Discharging patients with vaccine hesitant parents

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As an ethicist I try to always be as balanced as possible when I write columns like this one. This is not because I don’t have opinions or I’m afraid to express them. It’s because an important part being an ethicist is to facilitate good decision making by highlighting all the ethical considerations with respect to the relevant issue. I also tend to avoid statements like, “x is the right thing to do,” or “y is morally wrong,” largely because ethical issues tend to be more complex than they appear on the surface, and there can often be more than one reasonable response to an issue. But when it comes to parents who refuse to vaccinate their children, I have a hard time being balanced.  I do believe that vaccinating one’s children is clearly the morally right thing to do.

There are two reasons I believe this. One is that vaccinations are a very low risk way to prevent one’s children from being infected with a debilitating or fatal illness. There are literally dozens of studies published in a wide range of academic journals that have debunked all of the misconceptions related to vaccine risk, including the proposed link between vaccines and autism.

MORE: THE VACCINE CONTROVERSY

But don’t take my word for it – download the American Academy of Pediatrics document, “Vaccine Safety: Examine the Evidence,” a 21-page summary of all the published evidence related to vaccine safety (recently updated in April 2013).  Some people even question the benefit of vaccines, despite the fact that the introduction of vaccines virtually eradicated diseases like polio from the human race. And now, unfortunately, we’re seeing a resurgence of many of these illnesses around the world, coinciding with dropping vaccination rates.

The second reason I believe that vaccinating one’s children is the right thing to do is because it helps to prevent harm to others from contracting debilitating or fatal illnesses. As the Canadian Paediatric Society points out, a healthy unvaccinated child can spread a vaccine-preventable disease to more vulnerable individuals, such as infecting an infant sibling with pertussis or a pregnant woman with rubella. Not only that, but many of the infections can only remain controlled if a critical mass of the population is vaccinated (herd immunity).  If too many parents refrain from vaccinating their children, illnesses like measles can make a resurgence and spread around the world.

MORE: A LIFE OR DEATH DECISION

With that said, I want to shift to another aspect of the issue: the ethical responsibilities of paediatricians towards parents who refuse to vaccinate their children. A paediatrician by the name of Russel Saunders recently wrote a column that circulated through social media entitled, “Vaccinate your kids – or get out of my office.”  He asks new parents in his practice if their children are vaccinated, or if they plan to vaccinate, as part of his intake process.  If they say no, he tells them to find another paediatrician.  His rationale for doing so is that the physician-patient (parent) relationship is founded upon trust, which means the parents of his patients must be able to trust his judgment and expertise. If they can’t trust his judgment recommending vaccines, something that he believes is so clearly the unambiguous standard of care, how will they trust his judgment if the medical issues become more complicated? While he raises some valid points, the question is whether discharging such parents from his practice is an ethically appropriate response.

Both the American Academy of Pediatrics and the Canadian Paediatric Society recommend against discharging vaccine-refusing parents from practice, for several reasons. First, evidence shows that counseling does change the minds of many parents who initially refuse vaccines (or are at least reluctant to consent to vaccines). Scott Halperin categorizes vaccine-refusing parents into five groups, most of which can be counseled or reasoned with (though it can take time).  Only a very small percentage of parents are so committed to the anti-vaccine position that they can’t be convinced otherwise.  Thus, it is important for paediatricians to understand which group the parents belong to. (The Canadian Paediatric society refers to these parents as “vaccine-hesitant” to reflect the fact that not all of them are adamant about refusing vaccines).

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Second, discharging vaccine-hesitant parents certainly does not further the paediatrician’s goal of promoting child health. Discharge risks further alienating such parents and may fuel their distrust in the health care system, which can end up having detrimental effects on their children.  Discharge from practice cuts off all lines of communication and eliminates any chance for the paediatrician to build a trusting therapeutic alliance for the good of the child(ren). Additionally, if there are too many paediatricians who refuse to accept vaccine-hesitant parents into their practice, these parents may have difficulty finding primary health care for their children.  Not only does this increase the risk of potential harm to the children, but it also denies these parents equitable access to healthcare (especially in smaller communities with few paediatricians available).

In some extreme cases, if all efforts to work with the parents have failed, paediatricians may be justified in discharging such parents from their practice. The College of Physicians and Surgeons of Ontario policy states that physicians are not justified in ending a therapeutic relationship merely because the physician disagrees with the patient or because the patient refuses to follow the physician’s advice. There must be a “breakdown of trust and respect” in the relationship for discharge to be justified, and even then the physician is obligated to ensure that the patient has arranged (or has been given reasonable time to arrange) alternative services. Simply discharging them and sending them on their way is not an ethically appropriate way to respond to vaccine-hesitant parents.

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