Letters to the Editor  |   July 2009
Author Affiliations
  • KinKee Chung, DO
    Pediatric Associates of Cincinnati, Inc, Cincinnati, Ohio
Article Information
Imaging / Pediatrics / Preventive Medicine / Psychiatry
Letters to the Editor   |   July 2009
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 384-386. doi:
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 384-386. doi:
To the Editor:  
I am writing in response to the letter by Christopher D. Olson, DO.1 The idea that prenatal ultrasonographic examinations may increase the risk of autism poses a significant danger to public health. I want to share my concerns regarding Dr Olson's hypothesis, which has no evidence to support it. However, I would first like to address a related unsupported hypothesis—the false idea that autism is associated with vaccination. 
As a pediatrician with subspecialty training in developmental and behavioral pediatric medicine, I exercise special caution in the diagnosis of autism spectrum disorders (ASD). To many parents, these conditions are a complete mystery because of unknown etiologic factors. Parents often become desperate to find “the cure” for their child's condition, making them willing to accept any proposals that may seem to have sound scientific logic behind them, including the concept that vaccines can cause autism. The fearfulness of these parents may even drive them to believe in a conspiracy between the pharmaceutical companies and the medical professions to convince them of the need for vaccination or certain other interventions. 
Such “conspiracy theories” require no evidence to support their claims. In fact, any evidence that contradicts the theories is typically considered to be fraudulent or fabricated. The phenomenon of the conspiracy theory has contributed substantially to the belief that vaccination is the direct cause of autism. 
The origins of the supposed link between autism and the measles-mumps-rubella (MMR) vaccine can be traced to a 1998 article by Andrew J. Wakefield, MD, and colleagues.2 Although that article no longer has any scientific merit, the hypothesis of the autism-vaccine link has become deeply rooted among many parents who have children with autism. To this day, these parents accuse the MMR vaccine, thimerosal (a mercury-containing preservative formerly used in many childhood vaccines), or merely “many shots” of causing the onset of autism in their children. To such individuals, it does not matter how many scientific studies disprove the alleged associations or how much money was spent to conduct those studies. Thus, we are witnessing a disaster in public health caused by Dr Wakefield's unsupported claims.2 
The mistrust of parents toward pharmaceutical companies, government health agencies, and physicians who prescribe vaccination continues to fertilize conspiracy theories. Furthermore, when celebrities publicly condemn the American Academy of Pediatrics' recommended vaccination schedule3 and express disrespect toward pediatricians—as some have recently done4—the situation spins even more out of control. The present state of public ignorance regarding autism has reached a point similar to a metastatic cancer within the body of the pediatric population. 
Pertinent to this matter is the February court judgment, concerning the US Department of Health and Human Services' Vaccine Injury Compensation Program, against compensation for three alleged autism-vaccine cases.5 Also pertinent were the reports in 2008 of five cases of invasive Haemophilus influenzae type b (Hib) disease—including one death—in children in Minnesota.6 Three of these children had received no vaccinations at all for Hib due to parental refusal. One wonders whether any vaccine opponents were convinced by the provaccine evidence of these reports, or whether they simply viewed the evidence as more conspiratorial fabrication. 
Recently, in my son's elementary school, a case of mumps was diagnosed. Fortunately, the affected child had been fully immunized. Yet, I am concerned that some other children may not have received complete immunization. I am also concerned that our “herd immunity” may be breaking down, and that we may soon witness a reemergence of severe bacterial diseases in our schoolage population, as well as in the adult population. As a parent, I am worried about my own children's safety. 
I am also frustrated by those parents who refuse vaccinations for their children because of their false, though comforting, belief that disease will never come into their own household. Such families may benefit somewhat from health protections conferred to them by others who have received vaccination, while they themselves are like “ticking time bombs” that can explode on society at any time. 
I believe that a similarly dangerous public health situation can arise from Dr Olson's bold statements1—with no supporting scientific evidence—claiming that ultrasonographic examinations may cause the onset of ASD. Dr Olson did not conduct any form of investigation, such as a case report, case control study, retrospective chart review, or meta-analysis of the current evidence. In fact, Dr Olson1 stated, “I am not in a position to conduct research into such a possible connection, and I am also well aware of potential roadblocks to conducting such research.” He then proposed several research ideas and “challenged” our osteopathic medical colleagues to conduct such studies for him. By comparison, Dr Wakefield2 at least conducted a systemic study and presented his results in a peer-reviewed journal. 
Of course, every US citizen has the Constitutional right to free speech. But is it ethical to make the unsupported claim of an autism-ultrasound association without considering the damage it can cause to the general public and the osteopathic medical profession? 
I believe that Dr Olson's letter1—containing an assumption with great public health risk but no solid scientific data to support it—is an unacceptable way to present ideas of possible autism causes. I am quite disappointed in JAOA—The Journal of the American Osteopathic Association for publishing such a letter without considering the consequences for the greater public health and safety. I view the JAOA as a representation of the osteopathic physician within the scientific community. Do the JAOA's editors not realize the potential harm that such an unsupported claim can inflict on our public image? 
Such a claim will promote public fear and enhance the growth of conspiracy theories. However—for the sake of argument—let us say that the association between ultrasound and autism is possible. If that were the case, then it would logically follow that physicians should also worry about ultrasonographic examinations causing other developmental abnormalities, including attention deficit hyperactivity disorder, dyslexia, hypotonia, mental retardation without genetic inheritance, and seizure disorder. Furthermore, based on Dr Olson's assumption,1 the normal development of body organ systems would be placed in jeopardy as a result of ultrasonographic examinations. In fact, the list of potential health problems related to ultrasound might be assumed to be virtually endless—including any condition that might occur during fetal development. 
If the assumption of an autism-ultrasound link becomes widespread, I could only imagine the family tragedies, health expenses, and lawsuits against physicians that would occur as a result of pregnant women refusing prenatal ultrasonographic assessments. 
I do not know whether ultrasonographic examinations are related to the onset of autism. I do know, however, that healthcare providers need to exercise great caution when making any public statement regarding any disorder. As an osteopathic physician, I am proud to see my colleagues publish studies that provide evidence to support osteopathic principles and practice. It is our responsibility to help the public understand our profession through scientific research. It is also our responsibility to avoid misleading the public by making unsubstantiated assumptions without putting forth any effort to provide supporting evidence. 
As osteopathic physicians, we are given a certain power by our patients. How we exercise this power defines who we are as professionals. My mentors have often told me that with great power comes great responsibility. We walk a fine line between providing good care and potentially causing great harm. Most medical, diagnostic, and treatment procedures include guidelines to help physicians avoid harming their patients. Any deviation from these guidelines carries potential risks, requiring deep consideration and supporting evidence to justify a changed course of action. If we fail to gather and present such evidence, we will slip in our professional standards, and the resulting chaos can be lethal to our patients and our profession. 
The JAOA has a power over the public welfare that we, as individual community physicians, can never have. Without wielding such power carefully, the consequences can be unimaginable. Thus, I strongly urge the JAOA's editors to be more critical before publishing any assumption that does not have substantiated evidentiary support. 
Olson CD. Does prenatal ultrasound increase risk of autism [letter]? J Am Osteopath Assoc. 2009;109:71-72. Available at: Accessed July 6, 2009.
Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.
2009 immunization schedule. January 4, 2009. American Academy of Pediatrics Web site. Available at: Accessed May 8, 2009.
Gorski D. Jenny McCarthy, Jim Carrey, and “green our vaccines”: anti-vaccine, not “pro-safe vaccine;” June 9, 2008. Science-Based Medicine Web site. Available at: Accessed May 8, 2009.
Brady TM. Court decisions should allay parents' vaccine fears. AAP News. April(2009). ;30:1 .
Bocchini JA Jr. Hib cases underscore need for immunization with primary series. AAP News. March(2009). ;30:1 .