Bachmann, Perry and HPV

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Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

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97 Responses

  1. Avatar Silver Wolf says:

    The key difference between this and issues like smoking around your kids or poor eating habits is that this is a one shot deal while the others are lifelong choices. If the government had a vaccine for obesity that would work best in children at around age 12, I would argue that it is a compelling state interest to vaccinate all children at that age.

    It is hard to compare a problem that can only be solved with ongoing lifelong changes to one that is a shot in the arm and your done. In my opinion, the limited invasiveness of the vaccine increases the state’s right to mandate it.Report

    • I understand your perspective, SW. I think there is a compelling interest to advocate for it strongly. But my ideology still aligns with a parental right to refuse an intervention, so long as said refusal does not immediately threaten the child.Report

      • Avatar Silver Wolf says:

        Though I disagree with your position I agree that it is a reasonable position to have. We are now in the shades of grey area of the argument with both sides arguing a civil debate in good faith without the mad rhetoric.

        Tragically, most arguments are hijacked by the crazies on the ends.Report

      • Avatar gschu says:

        I was under the impression, from reading the quote above, that parents can opt out for any reason. I guess what I am saying is that this seems to be the government setting a default option of vaccination, which can be opted out of, instead of a mandate that has to be followed with few exceptions. When I look at it this way it doesn’t seem to impede anyone’s freedom to not get vaccinated. What would be your take on that?Report

        • Avatar Will Truman says:

          There seems to be some disagreement as to how easy or difficult it is to opt out. One of the Slate writers said that it was made to be a real hassle. But if it were to have been just a matter of signing a form, I would have a hard time finding that objectionable.Report

        • Avatar Silver Wolf says:

          Given the fact that this is not a disease that is contagious outside of sex, I would say that people could probably opt out. My biggest problem is that the overzealous parents get to use their daughter’s health as a plinth for their anti-science ravings.Report

  2. Avatar Tod Kelly says:

    A good post, Russell, and I find I agree with it totally. But reading it, I did find myself starting to question an assumption I’ve had about Bachmann.

    I have always assumed that she is very, very smart, and a sharp opportunist that had found a way to use (not in a bad way) the TP movement in a way no one else has been able to do. But the argument you make here seems like an obvious winner, and one that she could have used that would have been just as appealing if not more to her base, made her more appealing to those outside her base, and made Perry look pretty bad.

    So I am wondering if I am wrong about her, and she is really kind of bats**t crazy?Report

    • Avatar Silver Wolf says:

      She knows that a nuanced response like the one Russell gave doesn’t sell to the tea party. If it can’t fit on a bumper sticker it won’t fly.

      “Vaccines cause retardation!!1!!” is the best she could do with this bunch. Add to that the fact that a fair number of people believe that vaccines are all dangerous and a money grab and you see why she went this way.

      I’ll give you both here. She is crazy and she knows the tea party.Report

    • My argument rests on a somewhat nuanced understanding of how diseases may differ in their transmission and prevention. My understand of Rep. Bachmann is that she is one who doesn’t do nuance.

      That said, I also think she’s totally fishing nuts. YMMV.Report

      • Avatar Mike Schilling says:

        I keep hearing that she’s nuts but the evidence for it has always fallen short. Here, for instance, she’s telling an obvious lie, but it’s one she won’t be called on and the statement as a whole (opposing the “pro-promiscuity shot”) helps her.Report

    • Avatar Kim says:

      Tod, go cruise a bit on dailykos. if nothing else, they’re good for generating oppo research on TeaParty folks (did a lot of that when they sent someone up to Alaska)Report

  3. Avatar cfpete says:

    “the Tea Party’s own Jenny McCarthy”
    Citation please?Report

    • I do not understand this request.Report

      • Avatar cfpete says:

        In what way is Jenny McCarthy associated with the tea party.

        The left and the right have tried to pin the whole anti-vaccine movement on their opposition. The truth of the matter, is that the anti-vaccine movement is that rare issue which appeals to nut-jobs of all political stripes.

        The right wing nut-jobs believe it is all a government conspiracy to force them to do something to their children. The left wing nut-jobs believe it is a cabal, a conspiracy, between the government and the pharmaceutical companies to enrich and indemnify those companies in exchange for campaign contributions.

        If you are a pediatrician and believe this is some new right wing nut-job issue, I really believe you need to get out more.
        Please see: Robert F. Kennedy Jr. and Bill Maher.Report

    • Avatar Rufus F. says:

      I think you’re reading that as saying Jenny McCarthy is of the Tea Party, when it’s actually saying that Bachmann is big with the Tea Party and critical of vaccinations, which makes her similar to Jenny McCarthy, who is also anti-vaccinations.Report

      • Avatar cfpete says:

        I think you are being extremely charitable:
        “I don’t imagine the Tea Party’s own Jenny McCarthy would care about this issue at all were it not a way to take aim at an ascendant Rick Perry”
        Let me say that I fully renounce the tea party and their simplistic and ignorant ideas. However, I mostly blame the spread of the anti-vaccine movement on the left because the right wing nut-jobs never garnered the mainstream media presence afforded to the anti-vaccine left.
        Also, the anti-vaccine movement precedes the tea party by at least five years, but I am sure there is significant overlap between the tea party and anti-vaccine right wing nut-jobs.Report

  4. Avatar John Howard Griffin says:

    Here is a (possible apples and oranges) related question:

    Should the state have the right to mandate seatbelt (and child seat) laws?

    I don’t see a lot of daylight between HPV mandate and seatbelt mandate, though there is certainly some daylight between them.Report

    • Failure to buckle a child into an automobile threatens their safety and well-being much more imminently than does failure to vaccinate against HPV. Excluding perinatal conditions (typically relating to premature infants), motor vehicle collisions are the leading cause of child mortality in the United States. The risk of death from cervical cancer is not even close.Report

      • Avatar John Howard Griffin says:

        So, if I understand correctly, the issue of whether you support either of the mandates is based on numbers (how many might be harmed by not supporting it). That’s a difficult position, I think, but one that most people hold.Report

        • I would rephrase it as “risk of imminent harm,” which is of course expressed in numeric terms. The risk of imminent harm from failure to buckle in a child is much, much greater than risk of cervical cancer. It confounds a categorical response to questions of parental freedom and public health to take statistical considerations into account, but in my opinion that’s a better foundation for public policy.Report

  5. Avatar Chris says:

    I think the distinction you make between HPV and other diseases with mandatory vaccines is specious. While it is technically true that the only people who have to worry about getting HPV from an individual are those who have sex with that person. However, the difference between this and the other diseases is only one of degree, as a function of mode of transmission. The only people who have to worry about getting the mumps from someone who doesn’t get a vaccine are the people who are around that person when he or she has the mumps. Granted, the people who are around the people who were around the person with mumps then have to worry about getting it, but the same is true of HPV: the people who have sex with the people who had sex with the person who wasn’t vaccinated have to worry, too. It is a community health issue, same as mumps or measles.

    What’s more, “sex is risky” is a really bad argument against including a vaccine among those that are mandatory. You know what else is risky? Going to school or going to the hospital, where you might end up with one of the diseases on the mandatory vaccination list. So you know what we do? Make the vaccinations mandatory.

    Also, it wasn’t really mandatory. It was quite easy for parents to opt out of the vaccine for their daughters.Report

    • Being in passive contact with a person who is contagious for measles is very different than choosing to engage in sexual congress with someone. I agree that HPV is a community health issue, which is one of many arguments for why it’s a good idea. But every single person in the chain of HPV transmission is exposed to risk through a positive choice, not from the random misfortune of sitting next to someone on a bus.

      Yes, any number of activities carry risk. We cannot hope to prevent all risk to all people from everything, and I’m not advocating a laissez faire, throw-up-your-hands attitude. First of all, I think HPV vaccination is a really good idea. But sexual activity carries a specific set of risks, of which infection with any number of diseases is at the top of the list.Report

      • Avatar Chris says:

        Except no, that’s not true. People are exposed to disease because of choices, and while the choice behind HPV is specific, whereas the others may not be, the distinction doesn’t seem to carry any moral or policy weight in this case. Again, going to school (a choice: you can go to a different school, just like you could fuck a different person) is a risky behavior. The more you argue for the distinction, the less valid it seems to me. Choice? Yeah, but what isn’t? Risky? Yeah, but what isn’t. I mean, it seems to boil down to the residue of Puritanical views of sex.Report

        • Avatar Patrick Cahalan says:

          > Distinction doesn’t seem to carry any
          > moral or policy weight in this case.

          Well this depends entirely on what you establish as a reasonable baseline for the commons.

          I’m okay with, “traveling on a bus, or entering a public house, or going to a public building shouldn’t pose a health risk due to poor choices by some of the occupants”; that seems a reasonable baseline for the commons.

          “Going specifically to someone’s house” isn’t. If that someone wants to chain-smoke in their house, it’s not cricket for me to complain if I visit them regularly and get cancer from secondhand smoke.

          “Screwing in the backseat of a Chevy” would fall to the right of the previous.Report

          • Avatar Dan Miller says:

            Except that you know, before you go to someone’s house, that there’s second-hand smoke there (or at least you find out pretty quickly). There’s no such foreknowledge of HPV infection. In that regard, it’s much more akin to sitting next to someone on the bus. I agree with Chris, it seems like there’s an element of Puritanism in this argument.Report

            • There may not be foreknowledge of HPV infection specifically, but there is foreknowledge that sexual activity carries certain risks.

              I do not mean to come across as puritanical. I want sex to be as risk-free as possible, and would want parents to choose that for their kids. I think foregoing the vaccine for one’s child is a bad decision. But it’s one I feel parents should be free to make.Report

              • Avatar Dan Miller says:

                Yes, but there’s foreknowledge that going to school or riding the bus or whatever carries certain risks as well.Report

              • Avatar Patrick Cahalan says:

                Sure.

                I don’t think measles is a risk for riding the bus that we generally ought to think is okay.

                There’s lots of things you can get from screwing in the back seat of a Chevy that will kill you. You could get AIDS (or any one of a number of other things) from someone who has taken the HPV vaccine.

                Sharing bodily fluids with someone is going to open you up to a risk of a large number of diseases, even non-sexually transmitted ones; there’s not much you can do about that one except trust your partner. Bodily fluid exchange is inherently pretty risky.

                Sharing a doorknob ought not to be.Report

          • Avatar Chris says:

            What Dan said. Plus, what about the friends you choose? I mean, you’re more likely to get measels if you’re friends with a kid who isn’t vaccinated (even if you don’t know it). So, why should we mitigate the risks you take by choosing to be friends with certain individuals?Report

            • Avatar Patrick Cahalan says:

              This is just where I put the stake in the ground. There’s reasonable arguments to move it this way *and* that way.

              This is the place where I feel the best tradeoff between the public’s reasonable right to a reasonable commons and an individual’s equally reasonable right to tell people to eff off about their own body and what goes in it.

              That’s just me.Report

        • Avatar James Hanley says:

          Chris,
          a choice: you can go to a different school, just like you could fuck a different person

          An unusually specious argument from you. The different school is probably as likely to have unvaccinated students as the first one–unless, perhaps, one is moving from a low-income neighborhood school to a high-income neighborhood school or a private school. That choice just isn’t as easy as they choice to use a condom or to not have sex with this particular person.

          You are totally overlooking the concept of risk-assessment here, and in my (not so humble) opinion no policy argument that ignores risk-assessment can be taken seriously.Report

          • Avatar Chris says:

            James, I disagree. Anyone else I fuck is a risk, as well. If abstinence is the only solution, then there’s no solution at all. Same with schools. The best thing to do is protect the population.Report

            • Avatar James Hanley says:

              Chris,

              Then you’re disagreeing that the difference is significant enough to justify a policy difference. I might disagree, but that’s a reasonable position. What’s not reasonable is arguing that degrees of difference are irrelevant in considering whether a policy difference is justified.Report

            • Avatar James Hanley says:

              And I would add, total abstinence is not the only solution. Just as we can ask “are you on the pill?” and “do you have any STDs” we could ask “Have you had the HPV vaccination?” The idea that we’ll all be helpless if government doesn’t mandate vaccination is a bit unimaginative.Report

              • Avatar Kimmi says:

                strikes me that this is about as likely as people signing a contract on what to do about the baby, before having sex.
                That is to say: could happen, under some circumstances.

                The guy who gets a girl drunk to fuck her brains out isn’t gonna be asking no questions. And she sure as heck ain’t.Report

              • Avatar DensityDuck says:

                I dunno, maybe you could not drink so much.

                Or is that some of that “slut-shaming” we’re not supposed to do?Report

              • Avatar Kimmi says:

                Sir, you have obviously never set foot into a fraternity. Allow me to educate you: In Fraternity Houses, there are recipes passed around for date rape drugs. In Fraternity Houses, they use laughing gas and other commodities to remove the ability to produce informed consent.

                A rape is a rape, and you sirrah are an enabler. You speak as if it was the woman’s fault that she was raped.

                How much should a woman be charged for being raped? What is the privilege of being violated worth to you?Report

              • I don’t really have a dog in this hunt between the two of you, but you are painting with far too broad a brush when you speak about fraternities that way. While I was never in one, I was good friends in college with dozens of guys in fraternities, and I strongly doubt that they lived in an environment similar to the one you describe. Yeah, they liked to get laid, but they weren’t rapists,

                Maybe what you describe occurs in some fraternities, but not in Fraternity Houses writ large.Report

              • Avatar Pat Cahalan says:

                Disclaimer: I am not, nor have I ever been, a member of a social fraternity (I was in Pi Mu Epsilon, but that’s an academic fraternity and I never went to any meetings).

                I do, however, know more than one dude who was in a social fraternity. None of the fraternity guys that I know would condone the use of a date rape drug. Some of them might have used hits of nitrous oxide to make “The Wall” sound more trippy when they were already high as a weather balloon, but nobody hooked up a sorority sister with any of that stuff just to get in her pants.

                Although they all did get a lot of women falling-down drunk in college, this is largely due to them getting *everyone around them* falling down drunk in college.

                I’m readily aware that date rape drugs have been passed around fraternity members, and that guys have before collaborated to encourage a particular girl into out-of-her-mind drunkenness for the purposes of sexual exploitation. Yes, this happens. Probably with much more occurrence than ought. I’m not defending the system of social fraternities from all of their worst characteristics (quite frankly, I found them all to be the worst sort of baloney, myself).

                On the other hand, not all fraternities are full of roofie-packin’ rapists, either.

                P.S. -> I would hope that any parent would sit down prior to their daughter going off to college and explain in appropriate detail that getting so drunk you can’t stand up is an activity only to be engaged in while located in a safe house surrounded by implicitly trustworthy allies; that this is an unfortunate and unfair double standard which doesn’t apply to the same degree to men and that sucks, but it’s life.Report

              • Avatar Kimmi says:

                yup, you’re right, folks. Citing instances of bad behavior on the behalf of one fraternity is not a good way to generalize to all of them.

                Still, I will not have someone “lessening” the charge of rape, because the victim “deserved it.” Blame the victim talk is dangerous.

                “He used sleep-deprivation torture to get her to agree to having sex, so it isn’t rape.”

                Because she should have “known better” than to get into that situation.

                It’s rape. Just like it remains “attempted murder” even when you’re 5’4″ and he’s 6’8″, and you warn him off multiple times before drawing that knife and attacking (wif your friends). He’s dumb, and you’re going to jail.

                Thing is? Rapes don’t get prosecuted, to a large degree. And so women in general tend to be kinda prickly when you blame them for having fun, in a way that is socially acceptable.

                It is a fuzzy line between “she ought not to have gotten that drunk” to “she ought not to have dated that fool” to rule of thumb.

                okay, maybe not that last one. but this isn’t a laughing matter, my feeble attempts at humor aside.Report

      • Avatar sonmi451 says:

        “But sexual activity carries a specific set of risks, of which infection with any number of diseases is at the top of the list.”

        I think this sentence explains why you feel differently about HPV than the other diseases you support vaccination. Sex = not an innocent act like accidently sitting besides someone with measles. How is this very different than the puritanical sex = evil mindset?Report

        • Avatar James Hanley says:

          Sex = not an innocent act like accidently sitting besides someone with measles. How is this very different than the puritanical sex = evil mindset?

          It’s not about the morality of sex, but about the relative ease with which a person can make the choice, and their consequent degree of responsibility about their choices. As you note, sitting beside someone with measles can happen accidentally, so obviously it would be really odd for us to say “you should exercise caution about whom you sat next to in school/on the bus/at the hockey game, etc.” Sex doesn’t happen so accidentally, so it’s not that odd to say “you should exercise caution about whom you f**k.”*

          One can be wholly anti-puritanical about sex and still believe that sex is a choice that involves personal responsibility. In fact that’s probably the standard libertarian approach to sex, just as it’s their approach to drugs, liquor and guns.

          ______________________________
          * There is a caveat here–a big one–about rape. Obviously it would be astonishingly perverse to say “you should be more cautious about who rapes you.” But that’s an argument for why a person should get vaccinated–a point nobody here has argued against–and not such a strong argument for why government should force the person to get vaccinated. “A really bad thing could happen to you, with horrible results, therefore we’re going to force you to protect yourself”–that’s a logic that some people accept, but libertarians reject that kind of paternalism because they don’t think it’s government’s duty to protect us from the consequence of our own choices.Report

        • First of all, I am entirely supportive of vaccination against HPV. Every parent should choose it for their children. I am opposed to making it mandatory.

          And there is quite a difference between describing the risks inherent in any particular act, and viewing said act as evil.Report

    • Avatar James Hanley says:

      Chris,
      the difference between this and the other diseases is only one of degree, as a function of mode of transmission.

      Of course differences of degree do matter, if they are different enough. We wouldn’t arrest someone for driving a car after going back for seconds during communion, but we would arrest someone for driving after downing a couple of fifths of Jack.

      That’s a bit of a silly analogy, to be sure, but the point holds. If you’re argument is that the degree of difference isn’t substantial enough to justify different policies, that’s an arguable but legitimate position. But if your argument is that degree of difference can’t be a legitimate basis for public policy distinctions, you’re well off on the wrong track.Report

  6. Avatar trizzlor says:

    Let’s say a parent could inject their child with an agent that would increase their chance of cancer if they had sex. Would there be a compelling state interest in banning such a practice? Certainly the practice is now active rather than passive, but I think it’s reasonable to say that for a child – who cannot choose to vaccinate oneself – the active/passive distinction is blurred.

    (btw, this isn’t meant to lay some kind of bleeding-heart tirade trap, I’m also unsure on the question)Report

  7. Avatar DensityDuck says:

    A) Do condoms prevent the transmission of HPV?

    B) Is the vaccine still effective if administered during adulthood rather than adolescence?Report

    • A) Somewhat, but not to the degree that they confer protection against such other STIs as HIV, chlamydia or gonorrhea.

      B) There are four HPV strains in Gardasil, so even for patients who have been exposed to HPV there is still a benefit in getting vaccinated to protect against other strains. I do not believe that there is any benefit vis-a-vis strains to which a person has already been exposed (though I could be wrong).Report

      • Avatar DensityDuck says:

        Where I’m trying to go with this is to suggest that handing out free condoms would be just as effective at stopping HPV as the vaccine, and that the vaccine itself wouldn’t be less effective for being delayed until the person could make their own decision.

        Of course, that’s assuming that high school kids have the sense to use the damn things.Report

  8. Avatar Christian says:

    You seem to rely heavily on the assumption that sex is an activity of choice. 1 in 6 women are the victims of rape or attempted rape. 54% of rape victims are younger than 18, the legal age of emancipation). (1)

    Given this information, would you revise your position?

    (1) Report

    • Avatar Christian says:

      Sorry that my link failed to post, but my source for those statistics is the National Institute of Justice.Report

    • Avatar Kim says:

      and I’ll say those numbers are likely too low, given that much nonconsensual sex occurs when people are somewhat loath to call it rape (maybe might have had sex while “drunkenly passed out” at a party, even if someone deliberately got you that way)Report

    • I would not revise my position on mandating HPV vaccination, no. I would hope that parents would take the tragic possibility of rape into consideration, and would opt for the vaccine. But my belief that parents should have the right to make bad choices for their children is not altered.Report

  9. Avatar Creon Critic says:

    I think your view gives too much latitude for the parent to make bad decisions that have lifelong consequences. Bad is an understatement, it seems like a kind of negligence to me. Compulsory education is an invasive mandate infringing on the parental right to make bad choices for a child, it also contributes greatly to an important social good. Given herd immunity, I don’t see why HPV vaccination would be different. An educated populace, a healthy populace, both seem like absolutely essential community commitments to me.

    I agree with those commenters who don’t give as much weight to the method of transmission. I don’t understand why it is so important in this case, HPV is currently widespread and can be transmitted by a person who doesn’t know they have it. Building herd immunity is an important social goal.

    You’ve mentioned the rights of the parent several times, but you haven’t discussed the rights of the child. Does the child have the right to live a life without worry of HPV? Does the child have a right to health?Report

    • I don’t take issue with most of what you’ve said. I agree that it is negligent to a certain degree to eschew vaccination. I agree that building herd immunity is an important social goal. And I agree that a child should be able to live a life without worry of preventable illness.

      That said, there is a difference between the wholly passive transmission of other vaccine-preventable illnesses and the activity required to transmit HPV. A person with HPV is much less likely to expose the same number of people to infection as is a contagious measles or diphtheria sufferer. Those people who are exposed become so while engaging in voluntary behavior known to carry risks.

      Yes, the child has rights. But I am chary of using those rights as an argument for supersede parental prerogatives unless there is strongly compelling reason. In this case, I do not believe that there is such a compelling reason, as much as I may support the desired intervention.Report

      • Avatar Christian says:

        “Those people who are exposed become so while engaging in voluntary behavior known to carry risks.”

        Russell,

        This is untrue. You ignore my earlier NIJ statistics and the unfortunate fact that many women and girls are victims of rape who have not chosen to engage in risky behavior. By failing to acknowledge this fact, you are misrepresenting the truth.Report

        • Avatar Patrick Cahalan says:

          Your existing citation is limited in use.

          “1 in 6 women are the victims of rape or attempted rape. 54% of rape victims are younger than 18, the legal age of emancipation”

          That can be true, but it doesn’t apply in all specific sub-populations.

          I imagine the numbers are not distributed evenly.Report

  10. Avatar Dan Miller says:

    Again–going to a preschool, instead of staying at home, is also a voluntary behavior known to carry risk. So is hanging out in a crowded bar, using a public restroom–basically everything except remaining at home in a Seinfeld-style bubble.

    If you were to extend your position to cover, e.g., the MMR vaccine, I wouldn’t agree with you, but it would at least be consistent. But there really is no reason to treat the two differently.Report

    • Dan, you clearly view the attendant risks of sending your child to preschool as being commensurate with engaging in coitus. I do not. All behavior carries some risk, but some are much riskier, and have more particular risks, than others.

      The risk of passive exposure to HPV are nigh unto nil. This does not hold true for measles, which is highly contagious. The two diseases are not equal in their potential to infect large numbers of passive individuals.Report

      • Avatar DarrenG says:

        I don’t read anywhere in his comment(s) where he’s saying the risks from preschool and coitus are commensurate as you claim.

        Instead, he seems to be saying both actions are voluntary and occur along a continuum of risk, contra your claim that one action is of a fundamentally different nature from the other.

        I, also, think you are overstating the active/passive behavior distinction for HPV for the same reasons as other commenters. Riding a bus is an active choice, as is using a public restroom, sending your child to day care or pre-school, and many other actions that may substantially increase risk of exposure to infectious disease if the population involved is largely unvaccinated.Report

        • But as I said, some actions are more risky, and carry a more specific set of risks than others. The risk of exposure to disease weighs much more heavily on a decision to engage in sexual activity than it does with an otherwise unrelated decision such as whether to ride the bus.Report

          • Avatar DarrenG says:

            This seems like a better way to describe it, especially combined with your response to Burt below.

            I thought some of your other comments seemed to be making a case that HPV infection was a different kind of risk, rather than a different degree of risk, versus other preventable diseases.

            I also still think making a distinction based on transmission method is questionable. The more important perspective for me is the knowledge that without vaccination a significant percentage of the population will get exposed to the disease and will experience serious negative consequences from it, up to and including death.

            I would prefer to see non-coercive methods tried first, though (the carrot rather than the stick, as advocated above), but if those fail to achieve herd immunity within a reasonable amount of time I’m open to other options given the risks involved.

            Public health policy in areas like infectious disease and toxicology often gallops into huge moral and philosophical grey areas, so I’m glad to see others, including professionals in the field, struggling with this openly rather than immediately forming the barricades around a hardened position.Report

            • First of all, if I phrased things inelegantly then let me try to be more clear. I don’t think it’s a question of the type of activity, so much as the degree of risk and the reasonable expectation of same when deciding whether to participate in the activity.

              I really, really, really want people to vaccinate their kids against Gardasil. But I am very wary of making coercive choices that undercut parental autonomy. There are so very many ways that parents choose really poor things for their kids, and I can see how easily our desire to intervene on their behalf can become heavy-handed. (I am also wary of making intellectually weak slippery-slope arguments.)Report

  11. Avatar Burt Likko says:

    I have some sympathy for the point of view that parents should be able to make choices for their children, even if they are bad ones, and that liberty means tolerating when others make bad choices. I enjoyed the challenge to my own point of view made in the OP.

    With respect to public health issues, seems to me that the line of “your liberty ends when your fist hits my nose” is blurrier than what Dr. Saunders describes here. Contagious and readily-communicable diseases with serious consequences are public health risks, not private ones. There’s a good exchange starting here concerning how the mechanism of communicability might affect the kinds of public policy choices we as a society ought to make about vaccination.

    As I see it, STD’s are pretty rapidly-spreading sorts of diseases. They seem to go in fits and starts of rapid bursts of transmission, then not so much, then bursts again. Syphillis has a well-chronicled cycle of outbreak and quiescence, although it seems to be unclear if that is related to the behavior of the transmitters (the carriers of the disease and their, for want of a better word, victims), or something built in to the generational life cycle of the pathogen.

    It’s not just your daughter who’s at risk from HPV; it’s mine and that other family’s and everyone’s. STD’s are communicated rapidly. One in six Americans has genital herpes. There are 700,000 new gonorrhea infections every year. While transmission of an STD is less casual than, say, breathing in the same room as an infected person, seems to me that the reality of STD transmission is that it happens a lot.

    Nor are the harms inconsequential or isolated only to the victims. In the case of HPV, the chief risk is cervical cancer. Like many other kinds of cancer, cervical cancer is treated largely with chemotherapy, radiation, and excisement surgery. These are all expensive and take a significant toll on the available resources of hospitals, doctors, and the insurers who have to pay for it all. This uses up resources that could go elsewhere, and in almost no case is a private individual able to pay for it all out of pocket. Insurers, both private and governmental, are almost always involved in paying for this expensive suite of treatment. And there is the human cost on the patient and her support network, too.

    Now, we can take either the libertarian POV that Dr. Saunders has described in the OP or my community-risk-justification for an interventionist POV. Neither, as I see it, is evil and neither, as I see it, can make for a practical ideological basis for forming public policy. There is a public risk to almost every choice that people make, and there is a degree of liberty and choice inherent in making decisions. The real question is where is the reasonable line between the amount of public risk we are willing to tolerate in exchange for the private liberty enjoyed by individuals.

    For me, STD’s are communicable enough, and have serious enough consequences on more than just the individual indulging in risky behaviors, that the intervention of the government and corresponding diminishment of personal liberty is justified.Report

    • Avatar DensityDuck says:

      Dr. Saunder’s point is that it’s only a community risk in a community that you must take dramatic personal voluntary action to join. People who don’t engage in unprotected sex don’t get HPV (with the possible exception of sequential finger-banging.)

      It’s like saying that we should deal with the problem of parachute failure by requiring every person to carry a reserve parachute with them at all times.Report

      • Avatar DarrenG says:

        it’s only a community risk in a community that you must take dramatic personal voluntary action to join

        Except, of course, in the cases of rape or sexual assault as described above.

        And also as Dr. Saunders himself stated, condoms are not particularly great at mitigating the risk of HPV transmission even in protected sex.Report

      • Avatar Dan Miller says:

        Two problems with this. First is that even if everyone used condoms all the time, it wouldn’t stop transmission of HPV, per Russell’s comments to you above. So the risk is to anyone who engages in sex, unless both they and their partner are virgins. This figure is about 85% of the population.

        Secondly, as Christian pointed out above, not all sex is consensual or voluntary.Report

      • Avatar Burt Likko says:

        I’m unimpressed with the drama inherent in the decision to engage in consensual sex. Maybe from a personal, emotional perspective sex is (for some, hopefully most) a dramatic, rare, and carefully-weighted decision, and from a legal perspective it is an intimate, private, personal sort of decision.

        But from a public health perspective, sex is a very common behavior and public policy should be clear-eyed about that. People fcuk. All the time.Report

    • I respect that you draw the line more toward the public safety side of the question, Burt. I think it’s a defensible position.

      Perhaps mine is informed by the cavalcade of parents I see who make harmful decisions about theirs kids’ health all the time, some with ramifications just as dire (or probably more so) than a decision to decline HPV vaccination. I see how much leeway parents are sadly but appropriately allowed to damage their children, and don’t believe that HPV is sufficiently transmissible as to warrant a irruption on parental prerogative.Report

  12. Avatar Patrick Cahalan says:

    Responding to Burt:

    One thing we haven’t discussed on this thread which also informs my position is something I could have sworn I posted this morning but I can’t find it anywhere. Practicality. From that old post:

    Enforcing government mandated vaccinations is a very costly proposal. Some of the questions you need to consider include:

    What behavior are we trying to enforce?
    * A full vaccination schedule? Partial?
    Who decides what’s on the list?
    * The CDC? How often to they revisit the list?
    Who are we covering?
    * Just school-age children? Infants? Adults?
    How many of them are already doing what we want anyway?
    * In which coverage windows?
    How do you propose that they prove their compliance?
    * Required to… enter public school?
    * What about private schools? Daycare? Drive a car?
    * Register to vote?
    What are your avenues for authorization?
    How do you propose that we trust the authorization mechanism?
    * Who can sign off? Doctors? EMTs? Nickel clinic workers? How do the people who *check* the authorization actually check it? Do they check a doctor’s signature against an authoritative database? Is there a physician ID number? Who has access to this information? How do you secure it? How do you ensure that FERPA, HIPAA, and other privacy regulations (in the case of the U.S.) are followed and enforced?

    How do you have a reasonable audit?
    * You must assume that in the above there are going to be people who attempt to circumvent the process. Your audit design must therefore incorporate every weak part in the chain to a suitable degree, and in the above there are thousands of venues. How do you make sure that doctors are legitimately signing the forms? How do you make sure that school clerks who don’t believe in vaccination aren’t just rubber-stamping forms out of a sense of political freedom? How do you prevent fraud? How do you prevent forgery?

    How do you enforce the audit?
    * What is your penalty system when people circumvent the process? Do doctors lose their license? Do you expel children, so they’re now uneducated and unvaccinated? Do you revoke driver’s licenses, so drivers now can’t get insurance? Revoke licenses for professionals?

    Now keep in mind that most people vaccinate already (of course, there are communities of non-vaxxers, but we’re talking about universal policy here, not fixing the outliers)… so all of the above checking, auditing, authorizing, with all of the attendant red tape, paperwork, and frustration is being borne by all those people who vaccinate voluntarily to no benefit. We’re not even considering legal costs, legislative costs, etc. involved with getting such an initiative on a ballot and past the inevitable court challenges.

    Whatever you believe that is going to cost per capita (and keep in mind, there’s 80 million children under the age of 19 in the U.S.), that’s going to wind up being a pretty big chunk of change.

    The NIH funds cancer research at the National Cancer Institute to the sum of $660 million dollars (in 2007). Cancer kills a half a million people every year. If you’re going to convince me that this audit process is going to be worthwhile, you’re going to have to convince me that spending all that money is a better idea than just taking the lump sum and transferring it wholesale to the NCI.Report

    • Avatar DarrenG says:

      We’ve already paid most of the costs you describe for other mandated childhood vaccinations. The incremental cost of adding one more vaccine to the regimen is very small in most states, as best I understand it.

      I suppose you could argue that it was a mistake to mandate those other vaccines and build the infrastructure to regulate and audit their administration, but that sounds like a different, larger discussion than “should we add Gardasil for HPV to the list?”Report

      • Avatar Patrick Cahalan says:

        That is a fair counter.Report

      • Avatar Patrick Cahalan says:

        Although, note: most of the existing vaccination enforcement stuff is trivially circumvented as it stands.

        I mean, all you need to do is stamp “religious objection” in many cases and you get out. So the actual efficacy of the existing structure is debatable.Report

        • Avatar DarrenG says:

          True, but I think the evidence suggests that not enough people opt-out to compromise herd immunity, at least until recently when the anti-vaxxers started mucking things up.

          The numbers on efficacy of mandatory vaccines have been overwhelmingly good for a very long time before some recent negative changes in trends (which, should be noted, still leave us much better off than before we started mandating them).

          This also seems like a larger objection over public policy regarding vaccination in general, though, and isn’t specific to HPV.Report

          • Avatar Patrick Cahalan says:

            Absolutely.

            Well, I’m still not certain that the money wouldn’t be better spent on anything else, but I don’t have credible grounds to even estimate how much all of this costs, and (of that cost) how much of it is money that could be transferred to research. Most of it, probably not.

            But given that I’ve already got a particular view of the commons, this is enough to keep me standing on the fence that I’m on.Report