I read with interest the Pediatrics Perspective from Drs. Navin, Wasserman, and Opel regarding refusal to accept vaccine refusers in primary care.1 I myself am a general pediatrician and have practiced primary care for almost 22 years in a community which is home to one of the most active anti-vaccine organizations in my state. This experience obviously informs my perspective on this important topic.
While I appreciate the approach taken by the authors to categorize the values and motivations which are relevant to the question of accepting patients whose parents refuse vaccinations, it is my opinion that their arguments are perilously reliant on semantics and faulty casuistry. For example, the authors assert that the accepted freedom to select one's patients [American Medical Association Code of Medical Ethics (§1.1.2)] does not permissibly extend to the freedom to refuse patients whose parents do not vaccinate. Such a refusal to accept such patients would putatively be based upon the parents' demand for medically inappropriate care, the inability of the clinician to provide competent care, or the compromising of care of existing patients by accepting said new patients who refused vaccinations.
They state that the refusal to vaccinate is not an example of demanding medically inappropriate care but rather a refusal of appropriate care. I do not think that this is a meaningful difference and I find the argument unconvincing. One can also reasonably argue that being prevented from providing recommended vaccinations significantly reduces the ability to provide competent, good quality care. Being compelled to participate in care which is categorically substandard would also potentially injure the professional integrity of the clinician in question. Finally, there is the question of the clinician's duty to existing patients, which cannot be superseded by the clinician's duty to a possible new patient. While the quantity of risk of accepting patients who do not vaccinate may be debatable, that risk is not zero. The choice to not vaccinate one's child is not equivalent casuistically to a choice to provide poor nutrition to one's child. And, if the clinician makes an affirmative choice to accept patients who do not vaccinate and that results in transmission of a serious disease to existing patients in the practice, then that clinician is partly responsible for the morbidity or mortality that might arise from that occurrence.
Let me say that I quite agree that every opportunity should be undertaken to educate and counsel families who are vaccine-hesitant; I do this regularly and am successful in the vast majority of these encounters. This is a heterogeneous population and most may be educable and receptive to that counsel. However, there are some families who will be unreceptive and hostile to such counsel. If a primary care practice determines that a family is firm in their refusal to accept vaccinations and will be hostile to counsel on this topic, then it should be permissible to determine that beginning a doctor patient relationship will be fraught with risk and untenable.
CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.