Pediatrician’s Dilemma: Drop Families That Refuse To Vaccinate?

A young boy is vaccinated against MMR in Scotland in 2007.

Question: If parents refuse to have their children vaccinated, is it ethical for a pediatrician to respond by refusing to be their doctor?

Answer: That’s under continuing debate. But a new report finds that 25% of pediatricians do “dismiss” anti-vaccine families from their practices.

Question: Readers, what do you think? And please let us know if reading this post changes your opinion at all.

Dr. Ian Sklaver, an experienced pediatrician at Garden City Pediatrics in Beverly, welcomes parents’ questions about vaccines. If they want to spread out the shots so not as many are given at one visit, he’ll do it. He wants them to be as comfortable with vaccines as possible.

But if a family refuses crucial vaccines and will not be budged, “then I suggest to them that I am not the right doctor for their family,” he said in an e-mail. “I would not feel like I was providing good care to someone who was refusing immunizations. I certainly would try to change their minds, but I have had to ask a handful of patients to leave.”

“If the overwhelming abundance of scientific information and my own strongly held beliefs do not convince them, then I have to let them know that I think their decision is leaving their child at risk of grave harm and I would not want to be a part of that decision,” he said. “I also have to consider the other children in my waiting room who would be exposed to the unimmunized child, putting them at risk as well.”

A new study out this month finds that Ian is far from alone. The national survey of several hundred pediatricians found that a substantial minority, about 25 percent, do always, often or sometimes “dismiss families” from the practice if they refuse vaccines in the “primary series” — the basic vaccines including polio and diphteria.

Dr. Allison Kempe

It’s no easy decision. “The bottom line is that it really is an ethical dilemma for pediatricians,” said Dr. Allison Kempe, lead author of the paper in the American Journal of Preventive Medicine. “I can tell you that personally, it’s an ethical dilemma for me.”

The issue of vaccine refusal has bedeviled pediatricians for years, and persuading reluctant parents to vaccinate has become a huge time-sink in many practices. No matter how many scientific studies come out exonerating vaccines of any role in the autism epidemic and touting the good they do, many parents continue to fear the shots.

Dr. Kempe’s data, gathered in 2009, found that vaccine refusals appeared to be on the rise: nearly one-tenth of pediatricians and family practitioners reported that 10% or more of parents refused at least one vaccine in a given month. Almost 80 percent report at least one refusal in a typical month.

So at what point can or should a pediatrician ethically draw the line?

It’s such a difficult question that when it came up among pediatricians at Harvard Vanguard Medical Associates a while ago, they held a meeting with the chair of their ethics advisory board, Dr. Jim Sabin, and with Dr. Lisa Lehmann, director of the Center for Bioethics at Brigham and Women’s Hospital.

“This is an issue on the minds of a lot of pediatricians,” Lisa said, and it’s important to tease out what most bothers them. Her analysis, in distilled form:

Potential harm: By refusing to vaccinate their children, parents are potentially causing them harm in the future, and you could argue that the doctor is complicit in that harm.

Other children: What about the other children in the waiting room? Children under 22 months are too young to be fully vaccinated.

Liability: If you don’t vaccinate a child and then he develops measles or some other infectious disease, are you as a pediatrician somehow legally at risk?

Justice: Vaccines are not 100% effective, but if enough people get them, a community develops what’s called “herd immunity.” Children who are not vaccinated still benefit from the herd immunity, so some suggest they’re like free riders. The analogy in the ethics world would be people who refuse to donate organs but still want to receive organs. Also, society may have to pay for treatment for a preventable disease.

‘Why should you penalize the child whose parents refuse to vaccinate by not allowing them access to medical care?’

Despite those concerns, Lisa concludes that no, you don’t drop patients. In this, she concurs with the American Academy of Pediatrics, which also discourages doctors from dropping anti-vaccine families.

She sees the central issue as patient autonomy and “the right that parents have to make decisions for their children that they think are in their best interests.”

“The challenge is that there’s a fundamental clash of values and a disagreement about what’s in the best interests of the child,” she said. In such conflicts, “Unless there’s a really clear and serious potential for harm to the child, we generally respect parents’ decision-making preferences.”

Also, she said, part of the pediatrician’s role is to develop a relationship of trust with families. Terminating a relationship seems like “an easy out.” If a pediatrician conveys all the arguments in favor of vaccination in the context of a trusting relationship, she said, “hopefully, over time, people change their minds.”

If a doctor does decide to drop a family Lisa noted, it must be done properly so that the patient is not “abandoned:” The doctor must give notice, make sure the parents understand the reasons, and make sure they have another source of care.

But more broadly, she said, if too many pediatricians start refusing care to anti-vaccine families, “there could be a huge issue in terms of access to care. And why should you penalize the child whose parents refuse to vaccinate by not allowing them access to medical care?” Especially when, with time, it may be possible to persuade the parents. “Just saying ‘We’re not going to take care of you,’ is, to me, on some level, irresponsible.”

In Dr. Ian Sklaver’s experience, persuasion just doesn’t always work. Yes, he said, pediatricians are told to try to wear down anti-vaccine families over time. But “In practice, the families that really don’t want to vaccinate at all never catch up, unless they are pressed to so their kids can go to school. Of course that misses the crucial years when they are most at risk.”

Immunization ‘is such an important part of our care, and asking me to do without it is like asking a painter to paint a house without his hands.’

Dr. Allison Kempe, the vaccine study’s author and a University of Colorado School of Medicine professor of pediatrics, points out that there’s some critical data missing here: What are the effects of dropping or not dropping families?

“We haven’t studied whether it’s actually more effective to say to parents: ‘You’re asking me not to do something that I feel is really important and necessary for your child’s wellbeing, and I can’t go along with it.’ I’m not sure that isn’t a more effective approach,” she said. “I’m not endorsing it, I’m just putting it out there.”

She’s also troubled, she said, by the study’s findings that the practice of spreading shots out is increasing despite the lack of data on the potential harmful effects of this practice. And by “the message we are giving as a profession when we agree to compromise on what we think is right medically. Is the message, ‘Well, maybe you’re right?’ This might be causing more confusion on the part of parents.”

Dr. Ben Kruskal

What did the Harvard Vanguard pediatricians decide? The issue came to a head for two reasons, said Dr. Ben Kruskal, Harvard Vanguard’s director of infection control. One was concern about waiting-room contagion. The other was the feeling that immunization “is such an important part of our care, and asking me to do without it is like asking a painter to paint a house without his hands: It’s not like you can’t do it, but you won’t do a very good job. That’s a feeling most of us share.”

Ultimately, however, after many questions and much back and forth, the Harvard Vanguard pediatricians decided against dropping anti-vaccine families.

The waiting-room threat from unvaccinated children did not seem large enough, Ben said. Though, he added, “if that subgroup becomes bigger, that would become a true ethical question and reason to consider refusing care.”

The pediatricians chose to try to persuade families of the value and safety of vaccines over time. And “That in fact has been the experience of many of us,” he said.

To end on a note of consensus: Everyone in pediatrics appears to agree that vaccine resistance is a big problem, and it doesn’t seem to be going away. Allison Kempe’s paper found that 46% of pediatricians reported that having to combat it made their work less satisfying.

Her research suggests the need for ever more creative solutions to the problem, from group visits, social marketing and educational campaigns to better training for physicians on how to communicate risks.

The survey also found that one simple argument may be more effective than any data-based analysis: Telling patients, “Yes, I vaccinate my own children.”

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