By Randy Cohen

"As an infectious-disease specialist, I will be called on to be vaccinated early to counter any terrorist smallpox attack. I believe the chances of this are increasingly small and that the policy is primarily an effort to spread fear and build support for a war with Iraq. If I am vaccinated, I will be complicit with a policy I morally oppose and will unnecessarily endanger my own health, as the vaccine is one of the most dangerous available. Yet I feel duty-bound to be available to those suffering adverse effects from the vaccine. Should I be vaccinated?"

Hal Martin, M.D., M.P.H., Minneapolis

While your decision has political implications, it is above all a medical matter. You are not being asked to endorse the president's Iraq policy but to decide if vaccination is called for in your circumstances. Believing as you do that there is no medical necessity, you have no ethical obligation to be vaccinated simply because the president urges it.

As a doctor, you can judge the risks of vaccination. As a citizen of a democracy, you must decide if the president has made a persuasive case that a smallpox attack is likely enough to justify that risk. If you and your colleagues overwhelmingly reject the president's call, this may indeed be interpreted as a rebuff of his policy, but that should be a byproduct of your decision, not your reason for making it.

Right now, you must weigh your duty to your fellow health care workers, only a small percentage of whom are expected to become ill from the vaccine. This means that the vast majority of those health care workers who choose to be vaccinated will be available to attend that ailing few--a self-selecting, self-treating group--and thus your participation is not essential.

You would face a tougher choice if the president called for the vaccination of the general population. You might feel an obligation to your longtime patients to be available to treat those affected by the vaccine. This would mean either being vaccinated yourself or remaining unvaccinated and accepting the hazard of exposure as a matter of conscience.

And if you are wrong and there is a smallpox attack? That would be horrific. But you cannot escape the burden of choice by simply following orders.

There is another aspect of this question that concerns not only physicians but all Americans. Financing an expensive smallpox vaccination program necessarily means neglecting many pressing medical problems, both here and abroad. In our era of tight budgets, deciding how to allocate health care resources is a question with both moral and political dimensions.

The New York Times January 19, 2003

The following supplemental information is from USA Today January 20, 2003:

More than 80 hospitals spanning 22 states have opted to forgo Bush's voluntary smallpox vaccinations. While this is only a fraction of the 3,000 hospitals selected to receive the vaccination, it reflects the concerns growing among many that the risks of the smallpox vaccine, which include illness and even death, outweigh the risks of smallpox being used in a terrorist attack.

Most often, hospital administers cite the safety of the vaccine as the primary reason why they are choosing not to vaccinate. They are reluctant to risk the health of their employees to protect them against a disease that no longer exists and would only reappear if used as a weapon.

People with weakened immune systems, including cancer and AIDS patients, and those who have received organ transplants or have eczema or other skin disorders are particularly susceptible to adverse reactions to the smallpox vaccine and should not receive it. The vaccine is also risky for infants and the elderly.

Many hospital officials have said that they would begin vaccinations immediately if a case of smallpox appeared in the United States, or if the government warns that a terrorist attack using smallpox is imminent.