Physicians Struggle With Ethics of Barring Vaccine Refusers

Marcia Frellick

September 02, 2016

In a paper published online September 2 in Pediatrics, four physician experts in pediatric infectious disease discuss one of the most divisive issues that practices consider: how to respond to parents who refuse vaccinations for their children.

Refusals continue to climb, physicians said in the latest fellows survey from the American Academy of Pediatrics (AAP), as reported by Medscape Medical News.

In 2013, 87.0% of pediatricians said they had experienced parental vaccine refusals in the last year compared with 74.5% in 2006.

And in a change of policy, the AAP released a statement on August 29 saying that physicians can dismiss families for vaccine refusal, but only as a last resort.

Keep Them…Up to a Point

In the newly published perspectives paper, Angela L. Myers, MD, MPH, from the Division of Infectious Diseases at Children's Mercy Hospital and Clinics in Kansas City, Missouri, agrees that working with refusing families is preferred but says that if families are unwilling to discuss the issue, the pediatrician should consider severing ties.

"In situations in which it is clear that further discussion will not be fruitful, it is appropriate for the pediatrician to refer the family to a different health care provider, one who shares their values and with whom they can establish a trusting and nonconflictual relationship," she writes.

As opposed to refusing to force a child to wear a seatbelt, she says, refusing vaccines can affect other children.

She notes that the risk for exposure to a communicable disease in a waiting room is low, but not zero.

Also to be considered in weighing the arguments, she says, is that more than more than 68 million people in 2014 alone left the United States for international destinations.

"A significant portion of these trips are to places in which immunization is much less common and therefore the risk of contracting a communicable disease is considerably higher," she writes.

Harms of Excluding Families Trump Risk

In contrast, Kenneth Alexander, MD, PhD, from the Division of Infectious Diseases in the Department of Pediatrics, at Nemours Children's Hospital in Orlando, Florida, and the Department of Pediatrics at University of Central Florida College of Medicine in Orlando, and Thomas A. Lacy, MD, from Nemours Children's Primary Care in Orlando, say that small risk to vulnerable children is outweighed by the benefits families get from access to pediatricians.

"We as pediatricians do so much more than immunize," they write. "We teach, we advocate, we role model, and even when parents say no to immunization the first 10 times we bring it up, we bring it up an 11th and 12th time."

Continuing those relationships may, in the end, be the only way to change parents' minds, they reason.

The Two Biggest Reasons for Dismissing Patients Are Flawed

Meanwhile, John Lantos, MD, from the Bioethics Center at Children's Mercy Hospital and Clinics in Kansas City, Missouri, rejects both of the two primary arguments for dismissal: that the unvaccinated pose a threat to other children in waiting rooms and that refusal to vaccinate can poison the physician-parent relationship.

As to the waiting-room threat, he writes that the only way to truly protect an immunocompromised child would be to refuse care to any child with any communicable disease or a risk of getting one because kids are contagious before they have symptoms.

The greatest risk is probably parents who refuse to get children flu shots, he writes.

Regarding the threat to the physician-parent relationship, he writes that if that were true, physicians would be justified in dismissing parents who keep feeding junk food to obese kids or who refuse to stop smoking in their children's presence.

"Physicians care for the rape victim and the rapist, the enemy soldier as well as their own troops, the virtuous patient and the sinner," he writes. "Why, of all transgressions, should vaccine hesitancy be the one that obliterates professional obligations?"

He acknowledges that there may be good reasons for severing ties with nonimmunizers, but the two most often cited are not among them, he writes.

Art Caplan, PhD, from the Division of Medical Ethics at New York University Langone Medical Center, agrees that neither argument for dismissing patients stands up.

"The case is not persuasive…for kicking them out," he told Medscape Medical News. "If you're worried about infecting other people, then you put them on at the end of the day or you give them separate hours," he said, just as you might separate kids with violent tendencies.

Dr Caplan noted that in many parts of the country families don't have many convenient choices for medical care and if their physician rejects them, they may forgo care altogether.

It also isn't clear what effect a physician's refusal to work with the family would have on their decision not to vaccinate. "That's a study that ought to get done," he said.

In addition, Dr Caplan doesn't buy the argument that a child may get better care from a pediatrician who shares the parents' values.

"Someone who shares antivaccination values is not going to be much of a pediatrician," he says.

Advice for Physicians

Dr Caplan offers advice for physicians encountering vaccine refusers so that they can keep them in their practices and keep the conversation on point.

First, know the arguments on both sides and be ready to discuss them.

Then, don't run from the topic and consider it off-limits if parents say no, he says. "You have to go at it just as you should if you saw a child who is obese."

Dr Alexander is a paid speaker and consultant for Merck Vaccines. The other authors have disclosed no relevant financial relationships. Dr Caplan served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson's Panel for Compassionate Drug Use (an unpaid position) and serves as a contributing author and adviser for Medscape.

Pediatrics. Published online September 2, 2016. Abstract

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