Unvaccinated not welcome. This is the policy of many pediatric offices that exclude children if their parents opt out of standard vaccinations. At first glance, it may seem right for pediatricians to refuse service to families that oppose vaccination, but just under the surface the ethics of such decisions become sticky. In this month’s Ethics Rounds, Alexander et al. (10.1542/peds.2016-1597) provide three different viewpoints on this question and pull the reader into the uncomfortable situation of challenging the ethics of a common practice.
For the first viewpoint, Dr. Angela Myers supports the pediatrician’s right to refuse service to unvaccinated children primarily because of the need to protect other children. She recognizes that families often ignore the pediatrician’s recommendations, but these decisions do not affect others. “If we tell people to wear their seat belts and bicycle helmets, and they do not do so, they are only hurting themselves.” If something bad happens, it only happens to that person. However, when children are unvaccinated, they pose a risk to other children who are too young to be fully immunized or who are immunocompromised.
When children sit in the waiting room at the pediatricians’ office, the parents expect they will not be exposed to diseases that vaccination could have pushed towards eradication. She does however, recommend flexibility with parents in an attempt to gain trust of the parents and work towards the goal of full vaccination. “However, pediatricians should only go so far… Families who refuse vitamin K, erythromycin ointment, and the initial hepatitis B vaccine are more likely to continue to refuse all vaccines in the future.” If pediatricians cannot gain this trust early on, then there is little hope for future interactions and the relationship should be ended, argues Dr. Myers.
Drs. Alexander and Lacy offer a second viewpoint, in which they share many of Dr. Myers’ concerns. However, they raise the concern of what happens to children after they leave the pediatrician’s practice. They argue that children are best served by pediatricians even if they remain unvaccinated, rather than by less qualified practitioners “who may recommend disproven or unproven and potentially dangerous remedies, such as homeopathy or naturopathy.” They further argue that excluding non-vaccinating families is unlikely to protect vulnerable children from vaccine-preventable illnesses because “the family excluded from a practice for refusing to immunize their children is unlikely to seek immunization elsewhere.” By keeping these patients in a pediatric practice, “the very small risks brought to vulnerable children are exceeded by the large benefits brought to children in our non-immunizing families.”
Dr. Lantos concludes the paper by addressing fallacies in the arguments favoring dismissal of non-vaccinating families. First, he addresses the argument that a parent’s unwillingness to agree to vaccines shows a significant level of distrust that undermines the future relationship in an irremediable way. “But parents disagree with many of the things that their doctors recommend, often with consequences more dire than vaccine refusal… If disagreement or non-adherence with pediatricians’ recommendations about any one thing suggested broken trust on all things, then pediatricians would be left with very few patients indeed.” Further, he argues that pediatricians’ waiting rooms are very dangerous places to be for immunocompromised patients, whether unvaccinated children are present or not. In fact, parents who refuse yearly flu vaccination may put these children at the most risk, yet no one argues for their exclusion from practices.
Prior to reading this article, I blindly accepted the pediatricians’ prerogative to exclude parents and children who refuse vaccination. The pediatricians’ office for my children excludes non-vaccinating families. As a parent, I appreciated that my sons would not be exposed to pathogens that should no longer exist in this country. As a pediatrician, I saw this as a riposte against the pseudoscience we combat on a daily basis. But after reading this article, I am forced to reconsider the ethics at a deeper level. Hopefully this article will spur other readers to begin the uncomfortable process of questioning the ethics of good intentions.