Refusal of parents to vaccinate: dereliction of duty or legitimate personal choice?

Despite the risks to unvaccinated children, compulsory vaccination is not the answer

In a pluralistic society, there are many views on what constitutes acceptable child-rearing. In Australia and other Western societies, parental discretion is limited primarily by legislation against abuse or neglect. In treatment decisions, the legal starting point is that the united view of both parents is correct in identifying the child's welfare. A court will usually only override the parents' decision if the judge is convinced the child's life is endangered, such as when a child needs transfusion.2 Administration of a vaccine is never immediately life-saving in this sense, except in the case of post-exposure rabies vaccine,3 but vaccination satisfies ethical criteria for preventive interventions in children: it is effective, minimally invasive, and associated with significant societal benefits.3 Indeed, the highly favourable benefit-to-risk ratio of childhood vaccination is so well documented that healthcare professionals are understandably frustrated when faced with what seems to be an irrational decision by parents to refuse vaccination. This is especially so when this decision has resulted in failure to prevent a life-threatening illness, as in the tetanus case presented by Goldwater et al (page 175).4 This case raises issues for both the clinician and society. How do healthcare professionals understand and best respond to a conscious decision not to vaccinate? In a highly immunised population, what is the balance of risks and benefits to individual children and their contacts from refusal to vaccinate? Should a case such as this propel us towards compulsory vaccination?