Utilitarianism, Science, and Public Policy

One of the things that you hear over and over again from the anti-science crowd is that public policy should not “sacrifice” the life of one person for the good of the population. In the case of vaccines, many of the people who are convinced that vaccines cause autism will tell you that we should not “sacrifice” a child to autism even if it means preventing a whole lot of death and disability from vaccine-preventable diseases. Mind you, autism does not equal death for a child. But such is the mentality of the fanatic.

I wish that I could live in a fantasy world where there were no sacrifices for the good of the population, where no one in the absolute would have a reaction to a vaccine (no matter how mild). Unfortunately, such a world does not exist. However, there is this thing called science, and it prescribes the tools we can use to minimize the amount of suffering in humanity. With it, we’ve been able to cure diseases that used to kill people by the thousands (maybe millions) in centuries past. Sadly, there are those who have not benefited from the science and may have even been hurt by it. But such is life.

It seems cold to say, “Sorry about your luck, Suzy,” when Suzy has an allergic reaction to a medication or a vaccine. But there isn’t really much we can do. In the United States, medicines (including vaccines) are tested over and over and over again on thousands of people before they go to market. In those different phases of testing, we get to know what dose is good enough to reach a desired effect, what dose may be too high and cause injury, and, of course, whether or not the drug does what it’s supposed to do. Without this testing, medications are not allowed to go to market. Or, if they do go to market, they will include the Quack Miranda Warning, telling you that they have not been tested and are not intended to cure, treat, or prevent any disease (although they’re marketed as curing, treating, or preventing diseases).

During those phases, and even after the medication has gone to market, there are those “few” individuals who do get injured. (I write “few” to mean “not everyone who takes the medication”.) This is because those “few” individuals may be genetically predisposed to the bad reaction, or they have become sensitized and have an allergic reaction, or they were taking a medication that interacted with the new medication. It happens, but the rigorous testing regime in the US clinical trials and licensing process makes sure that the damage is minimal.

Still, there are those anti-science people who will say to you that “all medications that have ever been taken off the market were first approved by the FDA.” This is what we in the business call a “truism”. Yes, to be unapproved and taken off the market, the medication had to be first approved and taken to market. It’s like saying that all planes that have crashed were first airborne. It’s true. But it’s a deceptive way of trying to convince you that the FDA process of approving drugs is worthless, compromised, or corrupt. Well, if it’s any of these things, why was the drug taken off the market? I mean, if the conspiracy is deep, why did it not prevent the medication from being withdrawn?

The very fact that drugs are taken off the market is a clear indicator that the system works. It’s also not just FDA that keeps an eye out on medications post-licensure. Researchers in competing companies may want to test the drug to see if their competitor’s product is really as good as the marketing says it is. Other researchers in academic settings may also test it to see if the drug can be used for other conditions. And government researchers may also test it to make sure that the drug is safe in the long term.

It was precisely a combination of these types of post-marketing research that has led to the recall of many drugs that have been shown to not be that safe in the long run, or that were shown to interact with unexpected patient characteristics (e.g. genetics, diets, other medications and other conditions). So, yeah, there may be people hurt by a drug, but the drug was first shown to be of benefit to the overwhelming majority of people who need it. For example, children overdose on acetaminophen, aspirin, and ibuprofen by accident, but this doesn’t mean that these drugs are taken off the market, leaving us without a safe and effective way to treat pain and fever without “harder” drugs like morphine.

Still other anti-science people will point to the experience of “thalidomide” and try to trick you into thinking that the fiasco that happened with this drug was the responsibility of drug-regulating agencies in the United States. Long story short, thalidomide was a medication first licensed in Germany. It was used to treat morning sickness in pregnant women. Soon after it was licensed to be sold over-the-counter in Germany, children began to be born with severe malformations. But this drug never made it to American markets as a medication for pregnant women because an FDA investigator by the name of  Frances Kelsey reviewed the evidence of the drug in Europe and on pregnant women and their fetuses. Today, through additional research, thalidomide continues to be used as a drug for other diseases and conditions, but never on pregnant women or women who could become pregnant. In essence, so thalidomide could not cause damage here in the United States, it caused damage over there in Germany.

This is the spot where those of us who work in public health and public health policy find ourselves. On the one hand, we have these phenomenal technologies that will help prevent, treat, or cure diseases and conditions. We have the evidence that they do. We have a robust system of testing them that includes participants other than just the manufacturers themselves and their subsidiaries. On the other hand, there is an inherent danger in any medical intervention, no matter how small. Even a paper cut can get a Staph infection that kills you if you don’t wash it and dress it appropriately. A child with previously unrecognized sensitivity to penicillin may die from the treatment for Strep throat, but more children will die of Scarlet Fever or cardiac sequelae from an untreated Strep throat infection. A woman who is pregnant may have a child with a deformity because she underwent a series of x-rays after a car accident when she was only a few weeks along, but more women will die if their injuries are not identified by radiographic imaging.

This, dear readers, is the world we live in. It’s reality. It’s cold and uncaring.

We have this wonderful technology called the measles-mumps-rubella vaccine (MMR) which has been shown to prevent measles, mumps, and rubella in the overwhelming majority of people who are immunized with it. Because of it, rubella (German Measles) is virtually eradicated from the American Continent. (The whole, entire, goddamned continent.) I told you before what rubella can do to an unborn child. The cases I’ve investigated of Congenital Rubella Syndrome (CRS) are so few that I can count them in one hand, and they were all in babes whose mother went overseas and contracted rubella while pregnant and not vaccinated.

You know where vaccination for rubella is not mandatory, required, or otherwise? Japan. You know where they had 31 cases of CRS in 2013? In Japan. Thirty-one children were born with horrible deformities so the fears and apprehensions and misinformation over vaccination by their mothers could be allayed. Or, if you ask anti-vaccinators, 31 children were sacrificed to CRS instead of being “sacrificed” to autism because the MMR vaccine causes autism, all evidence be damned.

People like Andrew Jeremy Wakefield, Jenny McCarthy, and the rest of the merry band of anti-vaccine loons wackos who are convinced that vaccines cause autism will likely be hard to find in public, or hard to get an apology from, when CRS makes a comeback in the United States as levels of MMR immunity drop. Because they have a utilitarian view of the world, like I do. Except that their view sees random, rare events as being purposeful, unbelievably common events. Their view sees a “tsunami” of autism and other diseases caused by vaccines, and yet they fail to see that we had more cases of CRS in Japan in 2013 than cases of autism directly attributable to vaccines in the United States.

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9 thoughts on “Utilitarianism, Science, and Public Policy

  1. Reuben: I think you need to clarify your thalidomide comments, or people will point to them and say “Ha! He’s lying! Babies *were* born in the US with damage from thalidomide”. Please make sure you point out that thalidomide was not available in the US, but people were not stopped from bringing it in from Canada, Germany, Mexico, etc. There were no cases of US prescribed thalidomide, but there were US cases of births.

    • Thanks for that. I’m sure reasonable people will read the comments section, or come to the comments section to correct me.

  2. Children with autism have drowned in swimming pools and ponds. It is tragic and horrible. The reasoning of those such as Wakefield, McCarthy and the AoA horde is so unhinged that I’m surprised they haven’t called for “safer water” that we all would simply float upon. Heck , both water and oxygen can be toxic or even fatal to humans, so let’s “green” them as well. Have we even done safety testing on water (aka dihydrogen oxide) or oxygen? Will AoA propose a study where we take a group of children and test the safety of water and oxygen, with half getting oxygen and water and the other half getting placebos–because, after all, those of us who are pro-drinking-of-water and pro-breathing-of-air *really* haven’t tested water and oxygen *completely*. And if a child died in that RCT study from placebo, I’m certain AoA would then say that that child was “weak” and and its sacrifice was justified.

    Last night there was a post from AoA where some “scientist” (who clearly didn’t know the first thing about the scientific method) started postulating maybe autism is caused by vaccines, but in many different and low probability ways. In other words, even if Wakefield’s hypothesis wasn’t correct, maybe it was still correct for a much smaller percentage of children (“only for a sub-set of the sub-set” as this person actually wrote). And then this “scientist” goes on to say maybe there were contaminants in the MMR vaccine that caused autism, but only in certain lots of MMR vaccines–and to support this claim, the “scientist” give two very vague claims that all the children for two lots of MMR vaccine (back in the time of Wakefield’s “research”) caused all the children receiving those lots to become autistic or even die. Huh? It’s even more bizarre because the claim is these lot (“batch”) numbers were shared by groups of only 16 and 23 children autistic and/or dead children apiece. That’s just ridiculous. A single vaccine lot number does not cover just 10-20 children. Lot numbers cover much more—for example the recent voluntary recall of one lot of Gardasil vaccine by Merck (out of concern for possible glass particles in the vaccine solution (http://www.cdc.gov/media/releases/2013/s1220-gardasil-vaccine.html) was a single lot number which represented 743,360 vials of vaccine–not 23 vials of vaccine. And then the AoA crowd (and Mr. Wakefield, too) continue to shriek hysterically that autism rates are soaring (despite the drop in vaccine rates in the US (thanks largely to their AV spam)), not at all understanding that if somehow there are now mysterious contaminants in vaccines, then they’d have to be in a lot more vaccines to be causing this autism “tsunami” they oh-so-want to blame on vaccines. Of course extremely paranoid/delusional thinking is common for those folk, so they aren’t held back by any sense of logic or rational thought on this.

    But getting back to what you’ve said, Rueben–the tragedy is that unless there is more vocal, open and frequent speaking out against these anti-vaccine wackos, we are going to see the general public re-learn the importance of vaccination. Re-learned through the hard lesson of children being maimed and killed by vaccine-preventable infectious diseases–while the Wakefields, McCarthys and AoAers of the world care not a bit about how they are to blame.

  3. Those parents, catherinajtv, who don’t vaccinate on the premise that vaccine-preventable diseases are not common now are ignorantly assuming no other parents will come up with that same “clever” idea. They are also, whether they are aware of it or not, selfishly trying to hide their unvaccinated child in herd of children who are vaccinated. Again, this “clever” idea only works if other don’t get “clever” as well. We’re now seeing the consequences of too many stupidly “clever” parents not vaccinating their children.

    • There is pretty much only one place where I would not vaccinate children.
      On a colony on Mars. The probability of exposure is beyond miniscule there.

      Of course, there are other problems to worry about, as there is no colony on Mars, radiation would be a *really* big deal, lower gravity would prohibit repatriation to Earth, meteor impacts, lack of food, extremely problematic logistics for supplies…

  4. For some (many, not all) anti-vaccine minded parents, not vaccinating is the result of a risk assessment including high vaccination morale in their environment. They argue, the risk of contracting measles is so low that currently, there are more cases of encephalitis from MMR in the US than from measles. Therefore, my child has a lower risk of encephalitis if I do not vaccinate. This works if you are in a very stable environment where you are the one (or one of very few) people in that community who doesn’t vaccinate. It very much becomes a games theory scenario where risks are fluid and too complex for your average non vaccinating parent to oversee (and there is never any control anyway). This is why your post on the tragic case of rubella embryopathy was so important. You are talking about something that is very rare in this day and age, but when it happens, it happens to people (or children of people) who had every chance to be vaccinated and didn’t take it.

    • I’ve heard that argument from the “ChildHealthSafety” dynamic duo of Miller and Stone. They neglect that measles is now endemic in the UK, and that like minded folks tend to congregate so there are outbreaks even in the USA. Though they are not the most mathematically competent.

  5. Let us apply their standard to some things that have even higher instances of ruined or ended lives.
    Motor vehicles, before them, horse traffic. Roads are in common, we need to abandon all forms of transportation, it’s sacrificing lives!
    Roads are licensed and inspected, they fail, bridges fail, vehicles fail, we must abandon them all and those evil highways that go along with them! Why, Pierre Curie would still be alive it it weren’t for roads!

    Buildings are licensed, inspected and still collapse, sacrificing lives! We must abandon and prohibit all buildings, so that the many lives lost in structural collapse will be saved!

    Tents catch on fire, sacrificing lives!

    People kill each other, why there was a man killed in a Florida movie theater for texting a babysitter. Amputate all limbs, lower jaws and remove all teeth!
    And somehow get them into an open field, lest something collapse on them. Hanged if I know how, since roads were abandoned.

    Of course, then, everyone will be happy.
    As they slowly starve to death in the middle of a field.
    But, we’d save lives!
    Or something.

    • Addendum:
      Please let me know how to add additional silly and hyperbole to improve that thought experiment. 😉

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