Many pediatricians will not care for children whose parents refuse immunizations. Florida pediatrician Marcy Baker, MD, defends this approach: “We’ll work with them a little, but if they refuse to have the child vaccinated, we’ll discharge them.”1
In Pennsylvania, Brad Dyer, MD, does the same, “If a parent absolutely refuses all vaccinations, then we ask them to find another health care provider who shares their beliefs.”2
Doctors who dismiss patients from their practices give one of four reasons:
- The parents’ refusal to vaccinate the child indicates such a difference in values that the doctor feels it would be impossible to work together.
- The parents’ rejection of the doctor’s recommendation indicates parental distrust of the pediatrician. With such distrust, it is inadvisable to continue as the child’s primary care pediatrician.
- Having unvaccinated children in the waiting room is a health risk to other children to whom the doctor has a responsibility.
- Parents have a social obligation to vaccinate their children. Those who do not are “free-riders,” taking unfair advantage of herd immunity and the altruistic behavior of others.
The first two reasons go to the heart of the doctor-patient relationship. Must a patient (or parent) accept all of the doctor’s recommendations in order for the relationship to be functional? Is rejection of a doctor’s recommendation necessarily a sign of generalized distrust? We think that neither of these arguments are valid. Parents must be free to evaluate each and every medical recommendation and to decide whether or not they agree with it. Discussion about recommendations and alternatives should be seen as an educational opportunity. Of course, such discussions take time, and primary care pediatricians don’t have much time. That, however, does not then justify the dismissal of a family from one’s practice.
The argument based upon the obligation to protect children in the waiting room is also flawed. If a doctor really believed in eliminating disease from the waiting room, they would have to prohibit any child with an infectious disease to be in the waiting room. After all, such children pose a threat to other children in the room without that disease, to infants, and to immunocompromised patients. The net result would be a practice in which the doctor wouldn’t see any child who was sick. Even then, it would be inadequate, since children with infectious diseases are contagious before they are symptomatic.
The argument about social obligations raises two different concerns. First, if taken at face value, it implicitly assumes that immunizations are not beneficial for the child being immunized but is, instead, a public health measure. By this argument, parents should compromise their child’s interests for the benefit of other children. That is not generally a standard to which parents are held. Alternatively, if, as we generally believe, immunization is beneficial to the child who is immunized as well as to the community, then parents who refuse immunization are acting against their own child’s interest. This decision would need to be evaluated as any other parental decision is evaluated. Generally, parents may make risky choices for their children as long as the choices are not too risky. In the absence of an outbreak, immunization refusal would fall into the intermediate zone of risk.
The American Academy of Pediatrics suggests that, instead of dismissing children from a practice because their parents refuse immunizations, physicians should respectfully discuss the benefits and myths associated with vaccines. The AAP states, “Many parents have concerns related to one or two specific vaccines. A useful strategy in working with families who refuse immunization is to discuss each vaccine separately.”
A “difference in values” should not distract pediatricians from their main concern: the welfare of the child. Shared decision making requires compromises. Such compromises can build trust, solidify the therapeutic relationship and promote decisions that are best for children.
For more discussion on pediatric bioethical issues, visit Dr. Lantos' blog at www.childrensmercy.org/cmbcblog.
References:
1. http://www.kevinmd.com/blog/2009/10/doctors-fire-children-parents-refuse-vaccinate.html
2. http://www.pediatricsupersite.com/view.aspx?rid=36790
