Is it Ethical for Primary Care Practices to Refuse to Accept Un- or Under-immunized Patients? :

Management of patients whose parents refuse childhood immunizations in primary care is a contentious issue. In 2005, the American Academy of Pediatrics (AAP) published a clinical report written by the Committee on Bioethics which stated, “in general, pediatricians should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child.”¹ Coincident with increasing rates of immunization refusal, member dissatisfaction with this position grew and a resolution supporting “Changing AAP policy on providing care to families who do not follow standard recommended immunization schedules” was among the top 10 Annual Leadership Forum resolutions in 2012.² In 2016, the AAP published a clinical report written by the Committees on Infectious Diseases and Practice and Ambulatory Medicine stating pediatricians may consider dismissal an acceptable option.³  Some practices have subsequently moved from dismissing patients to refusing to accept un- or under-immunized patients.⁴

In the forthcoming issue of Pediatrics, Mark Navin, Jason Wasserman, and Douglas Opel analyze this emerging trend and argue that it is unethical to not accept immunization refusers in primary care (10.1542/peds.2020-1801). They argue that although physicians have freedom to choose their patients, this freedom should be exercised ethically. Only accepting compliant families, the authors argue, is intrinsically wrong. Other potential motivations, e.g., incentivizing immunization, are permissible, but not evidence-based.  Finally, some potential motivations are laudable, e.g., protecting other patients, but are outweighed by countervailing motivations such as children’s health and professional solidarity. 

While Navin et al provide strong reasons for distinguishing between not accepting and dismissing, and for an obligation to accept patients whose parents refuse immunization, it is unclear how much such arguments are likely to change practice. Substantial changes in practice may only come from highly effective, evidence-based interventions to increase immunization. Unfortunately, current evidence-based interventions produce only modest results.⁵ The other potential factor would be the elimination of nonmedical exemptions which was one of the top 10 resolutions adopted in 2019.⁶  How will you and your practice respond in the interim?

References:

1. Diekema DS, American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics. 2005;115(5):1428-1431.
2. Health care for immigrant children, families top ALF resolutions two years running. AAP News. 2012; 33(5):1.
3. Edwards KM, Hackell JM, The Committee on Infectious Diseases, The Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. 2016;138(3).
4. Chiaravalloti D. More pediatricians are dismissing patients who refuse to vaccinate. Board Vitals. March 22, 2019. Accessed November 6, 2020. https://www.boardvitals.com/blog/pediatricians-patients-refuse-vaccinate/.
5. Dempsey AF, Pyrznawoski J, Lockhart S, et al. Effect of a health care professional communication training intervention on adolescent human papillomavirus vaccination: A cluster randomized clinical trial. JAMA Pediatr. 2018;172(5):e180016
6. Update on top 10 resolutions adopted at Annual Leadership Forum. AAP News. July 2, 2019.