There was much buzz in the media last week about a recent Wall Street Journal article suggesting that more physicians are “firing” families who refuse to vaccinate their children. The article cites two recent studies that found that a range of 21-30% of physicians admit to this practice, versus 6% in a 2001 study. While this is still a minority of physicians, it seems to be a growing minority.
Since publication, many people on both sides of the debate have weighed in. Some health care providers state that they should definitely be allowed to fire these families, as the non-vaccinated children in crowded waiting rooms pose a potential risk to other children, especially young infants. They also say that, given such strong philosophical differences, the patient-doctor relationship in these circumstances is unlikely to be a good one.
Others, including families who have chosen not to vaccinate their children, have commented that physicians should not dismiss them. They cite physicians’ responsibility to their patients, the parents ultimate ability to decide what is best for their child, and the resulting limited access to medical care for some children that this practice would cause if widespread.
Immunization is is a big enough issue in pediatric practice that most pediatricians and family physicians have (and should) read and thought about it a great deal. The great majority of my patients’ parents tend to worry more about whether their child has somehow missed a needed vaccination, and come in hoping to get caught up. Nonetheless, the particular issue of families who are hesitant about vaccinating their children is something all child health providers have come across. I won’t dismiss patients/families for this reason. Here’s why:
- Firing families does not get kids vaccinated. If I believe that receiving vaccinations improves children’s health- and I do- then it doesn’t really make sense for me to send them away. It makes sense for me to care for their acute and chronic health needs and, over time, to form a relationship. I ask them to bring in the information they have found that leads them to be worried about vaccines, and I share the information that makes me believe that vaccines are truly important and safe for the vast majority of children. We discuss this information. Over time, if there are vaccines that they feel comfortable giving, it makes sense for me to administer them. And, there are logistical ways to reduce waiting room risk to newborns and other vulnerable patients in order to keep them safe.
- Firing families may decrease access to care for children. I work with families and communities who have difficulty accessing quality, timely healthcare. I just can’t stomach the idea of turning a patient away. This is particularly salient for those of us taking care of children. Should I dismiss them, disregarding their overall health, due to a difference of opinion with their parents? This is a slippery slope.
- Firing families does not increase trust. Ultimately, all good relationships are based on trust and mutual respect. . . even when there are differing opinions. The only way to form a relationship is to open dialogue. Refusing to see families with a different opinion from my own would certainly not increase their trust in pediatric health providers or the medical system in general. This could potentially be detrimental to their child’s future health. My ethical obligation is to provide quality care and do my very best to keep all of my patients safe and healthy.
Ultimately, I believe that child health providers, and certainly parents, are trying to do what they believe is best for children. We do that best by working together, not by standing behind battle lines.
For more information:
- National Network for Immunization Information: The mission of the National Network for Immunization Information (NNii) is to provide the public, health professionals, policy makers, and the media with up-to-date, scientifically valid information related to immunization to help them understand the issues and to make informed decisions.
- NY Times Armchair Ethicist from November 2011 with many, many reader answers to the question, “Is it ethical for pediatricians to refuse routine care to families that do not immunize their children?”
- AAP Policy “Responding to Parental Refusals of Immunization of Children”
“First and most important, the pediatrician should listen carefully and respectfully to the parent’s concerns, recognizing that some parents may not use the same decision criteria as the physician and may weigh evidence very differently than the physician does. Vaccines are very safe, but they are not risk free; nor are they 100% effective. This poses a dilemma for many parents and should not be minimized. The pediatrician should share honestly what is and is not known about the risks and benefits of the vaccine in question, attempt to understand the parent’s concerns about immunization, and attempt to correct any misperceptions and misinformation.”
What do you think? How should child health providers respond to this issue?
My Two Hats 
I agree with you, Heidi. There are plenty of other more harmful practices that we don’t even consider firing patients for (smoke exposure being the most obvious, but also feeding children fast food on a daily basis or soda for infants/toddlers). The potential exposure risk to other patients is certainly worth consideration, but I don’t think it justifies denying care. Most vaccine-resistant parents are well-educated and very attentive to the wellness of their families- we should be treating them like a partner in the care of their child! Thanks for the great articles.
As a pediatrician at an office with a strict immunization policy, I thought it would be worthwhile to make a few observations. First, saying that practices with strict immunization policies “fire” patients is just inflammatory and adds nothing to the conversation. My partners and I don’t “fire” patients. It pains us to have this policy in place, but found it necessary to protect our staff and patients. In the end, our families are choosing a practice that is unsafe and against the best evidence that we currently have. They are doing what they claim to have always wanted – take control of the healthcare of their child(ren). Second, your first statement, “firing families does not get kids vaccinated” does not seem to be true based on evidence from our practice. While we have had a strict immunization policy for well over 3 years, we continue to have vaccine hesitant/questioning families. More often than not, after educating those families, those families choose to vaccinate…not based on our education…not based on the science…not based on the fact that it is what is best for their child…but for two reasons. One, our strict policy. Without our policy, even though we had spent time educating them, they would have chosen to not vaccinate or vaccinate on an alternative schedule. And second, they trust us. Which may prove that your last statement may not true. When doctors spend time educating families and then do the exact opposite of what they just they spend a large amount of time advocating for, trust decreases. When you back your words up with action, i.e. when you back up immunization with a strict immunization policy, families start to trust you. They begin to understand that you truly believe what you preach.
Now, I can’t say that this evidence is definitive. I don’t know how many vaccine hesitant families DON’T come to us. It would be difficult to compare vaccination rates of practices with and without policies. But, it is clear that definitive statements on both sides should be avoided.
Lastly, and I cannot stress this enough – it MUST be understood that pediatricians with strict immunization policies are just as CARING, LOVING, and DEDICATED pediatricians as those who “don’t fire patients”. We perform the EXACT same duties as you…we just have different ways of doing it.
Thanks so much for reading and for your thoughts. You make a number of very interesting points. I actually agree that the term “fire” is a bit inflammatory, but it is the term being most commonly used for this practice. What term do you use in your policy? On your second point, it would be really interesting, and probably helpful to many health providers, to have more data around whether having a strict vaccination policy in place does indeed increase vaccination rates. I have searched for data suggesting this, but have found none. If that proved out, it might sway me a bit. However, I will say that even without the policy, my experience is that I also have great success achieving vaccination of previously hesitant families based on a trusting relationship and education alone. I don’t believe that I am doing the “exact opposite” of what I spend time advocating for. Finally, I absolutely, unequivocally agree that pediatricians with and without strict immunization policies can be very caring, smart, and dedicated to their families and patients. I never intended to suggest otherwise.
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