The recent HHS overhaul of the U.S. pediatric vaccine schedule “demoted” several vaccines from routine universal recommendation to shared clinical decision-making (and several others to risk-group targeting). The change touched off a firestorm of deserved criticism by public health and medical professionals. I agree with the critics that Secretary Kennedy and those under him are on weak ground when they suggest that any of these childhood vaccines carries substantial unrecognized or unacknowledged risks. They are therefore on weak ground when they imply that some of these vaccines ought to be optional because the science is unsettled. As the critics rightly insist, the evidence on safety and efficacy is robust and has not 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 healthcare 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 healthcare practitioners have made vaccination informed consent automatic, routinized, pro forma – arguably an ethical sham. Too often they have seen it as simply a barrier to vaccine uptake. It is that, sometimes. But it is also, or should be, a front-and-center feature of vaccine decision-making.
That failure predates the current administration. For years, “shared clinical decision-making” (SCDM) has been treated within vaccine policy as a grudging exception, a special category reserved for cases of equipoise – that is, for vaccines whose benefit-risk tradeoffs are uncertain or vary sharply from individual to individual. For “routine” vaccines (most vaccines), the implicit message has been: Don’t ponder whether you ought to take it, just roll up your sleeve.
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, and it has therefore minimized population morbidity and mortality.
But it also embodies the view that patients’ and parents’ agency is a nuisance to be managed rather than a value to be respected. The dominant opinion in public health circles and even pediatric circles appears to be that minimizing morbidity and mortality is so important that respecting freedom of choice is secondary – so secondary that in practice it becomes dispensable.
The most widespread advice to pediatricians on how to talk with parents about vaccines – if you have to talk at all – is to take a presumptive approach. CDC’s “Talking with Parents about Vaccines” (still) expressly advises:
Assume parents will vaccinate
Introduce the topic of vaccination with the assumption that most parents are planning to accept vaccines. State which vaccines the child needs to receive as though you presume that parents are ready to accept them during that visit. For example:
- Instead of saying “What do you want to do about shots?,” say “Your child needs three shots today.”
- Instead of saying “Have you thought about the shots your child needs today?,” say “Your child needs DTaP, Hib, and Hepatitis B shots today.”
This guidance is often defended as a way to reduce friction, not to deny choice. But its effect, and maybe its purpose, is to keep parents from feeling like they have a choice.
A recent New York Post op-ed described the “lived reality” of many families as “Question whether three injections in one appointment are necessary, and you’re warned that you’re endangering other children.” That piece is the only commentary on the new HHS schedule I’ve seen so far that stands tall simultaneously for vaccine safety and efficacy and for vaccine freedom of choice. I’d have preferred to see it in STAT, CIDRAP News, or MedPage Today, not a right-leaning tabloid.
It is probably inevitable, maybe even desirable, that public health professionals prioritize their health mission over extraneous values like agency and freedom of choice. But health policymakers aren’t out of line when they deploy a broader set of criteria – nor when they impose those broader criteria on medical practitioners.
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 is what should public health professionals say in response. Faced with a policy change they rightly oppose on scientific grounds, most vaccine proponents are making a strategic risk communication mistake. In fact, two mistakes:
- By continuing to equate SCDM with “optional,” they are boosting the very signal they fear most.
- By continuing to view patient and parent choice as the threat, they are granting Kennedy and his people the moral high ground.
Secretary Kennedy is wrong about vaccine risks, 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 healthcare providers will help them make these decisions wisely, though of course they should seek as much or as little guidance as they want from whatever sources they choose.
Shared clinical decision-making is an appropriate framework for vaccine discussions, all vaccine discussions – not because the evidence is weak but because agency and freedom of choice matter.
Insofar as we have neglected vaccine informed consent, on this we were wrong. On this important issue Secretary Kennedy is pushing us in the right direction, even if arguably for the wrong reasons.
We expect that most parents, after genuine shared decision-making, will conclude that vaccination is the best choice for their children.
We realize with regret that some will decide otherwise. In a free country, that is their right. Continued respectful dialogue is the appropriate response. It is our job to convince skeptics that what we’re telling them is correct, not their job to take our word for it.
I am confident that 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.
Imagine for a moment the opposite strategy: “HHS has reminded us that informed consent is fundamental, that we need to listen to parents’ concerns, take them seriously, and be ready with evidence-based answers. In Kennedy’s head, the reason for pushing shared decision-making seems to be his view that some vaccines are not proven enough to just give without a conversation. But for us in medicine and public health, it’s just a reminder to focus as much on what’s in our patient’s head as we do on what’s in our syringe.”
This is a problem not just of messaging, but of principle. Shared decision-making is not a concession to anti-vaccine ideology. It is 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. Pretending otherwise in the examining room does boost short-term compliance. But in the longer term it corrodes legitimacy.
Ideally, it seems to me, public health officials would be wise to calibrate the strength of their vaccine recommendations, even their universal vaccine recommendations: something along the lines of very strongly recommend / strongly recommend / recommend / neutral / recommend against. They’re reluctant to do that because they don’t want to help vaccine-hesitant parents trim the list. But when every vaccine recommendation is equally urgent, including the ones very few parents are following, the main lessons learned may be that no vaccine is especially important and that experts’ vaccine recommendations really aren’t worth attending to. The distinctions HHS has chosen to make may not be optimal, but failing to make any distinctions at all isn’t optimal either.
But that’s a different and more debatable point than the main point of this essay: No vaccine recommendation should feel to patients and parents like a presumption or a mandate. Every vaccine recommendation should be explicitly something for them to consider as they decide for themselves – with advice as needed – whether to say yea or nay. This position makes me in some sense more radical than Kennedy’s HHS. I want every vaccine recommendation to be a SCDM recommendation – some recommended more strongly than others, as the evidence dictates, but all recommended for the consideration of the Decider-in-Chief, the patient or parent.
The pre-Kennedy pediatric vaccine schedule provided for shared clinical decision-making only under equipoise. Let me rephrase that in ordinary language: According to the former schedule, healthcare providers should do genuine informed consent only when a vaccine’s benefits do not clearly exceed its risks. When pediatricians think the right choice is clear, they should aim for unthinking parental compliance, not thoughtful parental deliberation.
The new vaccine schedule under Kennedy doesn’t question any of that. It merely moves six vaccines from the category of “obviously the right choice, so don’t share the decision” to the category of “debatable, so share the decision.” The dispute between Kennedy and the public health mainstream is merely which vaccines, and how many vaccines, are obviously more beneficial than risky. They disagree on the science. But even Kennedy accepts the mainstream’s implicit value judgment that overriding patient agency is appropriate when the authorities are sure they’re right.
I think this value judgment is incompatible with 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. Kennedy’s authoritarianism. And public health’s authoritarianism. The paradox at work here: 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.
Repeatedly, articles on the new vaccine schedule quote experts worrying that pediatricians won’t stock or promote SCDM vaccines, that parents won’t ask about them, and in the worst case that manufacturers won’t produce them – all because too many parents won’t accept them. Taken at face value, this implies the astonishing belief that doctors and medical experts can’t convince ordinary people of the value of the vaccines once their right to demur is made explicit. That’s not Kennedy talking. It’s the public health mainstream, insisting fatalistically that vaccination is a tough sell; that presumption, not persuasion, has been doing much of the work – and that persuasion without presumption is doomed to fail badly.
I don’t actually take it at face value. I think it’s apocalyptic exaggeration more than actual fatalism. The real worry, the justified worry, is that some marginal parents who previously went along will now hesitate, leading to a modest rise in morbidity and even a small increase in mortality. So say that.
What do I think strong confidence in vaccine science would actually sound like? Saying all of the following things at once:
Do you think this messaging approach undermines vaccine confidence? I think it strengthens vaccine confidence.
To my ear, much of the public health profession’s response to the new vaccine schedule sounds less like confidence in the science than fear of the public. Fear that if parents are told the decision is theirs, they will decide badly. Fear that agency and even freedom must be traded for uptake.
I think that’s a losing bet. I think that if public health wants the public’s trust, it must begin to trust the public – not with the science, but with the decision. The alternative is to keep fighting patient agency itself, and to keep being surprised when the fight backfires.
I can’t confidently predict the net long-term effect on trust and thus on vaccine acceptance of moving to a decision model that foregrounds parental deliberation. It is plausible that respecting parents’ agency might increase their trust in vaccine proponents, precisely because they feel listened to rather than lectured at. Conversely, the existence of competing vaccination messages might leave some parents less trusting overall. Additional hypotheses in both directions are plausible, and the empirical truth will probably be complex.
Bear in mind that the question is no longer which is more conducive to long-term vaccine acceptance: foregrounding patient agency or ignoring it. The new pediatric vaccine schedule has preempted that decision to some extent, and patient agency is now front-and-center. So the question now is whether to accept it or fight it.
Only to some extent, of course. Many pediatricians, hospitals, pharmacists, and state and local health agencies have told reporters that they plan zero changes in how they talk about pediatric vaccines. For better or for worse – I think worse – many parents will continue to feel like they are unwelcome to make up their own minds. But I assume that Kennedy will continue to push the issue, since it’s his strongest argument. The time may even come when taking certain vaccines is no longer the unambiguous standard of care, and lawyers start advising doctors that they’d better have those conversations after all. Maybe Kennedy will even put through insurance reimbursement for them. One way or another, more and more practitioners will be called upon to respond to a growing sense that parents should actually share in the decision about which vaccines to give their children.
As a risk communication consultant, I made my living telling clients that truthfulness, power-sharing, and mutual respect are trust-builders, not trust-eroders. I think that’s true here. But in an essay urging public health and medical professionals to stop demanding that patients and parents trust them, I’m not about to demand that readers of this essay trust me. Make up your own mind whether I’m proposing a wiser or more foolish response to the new pediatric vaccine schedule than the response now so widely deployed.
My view in a nutshell: If the goal of vaccine advocacy is sustained confidence, advocates should keep insisting on the scientific evidence showing the value of vaccines (while acknowledging uncertainty where appropriate), but stop insisting on control over patients’ and parents’ decisions. Respect your audience’s autonomy not only because autonomy is ethically important, but also because insisting on unquestioning acceptance undermines credibility and may paradoxically reduce trust in the long run. And yes – the toughest part – accept that at least in the short run there will probably be some marginal increase in morbidity and mortality. This is a price free countries pay for preserving individual autonomy to make health-affecting decisions. It is a price you rightly hate to pay, but must be willing to pay for true informed consent.
Copyright © 2026 by Peter M. Sandman
