Think Twice Before Rejecting Patients Who Refuse Vaccines: Experts

By Carolyn Crist

November 09, 2020

NEW YORK (Reuters Health) - Primary-care doctors who reject patients refusing to take vaccines may want to consider the ethical and moral reasons behind their decisions, according to a group of bioethicists and pediatricians.

In recent years, more pediatricians have chosen to dismiss families who refuse vaccines, which could become problematic, particularly with the prospect of a COVID-19 vaccine on the horizon, Dr. Mark Navin of Oakland University in Rochester, Michigan, and colleagues write in Pediatrics.

"From a moral point of view, there's a world of difference between kicking a family out of your pediatric practice after they have consistently refused vaccines (perhaps over many months or years) and accepting families into your practice only if they agree in advance to allow their children to receive all vaccines," Dr. Navin told Reuters Health by email.

The American Academy of Pediatrics says that dismissing families who continually refuse vaccines is an acceptable option if substantial distrust or communication issues arise and all options have been exhausted. However, some practices have taken a step further and refuse to accept these patients from the start, Dr. Navin said.

"The AAP says the first practice is sometimes OK, but no one has been talking about the latter practice, even though we know it's been going on, and even though it's pretty clearly not covered by the AAP's policy," he said.

Dr. Navin and colleagues unpack several ethical issues around patient dismissal in their new report. For instance, the American Medical Association's Code of Medical Ethics says that the clinical relationship is a free association between doctors and patients, so clinicians may say they have a "right to choose" their patients.

At the same time, this freedom of choice doesn't necessarily mean that all of these choices are ethical, the authors write, adding that doctors should use their professional autonomy for good reasons and for the benefit of patients.

Doctors can reject patients if they demand medically inappropriate care, the authors point out, if the doctor can't provide competent care or if accepting new patients would compromise care for existing patients.

Although doctors may argue that vaccine refusers are demanding inappropriate care, the authors say that's incorrect - instead, the patients are rejecting a particular type of appropriate care. With this view in mind, vaccine refusers may be similar to those who reject recommended treatments or diagnostic tests.

Dr. Navin and colleagues also argue that doctors shouldn't only serve compliant families because it's inconsistent with the tenets of patient-centered care. Instead, doctors should be willing to collaborate with families and find compromises that match patient values and preferences, they write. When caring for diverse communities, doctors should embrace the values of openness and tolerance, they add.

In addition, clinicians' goals in turning away vaccine refusers can be misguided, the authors write. Doctors may believe that the threat of dismissal will create incentive for patients to obtain vaccines, but that strategy is unethical and can backfire, particularly in communities that don't have many pediatricians overall. This also creates an adversarial relationship rather than a caring, collaborative tone that could aid in conversations around vaccines, the authors write.

Ultimately, some doctors may dismiss vaccine refusers to preserve professional integrity and not allow substandard care in their practices. This makes sense as long as doctors have made "good-faith attempts" to educate families and advocate for the standard of care with regard to immunizations, the authors write. Those who don't attempt to have this conversation, however, may not be fulfilling their commitment to professional integrity, they write.

"Pediatricians who ultimately dismiss some vaccine-refusing families, after efforts at persuasion have failed, may have done their part to promote vaccination. At least they tried," Dr. Navin said. "But pediatricians who do not even accept vaccine-refusing families into their practices have likely not done enough."

With several potential COVID-19 vaccines up for approval within the next year, these conversations with vaccine-hesitant patients and parents may become increasingly important, said Dr. Joshua Williams of the Denver Health Medical Center in Colorado.

Dr. Williams, who wasn't involved with the new paper, has written about alternatives to dismissal for vaccine-hesitant families.

"It will be more important than ever for providers to work together to dispel myths and address concerns," he told Reuters Health by email. "Now is not the time to close our doors to vaccine-hesitant patients or parents - it's precisely the moment to open them."

SOURCE: Pediatrics, online November 6, 2020.