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http://www.ama-assn.org/sci-pubs/amnews/amn_02/edlt1202.htm#4

Regarding "Smallpox vaccine still a safety, liability concern" (AMNews, Nov. 11): As an infectious disease physician, I must consider whether I can, in good conscience, give a vaccine that is guaranteed to harm some recipients for an ambiguous benefit.

The horrendous nature of the vaccine side effects can rival those of smallpox itself: progressive gangrene at the vaccination site, widespread scarring pustules, brain-damaging encephalitis. One look at the Centers for Disease Control and Prevention's Web site, with photos of the skin reactions seen with smallpox vaccination, will sober all but the most callous.

We must balance this against the risk of smallpox, which is a terrible disease. Medical ethicists typically start with a utilitarian cost-benefit analysis to help decide if an intervention is worth the risk. But what is the risk of smallpox? Today it is zero, absolutely zero. Of course, if a terrorist or rogue state decides to use smallpox as a weapon, the risk will not be zero, but how likely is that? How big would the outbreak be?

Who knows, and whom can we trust to give us unbiased estimates?

Infectious disease physicians are in a curious position. We know the most about the disease and the vaccine and its side effects. We advocate vaccinations as the cornerstone of disease prevention. And yet the large majority of our daily patient load consists of the immunosuppressed, who would likely be harmed or killed by this particular vaccination.

I believe that we in the infectious disease community have an obligation to help prepare for a widespread vaccination campaign, whether targeted toward groups and cities at risk, or nationwide. But I do not believe we can advocate actually giving the vaccine at this time, outside of carefully controlled studies. Simply put, it is not ethical to give a medicine that will kill and maim persons for no demonstrable benefit. Assuaging fears about vulnerability to a potential disease is not a benefit any physician should accept.

So I would argue we should plan and prepare and stockpile. If we see definite evidence of smallpox as a weapon, it will not be too late to institute the plan we have outlined. But preemptive vaccination is not a reasonable choice. It is like giving dangerous chemotherapy before cancer has been diagnosed.

--Jeffrey S. Sartin, MD La Crosse, Wis.

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