Executive Summary

An increasing number of pediatricians are encountering families requesting an altered vaccine schedule or refusing vaccines altogether; some are responding by dismissing families from their practices, according to a study.

• Some states have made it easier to obtain vaccine exemptions.

• There is growing concern about unvaccinated children putting themselves and others at risk.

• Bioethicists can voice concerns publicly about vaccine refusers, experts say.


Ninety-three percent of pediatricians and family physicians reported that, in a typical month, some parents of children younger than two ask to spread out vaccines; most agree to do so either often/always (37%) or sometimes (37%), according to a recent study.1 However, the majority (87%) said such delays put children at risk for contracting vaccine-preventable diseases. A previous study reported that about 10% of physicians “often” or “always” dismiss families from their practice if they refuse vaccines entirely.2

“This is a very complex and difficult subject,” says Alexander A. Kon, MD, FAAP, FCCM, clinical professor of pediatrics at University of California San Diego School of Medicine. He notes that much of the distrust of immunizations arose from a discredited 1998 study that suggested a link between the Measles, Mumps and Rubella (MMR) vaccine and autism.

“In fact, every study looking at a potential link between immunizations and autism — and there have now been many — has not shown any such link,” says Kon. “Yet there remain lingering fears among parents who are misinformed by celebrities and others.”

A recent measles outbreak stirred public debate over vaccine refusers. “Those of us caring for sick children, however, never lose sight of this problem,” says Kon. Last year, Kon cared for a child who was admitted with a severe lung infection. He was infected with strep pneumonia — a very dangerous bacterium against which most children are immunized. “This child nearly died because his parents chose to withhold immunizations — a decision they made based on a false belief that immunization might cause autism,” says Kon.

The American Academy of Pediatrics recommends that physicians discharging patients from their practices solely because a parent refuses to immunize a child should be left for unusual cases, only after attempts have been made to work with the family.3

“That being said, many pediatricians do discharge patients from their practice if parents refuse immunizations,” says Kon. “They believe strongly that failure to immunize a child is so counter to the child’s best interest that they cannot be involved in what they view as medical neglect.”

For this reason, some pediatricians and ethicists support mandated universal immunizations. “In the United States, such policies are at odds with our strong support for individual autonomy and parents’ rights to raise their children as they see fit,” says Kon.

Under such programs, immunizations are given to children without parental consent. Only when the physician determines that immunizations are not indicated for the child, such as if the child is severely immunocompromised, can the physician withhold immunizations.

“The state may indeed have a responsibility to mandate immunizations, both for the public good and to safeguard the best interest of individual children,” Kon says.

Douglas S. Diekema, MD, MPH, attending physician and director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Hospital, is seeing more parents seeking at least an altered vaccine schedule, if not a full exemption. Both scenarios present ethical challenges for pediatricians.

School exemptions mean other children are exposed to unvaccinated children. “Delaying vaccines for completely non-scientific reasons means children remain unprotected at a fairly vulnerable time,” adds Diekema. He notes that in the past decade, there have been significant efforts in several states to eliminate or reduce vaccine requirements for school attendance.

Some states, however, have made vaccine exemptions more difficult to obtain. “How easy it is to get an exemption is probably the most important variable related to vaccination rates,” he says. “The easier the exemption is to obtain, the higher the exemption rate.”

Diekema says the majority of people see vaccines as a good thing without question, and a very small percentage are anti-vaccine and can’t be convinced. “Then there is a middle group, the vaccine-hesitant, who are worried about what they’ve read or heard,” he says. “This group comprises 20 to 30% of the population, and is the group that’s most amenable to education.”

There is growing public concern that vaccine exemptions are putting other children at risk. According to a recent Pew Research Center report, 68% of U.S. adults say childhood vaccinations should be required.4 “I wish legislatures would pay more attention to this sizable majority,” says Diekema. “The problem is that the people lobbying are the ones who don’t want vaccines to be required for school attendance.”

Diekema says an increasing number of physicians are discharging vaccine-refusers from their practices. Such families require time-consuming education; the eight to 10 minutes typically allotted per visit doesn’t allow for a lengthy discussion on vaccines, he says.

“From a public health perspective, I think refusing to see families who have chosen not to vaccinate their children is a worthless tactic,” says Diekema. “The families just end up somewhere else.” Providers lose the opportunity to convince them that vaccination is the right choice.

“I have some ethical concerns about turning away these families solely on the basis of their decision about vaccination,” adds Diekema. Physicians have an ethical obligation to their patients — in this case, a child whose parents have made a decision that you disagree with.

“It’s extraordinarily frustrating to have families rejecting what may be one of the most powerful tools we have to keep children safe,” Diekema says. “But while they may not be convinced at the first or second visit, the goal is to get the child vaccinated over time.”

Bioethicists should consider contributing editorials to newspapers or doing radio interviews on the topic of vaccine refusal, says Diekema.

“The academic literature has covered this pretty well,” he says. “But bioethicists and physicians have a responsibility to bring messages like this out to the general population.”


  1. Kempe A, O’Leary ST, Kennedy A, et al. Physician response to parental requests to spread out the recommended vaccine schedule. Pediatrics. Published online March 2, 2015 (doi: 10.1542/peds.2014-3474).
  2. Kempe A, Daley MF, McCauley MM, et al. Prevalence of parental concerns about childhood vaccines: the experience of primary care physicians. Am J Prev Med 2011; 40(5):548-555.
  3. American Academy of Pediatrics, Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics 2005; 115(5):1428-1431.
  4. Pew Research Center. Public and Scientists’ Views on Science and Society. January 29, 2015, Washington, DC.


  • Douglas S. Diekema, MD, MPH, Director of Education, Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital. Phone: (206) 987-4346. Fax: (206) 884-1091. Email: douglas.diekema@seattlechildrens.org.
  • Alexander A. Kon, MD, FAAP, FCCM, Clinical Professor of Pediatrics, University of California San Diego School of Medicine. Email: kon.sandiego@gmail.com.