WAR ON VACCINESQuiet Dismantling: How “Shared Decision-Making” Weakens Vaccine Policy and Harms Kids
Shared clinical decision-making was designed to acknowledge complexity where it exists. Using it to manufacture complexity where none exists is a betrayal of the concept and, ultimately, of the patients it was meant to serve.
On Monday, acting Centers for Disease Control and Prevention (CDC) Director Jim O’Neill signed a decision memo adopting the most significant weakening of childhood vaccine recommendations in modern American history. Vaccines against hepatitis A, hepatitis B (for infants born to mothers who test negative), rotavirus, meningococcal disease, and influenza were moved from routine recommendation to “shared clinical decision-making.”
The category sounds reasonable, even collaborative. It is neither. And it will put children’s health and lives at risk.
This decision did not emerge from the Advisory Committee on Immunization Practices (ACIP), which typically guides the CDC’s vaccine decisions. It did not follow the standard process of public deliberation, evidence review, and expert input. It came directly from Health and Human Services (HHS) Secretary Robert F. Kennedy Jr., justified by a 33-page assessment authored by Tracy Beth Høeg, MD, PhD, acting director of the Food and Drug Administration’s Center for Drug Evaluation and Research, and Martin Kulldorff, PhD, chief science and data officer for the Assistant Secretary for Planning and Evaluation. Both are longtime critics of the existing vaccine schedule who now hold the positions to dismantle it.
The category of shared clinical decision-making has a legitimate history. Understanding how it has been repurposed requires understanding what it was designed for and what it is being turned into.
The Original Intent
Shared clinical decision-making emerged as a recommendation category around 2015, initially for meningococcal B vaccines in adolescents, for situations of genuine clinical equipoise. These are cases in which individual factors meaningfully shift the risk-benefit assessment and population-level benefit is uncertain.
The clearest example is human papillomavirus (HPV) vaccination for adults aged 27 to 45, which ACIP placed in this category in 2019. By that age, most people have already been exposed to HPV, and vaccine effectiveness is lower. But some individuals, say, someone entering new sexual partnerships after a divorce who was never vaccinated, might still derive significant benefit. For that population, a blanket recommendation makes little sense, but foreclosing access entirely would harm the subset who could benefit. Shared decision-making threads the needle: The vaccine remains available and covered, but the default shifts from “vaccinate” to “discuss.”
This is a coherent framework. The problem is that it is now being applied where it does not belong.
