Is vaccine refusal reason to terminate relationship?

Provider autonomy must be considered

Refusing to have a child as a patient because of a decision made by the child's parent should always be a last resort, according to Douglas S. Diekema, MD, MPH, attending physician and director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle (WA) Children's Hospital. "However, when a substantial level of distrust develops, significant differences in the philosophy of care emerge, or poor quality of communication persists, the pediatrician may encourage the family to find another physician or practice," he says.

In these situations, the parent would probably also be better served by another provider, as long as one is available in the community, adds Diekema, but in the event that a physician feels it is necessary to terminate a relationship with a patient and parent, the physician must give sufficient advance notice to allow the parent to secure another health care professional to assume the care of the child.

"However, when a parent has a good working relationship with the physician, I don't think physicians should discharge them from the practice simply because the parent refuses to vaccinate his or her child," he says. Families with concerns about immunization should still have access to good medical care, and maintaining the relationship in the face of disagreement conveys respect and, at the same time, allows the child access to medical care, explains Diekema. "Continuing the relationship also allows the provider to have future opportunities to discuss the issue of immunization over time," he adds.

Vaccine refusal is "a classic case of clashing between parental autonomy and beneficence," says Daniel S. Kamin, MD, director of the Gastroenterology Consultation Service and member of the Ethics Advisory Committee, both at Boston (MA) Children's Hospital. Physicians must consider the welfare of the child, the welfare of the community, physician integrity, physician-parent relationship, and parental autonomy to determine an ethical response to this disagreement, he says.

"If a family were refusing to vaccinate a child bitten by a bat, in almost all circumstances the ethical response would be to seek a court order to compel vaccination, based on what we know about the risk and outcome of rabies infection, which often is death," he says. In contrast, if a family were refusing to vaccinate against human papillomavirus in a pre-teen, given that the risk is much lower for serious complications, that cancer can often be treated or avoided with good preventive care, and that the risk is way in the future, Kamin says that education would be an ethical response.

Some physicians feel very strongly that it is wrong not to vaccinate, and that they can't in good conscience continue to take care of children whose parents don't agree, however. "Physicians should not be forced to provide care they think is wrong," Kamin says. "Ethical responses include frank discussion and planned transition to a provider that is willing to consider not vaccinating."

Kamin says that unethical responses would include angry responses and refusals to continue caring for children, while missing the opportunity to understand the parent's position. "Parents are often super worried about terrible reactions," he explains. "They are perhaps mystified by misinformation, but are taken by the many compelling stories out there about bad responses." It is crucial for providers to understand that parents' greatest responsibility is to protect their children from harm, says Kamin. "Coercion by scaring parents or unnecessarily making it difficult to get care would also be questionable ethically," he says.

It is often reasonable policy, says Kamin, to both educate and use some coercion to increase vaccination rates, because of the interest in protecting the health of populations, especially children. "This is why mandatory school vaccination policies stand up to ethical scrutiny," he says.