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Why You Shouldn’t Shop for Medical Exemptions

Recently, filmmaker Leslie Manookian wrote a post for vaccine hesitant parents about how to pester physicians into giving them an inappropriate medical exemption. This interest in medical exemptions stems from the newly passed law in California that eliminates all non-medical exemptions. Parents who are now too scared to vaccinate their children are forced to make some tough choices. (Well, tough for them because of their misperceptions of the risks of diseases and vaccines.) They can either vaccinate their children or homeschool them.

Anyone following the anti-vaccine movement can understand how an otherwise reasonable but vaccine-hesitant parent feels about this choice. For them, the choice feels like deciding between certain death or certain economic doom. After creating the fears about vaccines, woopreneurs like filmmaker Leslie Manookian (and Bob Sears) have stepped in to capitalize on this fear by offering parents a way out of the vaccinate-or-homeschool conundrum. Thus Manookian’s “How to Claim a Medical Exemption in CA.”

Of course, the decision to shop for a medical exemption is unwise. To get a greater understanding about medical exemptions and how unwise they are, I asked two friends to weigh in. I talked to Dr. Anna Saporito, a family physician from New York, and Dorit Reiss, a professor of law in California.

Manookian claims:

More and more research is showing that individuals with a variety of conditions and genetic mutations are more susceptible to vaccine reactions.

These conditions and disabilities include already existing or a family history of previous vaccine reaction, eczema, food and environmental allergies, asthma, gut issues such as Crohn’s and IBS, autoimmune disease such as diabetes, lupus, MS, rheumatoid arthritis, ASIA, and others, chronic ear, sinus, strep or other infections, Lyme disease, PANDAS, POTS, learning disabilities, speech delay, ADD, ADHD, autism, seizures, bipolar, schizophrenia, thrombocytopenia, genetic variance, impaired methylation, detoxification impairment, and more.

Of course, most of us recognize this claim as fishing for an exemption. After all, can you imagine asking a doctor to forego vaccines for your child because he is prone to strep throat? (Why isn’t there a vaccine for that?) My supposition about this laundry list was right, according to Dr. Saporito, “There are actually very clear guidelines written by the ACIP and CDC outlining medical contraindications for vaccines.” You’ll notice that almost everything listed in Manookian’s litany is missing from the CDC’s guide to who cannot be vaccinated. In fact, many are actually listed on the CDC’s Commonly Misperceived as Contraindications list, including autoimmune diseases (such as diabetes, lupus, MS, etc.). Other items on her list are not included because learning disabilities and neurodevelopmental disorders are not contraindications to vaccines.

Manookian moves on to claim that parents can demand allergy and genetic testing before being vaccinated (with the assumption that something will pop and be used as reason for a medical exemption.) Again, Dr. Saporito notes that this approach is not warranted:

There is no evidence that genetic testing would provide any useful information in the prediction of vaccine reactions. Allergy testing might make sense, but not genetic testing. (If SCID [severe combined immunodeficiency] is suspected, that should be tested for, but usually that diagnosis is already known.) The American Association of Allergists and Immunologists have great guidelines about allergies and vaccines.

It is important to note that the American Association of Allergists and Immunologists’ document discusses how to test for allergies to vaccines after a vaccine is administered. It is not a standard of care to test children without a history of allergies for possible allergic reactions to vaccines they have never received.

Finally, I asked Dr. Saporito her stance on parents shopping for doctors who are more willing to provide medical exemptions for conditions that are not contraindications and whether or not family physicians are more likely to provide a spurious exemption:

The science is quite clear that vaccines are safe. I have vaccinated myself and my own child for this reason. I find it suspect that the doctors who offer this “service” of vaccine exemptions often do no take insurance. It seems there is more of a profit motive than a motive towards public and personal preventative healthcare, something I signed up for when I took my medical oath. In fact the AAFP [American Academy of Family Physicians] just this month came out against non-medical exemptions for vaccines.

From a medical perspective, the answers about medical exemptions to vaccines are as clear-cut as the case for vaccines themselves. However, I did want to find out about a legal perspective. What could happen, legally, to a parent or a doctor who presents a school district with a spurious medical exemption to vaccine requirements?

Dorit Reiss, who is becoming the foremost legal expert concerning vaccine issues, told me:

Manookian’s post is assuming someone can just pressure or get a doctor to give an exemption on false premises. First of all, I think doctors can and should consider reporting parents who are asking them to act dishonestly. The physician’s signature on a medical exemption should be based on true concerns/facts.

A parent getting a medical exemption based on things that don’t justify it doesn’t deserve the exemption.

But what about the doctors? What issues might they face if they become a mill for false medical exemptions?

The reality is that the doctor can probably get away with some of that. There is no mechanism in place for oversight now, and if doctor only gives a few, no one will look.

If a doctor is suddenly giving a lot of medical exemptions, there are a number of things that can happen. First, the Department of Health can try denying them as unjustified – which will probably be challenged in a court, and the department might lose. Second, the Department can bring a complaint with the medical board – and prove the problem. Third, the law can be changed to provide a penalty for abuse.

The doctor has to specify the conditions for exemptions. If a doctor is found to have lied, that could be a reason for disciplinary action.

Arguably, if a doctor provides an argument based on something that clearly shouldn’t be a contraindication that’s also reason for potential action. Most of the conditions Manookian lists aren’t caused by vaccines and are not contraindications. For example, a doctor choosing to help a parent not to protect a child with asthma from pertussis is arguably violating their responsibility.

The legal issues surrounding inappropriate medical exemptions for vaccine requirements, but there is enough gray area that parents should reconsider shopping for a family physician who will give them an exemption when none is warranted. Of course, the greatest disincentive to seeking an inappropriate medical exemption is the consequence of disease for a child left unprotected.

For a parent who has fallen prey to anti-vaccine scare tactics, skirting ethics and the law might seem a risk worth taking, but the real risk comes from the diseases that have historically sickened, maimed, and killed children.

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