persons with measles being hospitalized every year.”

I have no doubt that the anti-vaxxers are sincere in wanting to protect their kids against what they believe are ‘dangerous’ vaccinations, except that their beliefs are directly contradicted by the scientific evidence.   My Philadelphia-based employer, the American College of Physicians, is the largest physician specialty membership society in the world, representing 141,000 internal medicine physician specialists and medical student members.  On February 4, the College issued a statement declaring that: 

‘The scientific evidence clearly supports the benefit of the MMR vaccine and the lack of any association with autism. Physicians have a duty to provide the best care for their patients, as well as to protect the public health. At the same time, the profession has a duty to advocate based on accurate scientific data. Patient/parent autonomy is not absolute when it has the potential to compromise both individual and public health. Thus, we urge all Americans to embrace the sound preventive medicine practice of both routine pediatric and adult immunizations.’  

The American Academy of Pediatrics, Centers for Disease Control and Prevention, and the World Health Organization have affirmed the same: the MMR vaccine is safe, doesn’t cause autism, and saves lives.

It doesn’t help, though, when parents’ anxieties about vaccine safety are stoked by pandering politicians. Or when a small, yet influential, number of physicians spread falsehoods about the safety of vaccinations, which one prominent medical ethicist argues should be grounds for having their licenses revoked.

My fear about the impact of the anti-science movement though, isn’t limited to vaccinations.  Because of people who deny the science of climate change and oppose policies to mitigate it, we are looking at a future of “extreme heat waves, rising sea-levels, changes in precipitation resulting in flooding and droughts, intense hurricanes, and degraded air quality,[which will] affect directly and indirectly the physical, social, and psychological health of humans. . . climate change can be a driver of disease migration, as well as exacerbate health effects resulting from the release of toxic air pollutants in vulnerable populations such as children, the elderly, and those with asthma or cardiovascular disease.”

In a free country like the United States, everyone is entitled to their opinion.  But when your opinions put us all at risk, it is time for the rest of us to speak out, and demand public policies—and politicians who will carry them out--that are grounded in science, not mad anti-science denialism.”

For readers of this ACP Advocate blog, I think there are some important questions about what the medical profession’s role should be in challenging science deniers:

What should physicians say to patients who refuse to vaccinate themselves, or their children?

Should physicians decline to see patients who refuse vaccinations that put others at risk, as some pediatricians are being pressured to do? Would refusing to see such patients constitute patient abandonment?  This is what ACP’s Ethics Manual has to say about physicians discontinuing a relationship with a patient:

“When the patient's beliefs—religious, cultural, or otherwise—run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and the viewpoints of the patient. If the physician cannot carry out the patient's wishes after seriously attempting to resolve differences, the physician should discuss with the patient his or her option to seek care from another physician.

Under rare circumstances, the physician may elect to discontinue the professional relationship, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process.”

Should physicians who give credence to the views of those who believe that vaccinations cause autism have their licenses revoked?

Should physician membership organizations, including ACP, exert more leadership in warning the public about the health risks of climate change?  Should physicians be encouraged to advocate for public policies to mitigate global warming?

What about other manifestations of anti-science denialism, like the millions of Americans who reject evolution? Should physicians advocate that evolutionary biology be taught to pre-med students and in medical schools as one of the basic sciences, as a consensus group convened by The National Academy of Sciences recommends, because “Evolutionary biology is not just another topic vying for inclusion in the curriculum; it is an essential foundation for a biological understanding of health and disease?”

As members of a learned profession grounded in the scientific method, physicians should be expected to stand with science, especially when the views of anti-science dissenters threaten public health.  But when physicians take stances on hot-button issues—vaccinations, climate change, evolution—it puts the medical profession in the challenging position of going against the views of the millions of Americans (and elected politicians) who reject the scientific consensus on these issues, including many of the physicians’ own patients. What is the right balance between the medical profession being respectful of the views of people who don’t agree with the scientific evidence, and advocating for public policies, as supported by science, that are necessary to mitigate health risks to individual persons and populations?

Today’s questions: What are your responses to the questions I posed above?


PCP said...

Much like our collective inattention to physician led primary care, vaccines were taken for granted, made optional, and left up to someone to educate the public.
The results therefore are comparable and predictable.

Jay Larson MD said...

Tolerating a person's belief system is fine up to the point of direct harm to the individual or the population. Some things like climate change are hard to address with non believers because it currently does not affect them on a day to day basis. It is difficult to convince them that unless something is done now the long term effects will be harmful. This is similar to trying to convince a smoker to give up the cigarettes. The pleasures of the nicotine today outweigh the risk of harm down the road.

In regards to the measles outbreak, if a kid who can not get the MMR because of medical illness gets sick with measles from an unvaccinated kin, then the parents of the unvaccinated kid should be held responsible. There should be consequences for behavior that puts others at risk.