The recent overhaul of the U.S. pediatric vaccine schedule under Health and Human Services Secretary Robert F. Kennedy Jr. touched off a firestorm of criticism — most of it for demoting six vaccines from routinely recommended to “shared clinical decision-making” (SCDM). The implication was that these six vaccines are optional, less safe, or less useful than the routinely recommended ones.
Like nearly everyone in public health, I agree that the evidence for the safety and efficacy of the six vaccines is robust and hasn’t changed.
But in its urge to say what Kennedy gets wrong, the public health and medical community is actively resisting something he gets right: Vaccination decisions belong to patients and their parents, guided by candid advice from health care professionals.
Nobody disagrees in principle that informed consent is fundamental to all medical decision-making, and that vaccination is no exception. But in practice, too many health care practitioners have made vaccination informed consent automatic, routinized, pro forma — arguably an ethical sham. Too often they have seen it as a time-wasting barrier to vaccine uptake. It is that, sometimes. But it is also, or should be, a front-and-center feature of vaccine decision-making.
For years, SCDM has been treated within vaccine policy as a grudging exception, a special category reserved for vaccines whose risk-benefit tradeoffs are debatable. For “routine” vaccines (most vaccines), the implicit message to parents and clinicians alike has been: This isn’t something to think about or talk about. Just make sure you do it.
This posture makes scientific sense. If the data say a vaccine is beneficial for all, why encourage anyone to consider declining it? And this posture has unquestionably maximized not just efficiency but vaccine uptake, thereby minimizing population morbidity and mortality.
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But too many pediatricians have come to see minimizing morbidity and mortality as so important that respecting agency and freedom of speech is now secondary — so secondary that in practice it often becomes dispensable.
The most widespread advice to pediatricians on how to talk with parents about vaccines is to take a presumptive approach. The CDC’s webpage still expressly advises: “State which vaccines the child needs to receive as though you presume that parents are ready to accept them during that visit.”
Do I think Kennedy pushed out the new pediatric vaccine schedule because he is deeply committed to agency and freedom of choice? No, I think he wants to undermine vaccine uptake. But his bad faith doesn’t mean he has a bad argument.
The question, then, is what public health professionals should say in response. Faced with a policy change they rightly oppose on scientific grounds, most vaccine proponents are making two strategic risk communication mistakes.
First, by continuing to equate SCDM with “optional,” they are boosting the very signal they fear most.
A content analysis of media coverage of the new policy would yield just a few instances of HHS officials actually stating that some vaccines are optional — and endless instances of pro-vaccine commentators saying that that’s what HHS officials are signaling. If the public comes away believing that the federal government has declared many vaccines “optional,” it will not be primarily because HHS used that word. It will be because vaccination’s staunchest defenders did.
Second, by continuing to view patient and parent choice as a threat, they are granting Kennedy the moral high ground.
Why accept that SCDM is a signal of weak evidence? Why not redefine it as simply the clinical operationalization of informed consent, a cornerstone of ethical medical practice? Patients and parents are always entitled to decide whether to accept a medical intervention. Presuming otherwise in the examining room — the recommended “presumptive” approach — does boost short-term compliance. But in the longer term it corrodes legitimacy.
This position makes me in some sense more radical than Kennedy’s HHS.
The pre-Kennedy pediatric vaccine schedule provided for shared clinical decision-making only when a vaccine’s benefits did not clearly exceed its risks. The new schedule moves six more vaccines into that category. I would go further: I want every vaccine discussion to be a shared decision — some recommended more strongly than others, but all subject to a less pro forma version of informed consent than is currently the norm.
I think this change is better for both democracy and medical ethics. But I’m not a political scientist or bioethicist; I’m a risk communication expert. So let me share a core risk communication principle: Sooner or later, more often than not, authoritarianism leads to distrust and resistance. That is true of Kennedy’s authoritarianism. And it is also true of public health when it sidelines patient agency.
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The paradox at work here is this: Commandeering the patient’s and parent’s right to choose doesn’t demonstrate strong confidence in vaccine science. It demonstrates insufficient confidence in our ability to convince people the science is solid. By insisting on presumption, not persuasion, the public health mainstream has been doing much of Kennedy’s work on undermining vaccines for him.
Strong confidence in vaccine science would entail experts saying all of the following loudly and publicly, especially in the media:
- Kennedy is wrong about vaccine risks and wrong to imply that routine childhood vaccines lack a strong scientific foundation.
- Patients and parents are nonetheless entitled to make vaccine decisions, and they should be told so.
- Clear, honest guidance from health care providers will help them make these decisions wisely.
- Shared clinical decision-making is the appropriate framework for all vaccine discussions — not because the evidence is weak, but because agency and freedom of choice matter.
- After genuine shared decision-making, most parents will conclude that vaccination is the best choice for their children.
- Some will not, and that will negatively impact health. In a free country, that is their inalienable right. Continued respectful dialogue is the appropriate response.
Do you think this messaging approach undermines vaccine confidence? I think it strengthens it.
I’m not denying that the new schedule’s emphasis on SCDM will deter some parents on the fence from agreeing to every vaccine the pediatrician recommends. At least in the short term, the presumptive approach really does yield higher vaccine uptake.
But I suspect that in the longer term, parents will feel more respected by their pediatricians and by the public health mainstream — so maybe they will start to return that respect and uptake will go up. Or maybe not. Maybe even in the long term there will be a health cost for respecting parental choice.
Bear in mind that the question is no longer whether respecting parents’ agency or downplaying it is more conducive to long-term vaccine acceptance. The new pediatric vaccine schedule has already put parents’ agency front-and-center. I assume that Kennedy will continue to push this issue, since it’s his strongest argument. More and more clinicians will be called upon to respond to parents who expect to share in vaccine decisions.
So the choice for public health now is whether to support this change or continue to take an all-too-visible stand against it. I say support it. Keep insisting on the scientific evidence. But relinquish de facto control over parents’ decisions about their children’s vaccinations.
Peter M. Sandman is now retired after spending more than 40 years as a risk communication researcher, writer, and consultant. He has tried to put everything he knows on his website.
