The Problem Isn’t Shared Decision-Making. It’s How the ACIP Is Using It.
Why turning routine vaccine recommendations into “individual decision-making” undermines evidence-based guidance
Two weeks ago, the Advisory Committee on Immunization Practices (ACIP) voted to change the childhood hepatitis B vaccine from a routine recommendation to a shared clinical decision-making (or so-called “individual based decision-making”) recommendation.
The committee now frames this as a decision for parents and clinicians to weigh benefits and risks on their own. On the face of it, that framing sounds reasonable and even reassuring.
So, why did 67 leading medical, health, and patient advocacy groups publicly oppose the move, and why have health leaders across the country sounded the alarm?
The answer is simple. A policy tool intended for narrow circumstances is being weaponized to manufacture uncertainty where none exists, allowing the ACIP to abdicate its responsibility to provide clear, evidence-based guidance and instead shift the burden of evidence interpretation onto clinicians and parents.
What Shared Clinical Decision Making Means in Vaccine Policy
To understand why this matters, we need to be precise about what shared clinical decision-making (SCDM) is, and what it is not.
In vaccine policy, SCDM is not a communication style. It is a specific type of policy recommendation used when the evidence suggests a small, uncertain, or highly variable net benefit, such that a routine recommendation for the entire population is not warranted.
The ACIP began using SCDM in 2019, replacing older “permissive” or “Category B” language. Before this year, it had been used sparingly and only in limited circumstances, including adult HPV vaccination, meningococcal B vaccination for adolescents and young adults, hepatitis B vaccination for some older adults, and select pneumococcal recommendations.
SCDM designations have historically been reserved for rare cases where uncertainty is substantial enough that the committee cannot responsibly recommend a default course of action.
Policy Designation Is Not the Same as Bedside Decision Making
This is where much of the confusion and misdirection arises. There is a distinction between the application of SCDM as a vaccine policy designation and its use in clinical practice.
Shared decision-making in clinical practice is a collaborative, evidence-informed process that involves patients and clinicians working together to make healthcare decisions that align with values and goals. While definitions of clinical shared decision-making have evolved, it is most often understood as a tool for situations in which there is no single clearly superior option.
That distinction matters. The current committee is invoking the language of clinical shared decision-making in a context where uncertainty has been manufactured rather than demonstrated.
At the national vaccine policy level, SCDM has a very specific meaning. It signals uncertainty and suggests a small, unclear, or highly variable net benefit. Applying the SCDM label to routine vaccines that have strong, consistent evidence does not enhance patient-centered care or build trust. It creates the false impression that experts are divided on the best way to protect health when, in fact, they are not.
This framing also overlooks the influence of external actors on decision-making in the exam room. Much of the pressure to reframe routine vaccines as SCDM is not coming from patients or clinicians, but from distant actors who are far removed from clinical care. These voices use the language SCDM strategically, often stripped of context, to cast doubt on evidence and erode trust in expertise. Amplified through social media, they create the illusion of grassroots concern while fueling fear and confusion, even as they use misappropriated SCDM language to simultaneously imply that clinicians and parents should “figure it out” on their own.
Why “Individual-Based Decision Making” Is a Misleading Rebrand
In recent votes, the committee has intentionally shifted its language from “shared clinical decision-making” to “individual based decision-making.” That change is subtle, but not incidental. It wrongly implies that individualized conversations and informed consent were absent from the vaccine delivery process.
After changing COVID-19 vaccine recommendations from routine to individual based decision-making recommendations this year, acting CDC Director Jim O’Neill said, “Informed consent is back.”
But as I have written about before, informed consent is alive and well.
Patients have always had the right to receive information, ask questions, and decline vaccination. What informed consent does not require is neutrality when the evidence is clear, or giving equal weight to unequal evidence. A strong recommendation when the evidence is clear is not coercion or a mandate. It is a core ethical responsibility of medical professionals and can be given in the context of individualized, shared decision-making.
Yes, not all clinicians communicate effectively about vaccines, and not all consistently engage patients in respectful, individualized conversations when concerns arise. Many clinicians would also benefit from improved training in communication and responding to uncertainty. But that won’t be improved through a policy label. The solution to variable communication quality is investment in training and support, not the removal of clear, evidence-based guidance.
When Every Recommendation Becomes SCDM, Guidance Disappears
The ACIP exists to answer a core question for clinicians and public health professionals: “What does the best available evidence support, and how strongly should I recommend it?”
Under normal circumstances, that question is answered through clear, evidence-based recommendations. Today, many clinicians and public health leaders, including myself, no longer trust this committee to provide that guidance responsibly.
While less disruptive than eliminating recommendations altogether, SCDM is not neutral. It is still a form of guidance that shapes how vaccines are offered, discussed, reimbursed, and delivered. SCDM recommendations remain consequential policy choices with real downstream effects.
If routine vaccine recommendations are systematically converted to SCDM, the core question ACIP was created to answer goes unresolved. The vaccine schedule becomes a menu of options rather than expert guidance, and responsibility for interpreting the evidence shifts away from the advisory body charged with that task. While that shift may seem preferable to other alternatives given the committee’s current composition, it creates problems that will be difficult to undo.
In practice, SCDM recommendations outsource judgment to clinicians and families, many of whom lack the time, resources, or institutional support to independently evaluate complex vaccine evidence, especially in an information environment saturated with misinformation.
Who Pays the Price for Burden Shifting
This is the hidden cost of misusing SCDM vaccine policy recommendations.
Responsibility shifts away from expert bodies and onto individual clinicians and families. Clinicians are expected to review and synthesize vast scientific literature independently. Parents are asked to navigate complex risk-benefit calculations in an information environment saturated with misinformation.
Individuals with lower health literacy, limited access to trusted healthcare, and fewer resources are disproportionately affected. Far from promoting choice, this approach widens disparities.
Clinicians face real professional and legal risks when vaccine recommendations are muddled or inconsistently applied, a reality that has gone unaddressed during recent ACIP meetings. Pediatricians have been sued for failing to fully inform families about the consequences of vaccine-preventable diseases and for failing to offer recommended vaccines.
Here is the bottom line. A SCDM recommendation is a convenient way out for this committee. It shifts responsibility onto parents and clinicians, allowing the committee to avoid owning the consequences that come with making a complex public health decision. If these vaccines truly carried the concerns erroneously claimed during recent ACIP meetings, the committee would have reflected that with a vote not to recommend them. They have not done so because that would require real evidence, a transparent and rigorous review, and the willingness to stand behind such a consequential decision in the face of scrutiny from the overwhelming majority of the public who want vaccines and real experts. Leadership requires making clear decisions and accepting responsibility for their consequences. Shifting that responsibility onto others is not shared decision-making. It is a failure of leadership.
One Last Thing: ACCV Meeting Rescheduled for December 29 — Why This Matters
Before you go, one final development is worth flagging. A meeting of the Advisory Commission on Childhood Vaccines (ACCV) has been scheduled for December 29, 2025, according to a newly published Federal Register notice. The meeting was originally scheduled for this week and then moved to the narrow window between Christmas and New Year’s—a time when public attention, media scrutiny, and stakeholder participation are typically limited.
The ACCV is the federal advisory body charged with providing recommendations to the Secretary of Health and Human Services on the National Vaccine Injury Compensation Program (VICP), including proposed changes to the Vaccine Injury Table, which is a list of injuries presumed to be caused by vaccines for no-fault compensation. Any proposed changes to the Vaccine Injury Table must move through ACCV review as part of the federal rulemaking process.
It is worth remembering why the VICP and ACCV exist. They were created in the late 1980s to address two intertwined problems: ensuring that individuals who experience rare but real vaccine-related injuries are compensated fairly and efficiently, and protecting the nation’s vaccine supply from collapse under the weight of litigation, including claims not supported by evidence. The program was designed as a careful balance of supporting those injured while preserving broad access to vaccines by providing manufacturers and clinicians a stable, predictable liability environment.
That balance matters. If compensation and liability standards are broadened in ways that are not tethered to evidence, the VICP and vaccine infrastructure it supports risk becoming unsustainable. A compensation system that is overwhelmed by claims not causally linked to vaccines would ultimately undermine vaccine availability, affordability, and participation by providers and manufacturers.
To be clear, there are reasonable conversations to be had about improving the VICP. Many experts agree that the program could be faster, more transparent, more generous in certain cases, and more responsive to families navigating it. But those reforms must be evidence-based and carefully calibrated to preserve the program’s core purpose.
This upcoming ACCV meeting matters because the administration has signaled interest in revisiting the Vaccine Injury Table, and reporting has documented discussions about potentially expanding neurologic injury categories in ways that could allow children with autism diagnoses to qualify for compensation. As reported by Politico, advisers to Secretary Robert F. Kennedy Jr. have openly discussed efforts to “capture” autism cases within the VICP framework by broadening definitions, despite decades of evidence showing no causal link between vaccines and autism.
The health administration can either reform the VICP so it functions better for families who experience rare vaccine-related injuries, or approve changes that destabilize and ultimately break the program. It cannot do both.
The unusual timing of this meeting raises legitimate concerns about transparency and public oversight at a moment when changes to the vaccine compensation system could have serious downstream effects. As public focus remains fixed on the chaos surrounding ACIP and vaccine recommendations, consequential structural changes to the VICP may be moving forward with far less scrutiny.
This is something to watch carefully, as changes under the banner of reform could cause lasting damage to vaccine access, stability, and public trust.
Thanks, as always, for being part of this community.
-David
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