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AAP Gateway: Should Pediatric Practices Have Policies to Not Care for Children With Vaccine-Hesitant Parents?

One of the most divisive issues in pediatrics today concerns the proper response by pediatricians to parents who refuse routine childhood immunizations for their children. Many pediatricians refuse to care for such families. Others continue to provide care and continue to try to convince parents that the benefits of immunizations far outweigh the risks. In this Ethics Rounds, we present a case of a pediatric practice trying to decide what their policies should be regarding immunizations. We asked experts in pediatric infectious disease to offer their advice.

Dr. Angela Myers comments:

Physicians are obligated by oath to “do no harm.” Although this obligation sometimes conflicts with other obligations (eg, when we prescribe chemotherapy for a patient with cancer), it is the spirit of this oath that we carry with us every day. In addition, physicians are expected to provide beneficence to patients while minimizing maleficence.

In the pediatric setting, immunization is second only to hand-washing in terms of “doing good” by promoting the health and well-being of children. However, this idea falls flat when a parent refuses to follow our recommendation to immunize their children. Of course, we recommend many things, and parents often do not follow our recommendations. Generally, we continue to care for their children and encourage them to lead healthier lives. I think immunizations are different. Let me explain why.

The difference is in the implications that vaccine refusal has on other children. If we tell people to wear their seat belts and bicycle helmets, and they do not do so, they are only hurting themselves. If, as a result of not following our advice, something terrible happens, such as being thrown from a vehicle during a crash or experiencing an intracranial bleed from hitting their head on a curb, it happens only to that person. There is no risk to others conferred by their reckless decision.

The lack of risk to others is not the case with immunizations. When a nonimmunized child gets measles or an infection with Haemophilus influenzae type b, they have exposed other children to these life-threatening diseases. The exposure begins in the days before the illness even began, when they were completely asymptomatic. Secondary cases can be seen in closed communities of nonimmunized and underimmunized populations but can also be seen in larger populations.

Dr. John D. Lantos comments:

The debate about vaccines is an excellent example of a situation in which people on opposing sides disagree about the most fundamental facts. As a result, arguments that are based on those contested facts cannot possibly persuade those who do not accept the facts as a basis for argument. The result is that arguments become more and more strident, the conclusions more and more extreme, and the ethical implications that follow from those conclusions more and more questionable.

This outcome happens both at the impersonal level of policy making (eg, which vaccines should be mandated and what sorts of exemptions should be permitted), as well as at the deeply personal level of the individual physician–patient–parent relationship.

The fallacies of parental arguments against immunizations are well rehearsed and well understood by pediatricians; thus, I will not re-analyze them here. Instead, I will highlight the fallacies or inconsistencies in some of the more common arguments made by pediatricians in support of decisions or policies not to care for vaccine-refusing parents.

The first and most powerful argument that is often put forward by pediatricians to justify the dismissal of such parents is that the parents’ unwillingness to follow the pediatricians’ recommendations regarding immunization leads to a breakdown in trust and thus a fatal blow to an ongoing physician–parent relationship. However, parents disagree with many of the things that their physicians recommend, often with consequences more dire than vaccine refusal. Many parents continue to feed unhealthy diets to their obese children, despite constant exhortations by physicians to curtail the child’s junk food consumption. I know of no pediatricians who suggest that they should refuse to care for obese children. Many parents continue to smoke, putting their children at risk for infections and asthma. I know of no pediatricians who refuse to care for children whose parents smoke. Parents do not insist on bike helmets, they do not apply sunblock, they keep firearms in their homes, and they let their children play football. These actions are all associated with childhood injuries and deaths. If disagreement or nonadherence with pediatricians’ recommendations about any one thing suggested broken trust on all things, pediatricians would then be left with very few patients indeed. Instead, a centerpiece of medical ethics from the time of Hippocrates until today has been that physicians should care for patients regardless of the patients’ beliefs, values, or practices. Physicians care for the rape victim and the rapist, the enemy soldier as well as their own troops, the virtuous patient and the sinner. Why, of all transgressions, should vaccine hesitancy be the one that obliterates professional obligations?


Read the full article via AAP Gateway.