Book Reviews

Mark A. Largent, Vaccine: The Debate in Modern America, Johns Hopkins University Press, 2012; Mark Navin, Values and Vaccine Refusal: Hard Questions in Ethics, Epistemology, and Health Care, Routledge, 2016

Over the last twenty years or so, vaccines have developed as one of the standard examples of major public scientific controversies, alongside climate change and genetically modified foods. This public contention has attracted scholarly attention, and the current review examines two recent attempts at such scholarly intervention. While both books have their limitations, I recommend both to anyone interested in a sophisticated introduction to the vaccine controversy. Specifically, the first substantive chapter of each book would be an excellent set of readings for one-session discussion of the controversy in a bioethics class or science communication workshop.

Mark Largent’s Vaccine: The Debate in Modern America was published in 2012 by Johns Hopkins University Press (Largent 2012). Largent is a historian of science at Michigan State University, and most of the book takes the form of historical narratives of some key figures or moments in the development of the vaccine controversy. Mark Navin is a political philosopher at Oakland University in Auburn, Michigan, and so his Values and Vaccine Refusal—published in 2016 by Routledge—focuses on a more abstract analysis of arguments (Navin 2016). Both books are broadly accessible. While Largent’s book was published a few years ago, the two books work well together; thus the current, joint review.

Before getting into the details, let me introduce some terminology and provide a brief overview of the state of the vaccine controversy and vaccine compliance. Following Navin, vaccine denial is a denial of mainstream medical beliefs about the safety and efficacy of vaccines, while vaccine refusal is the behavior of refusing routine childhood vaccinations. That is, roughly, denial is a matter of belief while refusal is a matter of behavior. Public health officials often focus on vaccine compliance, which is simply the logical negation of refusal, viz., accepting all routine childhood vaccinations; or on vaccine coverage, which is the percentage of a population (often children in kindergarten) who have received recommended vaccinations. Largent focuses on vaccine hesitancy, which refers primarily to (subjective) doubt about vaccine safety and efficacy, and so secondarily the prudence of vaccine compliance or refusal. The difference between vaccine denial and hesitancy is the difference between confident rejection and uncertainty. Vaccine hesitant or denialist parents will often have more or less specific and well-articulated vaccine concerns. These concerns can be narrowly understood as reasons to doubt the safety or efficacy of vaccines, or they can be understood more broadly as reasons to doubt the all-things-considered prudence of vaccine compliance. The possibility that vaccines can cause autism is a widespread vaccine concern, despite being thoroughly rejected by the mainstream medical community.

Popular media coverage of the controversy often gives an oversimplified impression of a rapid, widespread drop in vaccine coverage. Nationally, coverage rates for four major, longstanding immunizations (MMR, DTP/DTaP, polio, and HepB) have remained steady since 2000, at around 90% or more of preschool children (Centers for Disease Control and Prevention 2015). Coverage is lower for immunizations that have been added to the recommendation list more recently, such as rotavirus and HepA, but even here the national trends are towards increased coverage over time. By contrast, there is more variance at the state and county level (Ernst and Jacobs 2012), including some state-level increases in personal or philosophical exemption rates since the 1990s (Omer et al. 2012; Richards et al. 2013). Some epidemiological research has shown that vaccine refusal tends to occur in geographical clusters (Lieu et al. 2015), such as Ashland, Oregon, and parts of the Bay Area in California. Such vaccine refusal clusters have been associated with preventable disease outbreaks, such as an outbreak of measles in San Diego in 2008 (Sugerman et al. 2010); although other outbreaks, such as outbreaks of pertussis, appear to be due to “waning immunity” rather than vaccine refusal patterns (Phadke et al. 2016).

Compared to vaccine compliant parents, vaccine hesitant parents tend to be better educated, have higher socio-economic status, and be more knowledgeable about vaccines (Navin 2016, 10). These patterns conflict with popular representations of vaccine hesitant or denialist parents as ignorant or “antiscience” (for example, Novak 2016), though not with representations of them as privileged (for example, Powell 2015). Vaccine risk perceptions are not (or not strongly) correlated with political party identification or similar measures (Blank and Shaw 2015; Kahan 2015), meaning that vaccine hesitancy is not an example of “liberal antiscience” in the way that climate skepticism is associated with political conservatism. Indeed, the social psychologist and science communication researcher Dan Kahan has argued that this comparison is dangerous; in the terminology I’m using here, linking vaccine hesitancy to partisan political identities might drive vaccine hesitant parents into entrenched denial, and thus exacerbate the controversy (Kahan 2013).

I proceed as follows. The next two sections provide critical overviews of Largent’s and Navin’s books, respectively. I conclude with an overall, pragmatic assessment of the two books.

LARGENT

Largent’s overall thesis is stated succinctly in the first sentence of the second paragraph: “The modern American debate over vaccines and autism is a proxy debate” (1; unheaded citations in this section are to Largent 2012). That is, while some parents have genuine concerns about the possibility that vaccines can cause autism, they also have broader concerns about—among other things—condescending medical authorities, corporate power, and their individual responsibilities to protect and care for their children. These broader issues cannot be settled by evidence that vaccines are safe and effective. Consequently, Largent suggests, the controversy cannot be settled by educating “ignorant,” “hysterical” parents; and some policy proposals, such as strengthening laws in order to compel vaccine compliance, might make things worse.

Chapter 1 introduces an extremely insightful distinction between two conceptions of risk. Public health officials work with what we might call a statistical conception of risk, which is characteristic of epidemiology, decision theory, and related disciplines. Risk is the (quantitative) probability of a (quantifiable) hazard, such as the chance of contracting measles or suffering a serious side effect from a vaccine. Society is a (possibly structured) mass of individuals; when applied to this mass, risk probabilities can be expressed as frequencies, expected total numbers of individuals who will suffer the hazard. Insofar as probabilities are implicitly understood as bets, mass society functions as the casino, with each individual who is vaccinated (or not) a single roll of the dice; the “rational” policy is generally assumed to be the one that produces the “optimal” “long-run” ratio of wins to losses.

Largent points out that this is not how parents conceptualize risk: “While health officials work with a sample size of thousands or even millions, parents consider risks one child at a time. . . . ‘What if your child is that one in a million?'” (20-1). We might say that parents have an individual conception of risk. For a parent, the probability that their child will suffer a side effect from a vaccine cannot be conceived as a bet or gamble: if this roll of the dice is lost, the parents cannot adjust their strategy and try again on the next roll. This is because, simply, for a parent their child is not an indistinguishable, interchangeable molecule in the social mass. (Paul Thompson has made a related distinction throughout his career; see Thompson 2012).

Since Largent doesn’t tease out the epistemological implications of these two conceptions of risk, permit me a paragraph to do so here. A statistical conception of risk does not necessarily need to understand why or how, say, a vaccine causes a certain side effect. So long as public health officials can reliably predict the number of children in society as a whole who will suffer side effects or contract measles, they can determine “optimal,” and therefore “rational,” vaccine policies. By contrast, for an individual conception of risk, the details of the causal connections between the vaccine and side effect are crucial, because vaccine hesitant parents urgently need to know whether the vaccine will cause the side effect in this particular child. Consequently, because of their different conceptions of risk, vaccine hesitant parents and public health officials have different epistemological goals—reliable population-level predictions vs. individual-level causal understanding. These different epistemological goals lead to different research priorities, in line with an observation by philosopher Maya Goldenberg: “While some [groups of vaccine hesitant parents] accept that a serious adverse event after vaccination is extremely rare, they think that research into the factors precipitating those rare events must be a priority. . . . This is not anti-science; it is a demand for participation in setting the research agenda” (Goldenberg 2016, 568). Further, evidence that is adequate for public health officials—such as findings from strictly correlational epidemiological studies with high statistical power—can be deeply inadequate for vaccine hesitant parents—insofar as such studies provide no causal understanding. Because public health officials and parents have different conceptions of risk, they have different epistemological goals; and so they may disagree about what research methods are needed to produce evidence that vaccines are safe and effective (compare Hicks 2015).

Largent’s next chapter examines the ways in which vaccine concerns moved from fringe religious, “alternative medicine,” or “anti-government conspiracy theor[y]” communities to the American mainstream. Largent begins with a review of early twentieth century vaccine concerns and vaccine denialist communities, focusing on the development of chiropractic as one of the major forms of alternative medicine (39-51). Largent argues that many contemporary vaccine concerns and views first emerged among chiropractors, but also that trust-building and engagement has been effective “in swaying chiropractors over to supporting, or at least not overtly undermining, vaccines” (50). Largent next argues that, over the last two decades of the twentieth century, fringe views moved into the mainstream due to high-profile controversies about connections between, first, HIV/AIDS and polio vaccines (51-61), and second, Gulf War syndrome and anthrax vaccines (61-7). As he puts it, “The public and professional debates . . . imported some of the alternative medical community’s concerns about the unintended consequences of vaccines into mainstream discussion” (61).

Chapter 3 begins Largent’s extensive discussion of the specific autism-vaccination controversy. Here Largent examines “two distinct notions about autism” (72). On the one hand is the mainstream medical conception, which recommends behavioral and pharmaceutical treatments to manage the symptoms of autism, asserts that the “autism epidemic” is an artifact of more adequate diagnostic standards, and is confident that there is no link between vaccines and autism. On the other hand is an approach associated with alternative medicine that sees autism as preventable and perhaps even reversible, especially through dietary interventions and avoiding hypothesized triggers such as vaccines (72-3). Much of the chapter focuses on thimerosal, a mercury-based preservative. Historically, thimerosal was widely used; since 1999, in response to public concern, it has gradually been taken out of most vaccine formulations, but is still used in annual flu vaccines.

Chapter 4 examines the case of Andrew Wakefield, the British medical researcher who is (in)famous for his highly controversial 1998 paper arguing for a causal connection between autism and the MMR vaccine. The first quarter of the chapter provides context, namely, Wakefield’s work in the 1990s on connections between viral infections and inflammatory bowel diseases. Largent notes two features of Wakefield’s rhetoric during this time period: he “all[ied] himself and his work closely with his patients” (100, 112) and argued for the publication of controversial work (linking Crohn’s disease to the MMR vaccine, for example) on the grounds that “if his group’s research was not publicized and it was later learned that [their findings were true] . . . the public’s faith in vaccines would be irrevocably damaged” (104). The first feature helps explain why vaccine hesitant parents might trust Wakefield more than more “distant” or “impersonal” public health officials: he shares parents’ individual, rather than statistical, conception of risk. The second feature challenges simple interpretations of Wakefield as “antivaccine” or “antiscience.” Taking Largent’s gloss (and the supporting quotations from Wakefield) at face value, Wakefield appears as an advocate for more and better scientific research on vaccine safety, not an irrational opponent of vaccines as such. At the same time, Wakefield’s critics argue that his findings are easily misinterpreted by the general public, sparking excessive fear and prompting parents to “shun immunization” (quoted on 111).

Most of the rest of chapter 4 examines the fallout from the 1998 MMR-autism paper. As criticisms mounted and reasonable debate became invective, Wakefield became entrenched, alienating his collaborators. From the perspective of the medical establishment, the conclusive refutations of a MRR-autism link were three large epidemiological studies (one of these included all children born in Denmark from 1991 to 1998) (121-2). In 2004, in light of the countervailing evidence and the effects of the 1998 paper on vaccination rates, ten of the thirteen authors—not including Wakefield—voluntarily retracted the paper (131-2). Around the same time, a journalist raised allegations that Wakefield had committed serious research misconduct, including conflicts of interest, manipulating data, and deceiving the ethics committee; the Lancet rejected several of these allegations, but did find that Wakefield failed to disclose conflicts of interest (129-30). Ultimately, in May 2010, Wakefield’s registration to practice medicine in the UK was removed.

Chapter 5 focuses on high-profile participants in the public vaccine controversy, especially Jenny McCarthy (138-48), and to a lesser extent Paul Offit (148-9) and Amanda Peet (149-52). Largent argues that McCarthy should be understood as a representative of vaccine hesitant parents, that is, as a consequence rather than a cause of vaccine hesitancy; as he puts it, McCarthy “has not started a campaign; rather, she has stepped into a void to give voice to millions of Americans who have a tremendous anxiety over the modern vaccine schedule and have found little or no support from science or medicine” (147). McCarthy was raised in a middle-class Catholic family in Chicago (139), and as an advocate she emphasizes parental agency (142, 147) and rejects mainstream medicine’s “fatalistic attitude towards autism” (144). These aspects of her persona make it easy for parents concerned about vaccines or autism to identify with her.

In the final substantive chapter, Largent offers an overview of the concerns and structural factors that, on his view, drive parents’ concerns and otherwise contribute of the vaccine controversy. Briefly, these are

  1. significant increases in the number and pace of vaccines recommended for young children;
  2. vaccines, such as varicella (chickenpox), that trouble a distinction between therapeutic and enhancement medical technologies;
  3. the lack of a clear and realistic goal for vaccine policy;
  4. gender divisions between public health officials (often men) and vaccine-hesitant parents (often women), mothers and fathers, and parents (often mothers) and children at risk for autism (boys more often than girls);
  5. concerns about the postmarketing surveillance system for vaccines, including the possibility that adverse events are underreported and that “long-term side effects are easily overlooked” (166);
  6. the “all-or-nothing approach to vaccination,” which provides no room for parents who might prefer to delay some vaccinations or spread out bundled shots (such as the MMR triple-shot);
  7. the fact that “the duty of policing vaccine compliances [is placed] on daycare and school administrators and staff” and the use of the law to compel vaccine compliance (170); and
  8. insurance structures that create strong incentives for pediatricians to bundle vaccinations and “spend as little time as possible discussing . . . vaccines with parents” (170).

Largent also makes occasional comments relevant to what Foucauldians call “biopolitics”—that is, the use of “health” as a rationalization for governing individual behavior (see, for example, 158)—and concerns about “inappropriate corporate influence” on vaccine development, testing, and policy (171).

From a perspective informed by the methods of sociology and anthropology, Largent’s claims about the eight concerns or contributing factors often seem weakly supported. That is, Largent might be correct that, say, increases in the number and pace of vaccines are a major concern for vaccine hesitant parents; and he does provide at least some evidence to support these claims, e.g., demonstrators chanting “Too many, too soon.” But this evidence is often quite limited. By my lights, survey or interview data from vaccine hesitant parents would make this final chapter more compelling. On the other hand, treated as hypotheses, Largent’s claims are at least plausible. They suggest important policy alternatives to removing exemptions or imposing legal penalties on vaccine-hesitant parents.

NAVIN

Navin’s book neatly divides into two halves. The first, comprising chapters 1-3, deals with what we might broadly call epistemological issues. Here Navin draws heavily on conceptual tools from social epistemology, feminist epistemology, and cognitive and social psychology. The second half, comprising chapters 4-6, examines political issues surrounding mandatory vaccination, working within the public reason tradition of liberal political philosophy.

Navin’s arguments in the first three chapters challenge or significantly complicate three widespread explanations of the controversy, namely, that vaccine denialist parents are ignorant, irrational, or emotional. Such narratives are all instances of what science communication and STS [science and technology studies] scholars call the “deficit model” of public scientific controversies (Wynne 1991; Gross 1994; Durant 1999). These scholars have argued that the deficit model rationalizes the use of coercion or technocratic intervention rather than democratic deliberation, leads to the neglect of non-credentialed expertise, and stigmatizes critical publics. As an example of the last point, Navin notes that vaccine denial is sometimes described as “hysteria,” thereby activating sexist stereotypes (21; all unheaded citations in this section are to Navin 2016). For these reasons, it’s highly plausible that the deficit model can lead to polarization, which can make a controversy even worse.

Chapter 1 examines the epistemology of vaccine denial, drawing heavily on José Medina’s work in virtue epistemology, Miranda Fricker’s concept of testimonial injustice, and feminist epistemologists including Sandra Harding and Lorraine Code. Navin argues that, in response to “physicians’ historical and ongoing abuse of their epistemic power,” vaccine denialists have formed “democratic communities of ‘parent-researchers’ that reject the authoritarianism of traditional medical practice” (22). Navin characterizes a number of criticisms of mainstream medicine, including historical and ongoing paternalism, the influence of commercial interests, and the failure to respect the testimony and concerns of vaccine hesitant mothers (24-31). These concerns seem to justify parents’ distrust of mainstream medicine, and Navin goes on to praise vaccine denialist communities for their “democratic norms for allocating epistemic authority” and fostering “collaborative relationships between pediatricians and parents” (34ff).

However, Navin also argues that vaccine denialist communities suffer from some serious epistemic vices, especially their disregard for “differences in expertise and competence” (41). He goes on to offer (by my count) four arguments that parents should defer to physicians’ expertise about both “the likely outcomes of various options” and “value judgments about which medical interventions would be best for children” (39). Three of these arguments appeal to the epistemic reliability of either credentialed medical experts or “meta-experts,” that is, experts on who has expertise. I worry that these arguments will strike vaccine denialist parents as question-begging: by their lights, it’s at least not obvious that these experts really are epistemically reliable. A fourth argument is more interesting, I think. Navin points out that the “The reason to make space for mothers’ concerns, questions, and experiences” is to produce a “creative tension with the views of experts” (40), that is, to subject the assumptions and methods of mainstream medicine to critical scrutiny that is informed by parents’ experience and interests (elsewhere in this chapter, Navin cites Longino 2002). However, since vaccine denialist communities do not engage with mainstream medical experts, this creative tension is never realized.

At the end of the chapter, Navin offers at least three pieces of advice to the mainstream medical community: to develop “more democratic practices for allocating epistemic authority among parents and pediatricians” (45), to address gender inequalities that lead to condescension towards concerned mothers, and to build bridges to the vaccine denialist communities (46). This chapter offers valuable insight and advice for mainstream public health officials and science communicators who need to understand the vaccine denialist perspective.

In chapter 2, Navin applies the bias and heuristics literature in psychology to vaccine hesitancy, denial, and acceptance. This branch of cognitive psychology aims to understand actual human reasoning in terms of “heuristics,” “quick and dirty” inference patterns that are simple and fast but can be contextually unreliable (Kahneman, Tversky, and Slovic 1982). Here Navin examines how these inference patterns could help explain some vaccine hesitancy. For example, vaccine hesitant parents might recall dramatic online videos about vaccine side effects much more easily than dry statistics about measles epidemics, and infer that the side effects pose a much greater risk than measles; this would be an instance of the availability heuristic or bias (63).

Many analysts and commentators on the vaccine controversy have proposed that vaccine denial can be explained by such cognitive heuristics (see, for example, Goldman 2010; Lombrozo 2015). Navin’s discussion is more sophisticated than these others in three respects. First, Navin repeatedly notes that his analysis is speculative. He cites empirical support when it is available, but does not overstate the strength of this evidence. He is explicitly developing hypotheses, not claiming to have conclusively explained vaccine hesitancy. Second, Navin explicitly rejects the further claim that vaccine hesitancy is irrational merely because it is (assuming that it is) explained by heuristics and biases (57). This is because, third, Navin repeatedly points out that vaccine acceptance can also be explained by heuristics and biases. As he puts it, “The same forms of automatic reasoning that lead some parents to reject vaccines lead other parents to embrace them. Also, pediatricians are not immune to the influence of common cognitive shortcuts” (57). That is, almost no one forms their beliefs through a systematic review of primary research and a careful calculation of costs and benefits. Instead we rely on the messy combination of half-remembered testimony, dramatic narratives, and epistemic trust. Thus, condemning vaccine hesitant or denialist parents as irrational would also imply that vaccine compliant parents and clinicians are irrational.

Chapter 3 draws on cognitive psychology research on disgust, purity, and other strong emotional reactions. Navin suggests that “some parents seem inclined to refuse vaccines because they are especially committed to a cluster of ideals, including ‘purity’, ‘cleanliness’, ‘sanctity’, and ‘the natural'” (97). The ambiguity here is intentional: part of Navin’s point is that different people might understand these ideals in different ways, such as a religious obligation vs. a concern with chemical “toxins.” Most of the chapter is devoted to laying out different varieties of this “ethics of purity.” Like chapter 2, Navin’s argument is explicitly speculative: he is showing how a commitment to one or another version of the ethics of purity could lead to vaccine refusal, not making a confident claim that many vaccine refusers do indeed have such values. At the end of the chapter, Navin includes two sections, respectively discussing the implications of his analysis for public health officials (120-2; primarily that education about safety and effectiveness may not be an effective response to vaccine refusal and that framings that effectively address one variety of the ethics of purity may be counterproductive for other varieties) and briefly presenting three theoretical critiques of the ethics of purity (122-4; namely, that it fails a public reason test for public political discourse, that some purity ideals are unrealizable, and that some purity ideals cause harm).

The second half of Navin’s book, chapters 4-6, takes up a series of political philosophy issues relating to mandatory vaccination. Chapter 4 argues for a moral duty to vaccinate. Navin first notes that “Utilitarianism is the dominant . . . moral backbone of much public policy, including public health policy” (138). Obviously utilitarianism provides a powerful case for vaccination; just as obviously, most parents are not utilitarians about their children’s health, in ways that parallel Largent’s discussion of the two conceptions of risk. Setting aside utilitarianism, Navin goes on to offer two broadly deontological arguments for a duty to vaccinate. First, he argues that herd immunity is a valuable public good (141-2), and that we have duty to make a fair contribution to established schemes for maintaining valuable public goods (142ff). Second, we have a duty to “show special concern for people who are at heightened risk of harm” (149); in the context of vaccines, these include both people who cannot be safely vaccinated (including young children and sufferers of certain autoimmune disorders) (149-50), as well as people who are especially vulnerable to the economic harms of epidemics (150-2). For example, many working class single parents may not be able to afford to take time off work to care for sick children or stay home during a quarantine. While these arguments are common in public discourse about vaccines, as far as I know Navin is the first person to develop sophisticated versions that frame them in terms of major ethical theories.

Chapter 5 justifies coercive or mandatory vaccination laws on the grounds of “protecting children’s fundamental interests,” preventing harm, and “ensur[ing] the fair distribution of . . . costs” for the public good of herd immunity (164). This last argument builds on the public goods analysis of herd immunity developed in chapter 4 (178-83). This chapter also includes important discussions of informed consent (166-8), paternalism (168-73), and the use of coercion (181-84). While Navin’s analysis in this chapter is forceful, he also introduces several qualifications: “less coercive (and, indeed, non-coercive) measures are preferable when they are effective” (166, 181, 186); the use of coercion is generally less justified for vaccines against less harmful or non-communicable diseases (173, 175-6) and when herd immunity is sufficiently robust that vaccine refusal is unlikely to increase anyone else’s risk (184); and that the political decision to use coercion depends on “pragmatic considerations,” such as whether “using less coercion would prevent forms of political and social backlash that would weaken herd immunity even more” (186).

Finally, in chapter 6, Navin argues for three claims regarding exemptions to mandatory vaccination laws. First, arguments from principles of liberal justice and protection for conscientious objectors do not provide compelling arguments in favor of exemption (199-204), although pragmatic considerations—such as the possibility of backlash or polarization—can provide compelling arguments in some cases (204-5). Second, for conceptual and epistemological reasons, the state is not in a good position to distinguish “religious” and “philosophical” exemptions (205-11). And third, burdensome exemption policies—such as requiring parents to attend a vaccine education session in order to receive an exemption—can strike a reasonable pragmatic compromise (211-3). Even if such policies do not actually change anyone’s mind—recall that vaccine denialist parents tend to be better-informed about vaccines than vaccine compliant parents—the burden may prevent some vaccine hesitant parents from rejecting mandatory vaccines, without the kind of heavy-handed coercion that could trigger polarization and backlash. In January 2016, Navin and Largent co-authored an opinion piece in the Detroit Free Press that argued in favor of this kind of burdensome exemption policy (Largent and Navin 2016).

While Navin’s analysis in these chapters is rich and nuanced, I have two deep concerns. First, throughout these chapters—as in chapter 1—Navin relies heavily on the assumption that mainstream medical officials are epistemically reliable experts, and thus that their claims about vaccine safety and effectiveness should be accepted. Of course, vaccine denialists reject this assumption. In response, Navin assumes that the epistemic vices identified in chapter 1 can be idealized away, and that once this is done, “many vaccine denialist mothers would agree that coercive vaccination laws are justified” (165). Yet a vaccine denialist parent might question Navin’s grounds for thinking that we can idealize vaccine denialism away like this. But then the controversy erupts again, at the meta level: what beliefs, epistemic practices, or values can and can’t be legitimately idealized away for the purpose of formulating generally acceptable vaccine policies? More generally, this hypothetical approach to political philosophy has been the target of serious criticisms by deliberative democrats (Young 2000; Richardson 2002; Gutmann and Thompson 2004).

My second concern is with Navin’s focus on mandatory vaccination policies itself. As indicated above, Navin’s discussion of this topic is nuanced, and he ultimately argues for the use of non-coercive measures, such as education sessions. But these subtleties are often mentioned only briefly, and therefore can be easily overlooked. Specifically, I worry that many readers might conclude that completely eliminating non-medical vaccine exemptions would be justified, use simplified versions of Navin’s arguments to push for such policy changes, and that these changes would cause a polarizing backlash. While this is clearly not Navin’s intention, it seems to me like a foreseeable consequence of the way he has framed the book: “exemptions aren’t justified, but can be part of a good pragmatic compromise” can easily be read as “exemptions aren’t justified.”

CONCLUSION

Both Largent’s and Navin’s books are attempts to intervene in the vaccine controversy. A successful intervention, I assume, has at least three constitutive goals: to facilitate understanding and rectify misconceptions across the two sides of the controversy, to diagnose underlying problems that contribute to it, and to suggest previously unrecognized paths forward. Thus, beyond their scholarly merits, both books can be judged in terms of these three pragmatic goals.

Both books offer extremely valuable insights, especially into the epistemology of vaccine denial. As I sketched above, Largent’s distinction between the two conceptions of risk and Navin’s discussion of vaccine denialist communities point to much deeper issues, and I do not think we can expect to make progress in the controversy without coming to terms with their implications.

Next, both books identify several of underlying problems that contribute to the vaccine controversy. Both identify mainstream medicine’s habits of paternalism, arrogance, and dismissal of parents’ concerns—exacerbated by gender dynamics—as major contributing factors; Navin also points to the socio-epistemic isolation of vaccine denialist communities. While these diagnoses are speculative, they still provide a touchstone for generating new policy approaches to the controversy.

What about paths forward? Given their analyses, what should parents, or pediatricians, or science communicators, or public health officials do? Both authors occasionally offer a few pieces of advice, such as Navin’s defense of burdensome exemption policies. However, neither offers anything like a chapter of concrete proposals. This might be because so many of their diagnostic claims are hypotheses, with limited empirical support; but it seems to me that they could still be used to suggest some potential policies. Indeed, taking an adaptive management approach, the best way to gather evidence that could support Navin’s and Largent’s diagnoses might be to use them to design policy interventions (Norton 2005).

All together, while Largent’s and Navin’s books may be weak on constructive suggestions, they make important contributions to understanding the vaccine controversy. They are especially worthwhile for anyone interested in developing a sophisticated and informed perspective on vaccine hesitant and denialist parents. I highly recommend both books.

Daniel J. Hicks
Science and Technology Policy Fellow
American Association for the Advancement of Science
Washington, DC, USA

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