In 2017, a 6-year-old unvaccinated boy cut his forehead while playing outdoors on a farm (Guzman-Cottrill, JA, et al. Notes from the Field: Tetanus in an Unvaccinated Child. MMWR Morb Mortal Wkly Rep. 2019 Mar 8;68(9): 231-232). The wound was cleaned and sutured at home. Six days later, the boy suffered episodes of crying, jaw clenching, involuntary muscle spasms, and arching of the neck and back (opisthotonus). Later that day, he had difficulty breathing. As his breathing became more labored, he was transported by helicopter to a tertiary care pediatric center where he was intubated and mechanically ventilated.

To their credit, the doctors correctly identified this boy’s disease as tetanus and administered 3,000 units of tetanus immune globulin and one dose of DTaP vaccine. The child did poorly, suffering worsening opisthotonus as well as the necessity for continuous doses of medicines to control his pain and muscle spasms. Because it was clear that he would be ventilated for a prolonged period of time, he received a tracheostomy. On the 54th day of his illness, the tracheostomy was removed, and he was sent to a rehabilitation center for an additional 17 days. The total cost of his hospital care was $811,929, more than 70 times the average cost of a pediatric hospitalization in the United States.

The family declined a second dose of DTaP vaccine — or any other vaccines for the child.

This story begs two questions:

  1. Who should pay for the hospitalization? Given that the parents had chosen not to vaccinate their child, shouldn’t they be liable for the cost?
  2. When does a parent cross the line from individual choice to medical neglect?

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