The story
“Shared decision-making on vaccines is not the enemy,” by Peter M. SandmanThe response
Peter Sandman’s recent STAT First Opinion is deeply misleading in its framing of “shared clinical decision-making,” or SCDM, as synonymous with informed consent. Its false implication is that critics of policy changes somehow misunderstand patient autonomy.
SCDM is neither a medical-legal synonym for informed consent nor a safeguard for vaccine access. Suggesting otherwise is gaslighting: It suggests prior clinical practice lacked informed consent, which is untrue, while obscuring the real consequences: reduced vaccine uptake.
It is useful to distinguish among four different concepts.
First, in clinical practice, “informed consent” is a well-defined ethical and legal obligation: A clinician must disclose the material risks, benefits, and alternatives of a recommended intervention and obtain the patient’s voluntary agreement to proceed. The doctrine emerged from early 20th-century tort law grounded in bodily autonomy and it protects patient agency in every medical encounter – vaccination included – regardless of whether a recommendation carries an SCDM label.
Second are routine vaccine “recommendations”: evidence-based determinations that a person should receive a vaccine because experts have concluded the benefits clearly outweigh the risks, communicating that vaccination is the medically preferred course of action. Informed consent still applies – risks and benefits are discussed, questions answered, and patients may decline.
Third, recommendations are not “mandates.” Recommendations do not compel vaccination. States may independently require certain vaccines for school attendance or health care employment to protect population health. This is a distinct policy choice that balances individual liberty with collective risk. In 1905, as the concept of informed consent was taking shape, the Supreme Court upheld vaccine mandates in Jacobson v. Massachusetts, recognizing an acceptable coexistence.
Finally, SCDM is an unclear, amorphous and frequently misconstrued policy label. SCDM is not a legal standard for patient consent and it is not a clear recommendation.
I criticized SCDM long before it was misappropriated by anti-vaccine activists because it fails to convey clear and actionable guidance to providers and patients. The current administration has worsened this problem by taking evidence out of the equation and providing even less guidance to health care providers. Robert F. Kennedy Jr., his advisers, and compatriots in the anti-vaccine movement are not serious about protecting patient autonomy or access to care. They do not share an objective to reliably facilitate meaningful patient-provider conversations about vaccines or to preserve vaccine access. Rather, their goal is to raise public doubt and to guide Americans to dangerous and unsupported conclusions about vaccines.
—Richard Hughes IV, Epstein Becker Green/George Washington University Law School
The response
Peter Sandman is right about one important thing: Vaccine conversations can and should be better. I also agree that shared decision-making (SCDM) is not inherently wrong as a framework for discussing vaccines, nor is patient agency something clinicians should fear.
Where I diverge is in the assumption that presumptive recommendations undermine agency or ethical informed consent. In daily pediatric practice, shared decision-making is already happening, often more than is acknowledged. A presumptive recommendation does not remove choice. It establishes a starting point grounded in evidence and professional responsibility, then opens space for discussion.
What erodes trust is not presumption, but the failure to listen, to acknowledge fear and identity, and to recognize that vaccine hesitancy is rarely about data alone. Too often, the real breakdown occurs when the conversation becomes narrowly focused on “getting the vaccine given” rather than on building understanding and trust.
In practice, we routinely share the vaccine information statement, review benefits and risks, and answer questions. That process is informed consent. That process is shared decision-making. Families are not passive recipients of care in these encounters, even when clinicians begin with a strong recommendation.
Prevention adds a unique challenge. When children are healthy, the absence of harm is easily misinterpreted as absence of risk. The threat is abstract, the benefit invisible. These are emotionally charged conversations, shaped by identity, past experiences, and broader system frictions, not simply by evidence quality.
Much of the resistance to SCDM among clinicians stems from uncertainty about documentation, variability in who can engage in it across states, and fear of added administrative burden, not from disregard for patient agency. Labeling certain vaccines as SCDM risks reinforcing the false signal that evidence is weaker, even when clinical conversations have not meaningfully changed. If a clinician makes a presumptive recommendation, shares the VIS, listens carefully, and addresses concerns honestly, shared decision-making has already occurred.
The solution is not abandoning presumption, but restoring empathy, curiosity, and trust as the central goals of vaccine conversations.
—Diego Hijano, St. Jude Children’s Research Hospital
Copyright © 2026 by Peter M. Sandman
