There is a serious question among pediatricians about whether they should retain patients whose parents decline vaccinations. There is an informative discussion about the ethics of dismissal in this issue of JAMA Pediatrics, and a podcast debate about the issue here. The debate itself illustrates an interesting and important difference between medical and legal ethics.
In 2016, the American Academy of Pediatrics issued a report affirming the right of practices to refuse to accept unimmunized patients, though with some cautions:
The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view. Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option. In all practice settings, consistency, transparency, and openness regarding the practice’s policy on vaccines is important.
Nonetheless, many physicians – including Clay Jones, a pediatrician who blogs at the super-credible Science Based Medicine – believe that it is wrong to exclude unvaccinated children.
Here is how Jones frames it:
[Some physicians] focus on one common justification given by pediatricians who dismiss vaccine-hesitant families: children who are not appropriately immunized increase the risk to patients in a practice of acquiring a vaccine-preventable illness. This would seem to fulfill a pediatrician’s obligation to provide a safe environment for their patients. But, they point out, this merely shifts the risk to the patients in another practice. It also likely increases risk to the community.
If there are increasingly fewer pediatricians or family practice doctors in a community who do not dismiss vaccine-hesitant families, or if hesitant families are forced to turn to less science-based care, then these partially or non-immunized children may begin to form clusters. This would increase the risk of outbreaks should measles or some other vaccine-preventable disease make an appearance. This could increase the burden of risk for the patients of well-meaning providers who are comfortable continuing to promote vaccination and to the community. . . .
Pediatricians must take into consideration the health of not only their personal patients but also the community in general, particularly children. Promoting timely immunization practices is only one of many ways that we focus on public health. Usually our approach to managing pediatric healthcare achieves both ends, but these dismissal policies may actually result in a breach of our commitment to the community.
Putting aside, for now, the merits, it is interesting to see how legal and medical ethics diverge. Lawyers owe their obligations almost exclusively to their own clients, even if that imposes costs on the broader community. We are all familiar with the quotes. “Let justice be done though the heavens fall." And,
An advocate, in the discharge of his duties, knows but one person in all the world, and that person is his client. To save that client by all means and expedients, and at all hazards and costs to other persons, and, amongst them, to himself, is his first and only duty; and in performing this duty he must not regard the alarm, the torments, he destruction which he may bring upon others.
The notion of endangering our own clients out of a general “commitment to the community” is totally foreign to us. Following through on it would likely lead to malpractice liability, if not professional discipline.
I am not arguing that physicians should adopt the legal model. There are good and important reasons for doctors to have ethical obligations to protect public health.
On the other hand, I wonder how many parents would willingly risk the health of their children by seeing a pediatrics practice that accepts unimmunized patients. There are many children who cannot be vaccinated – those under a year old, those with certain illnesses or medical conditions, those with already compromised immune systems due to cancer – and who are therefore endangered by the presence no non-immunized kids in the waiting room. Even granting the physicians’ obligation to public health, don’t they also have an obligation to “do no harm” to their own actual patients? Or at least to enable their patients to exercise informed decisions about where to obtain care.
Perhaps the answer is disclosure. There could be a sign in the waiting room or a notice to new patients:
WARNING: This practice accepts non-vaccinated children.
This may pose medical risks to other patients who cannot yet be immunized.
I do not know the solution to this dilemma. Legal ethics place client autonomy above nearly all other considerations, while medical ethics require compromises for the sake of public health. My own children are adults, but I am pretty sure that I would not have knowingly taken them to a pediatrician who allowed non-vaccinated kids in the waiting room.
NOTE: The comments following Jones's post are extensive and extremely interesting; most of them are from pediatricians and other physicians. I recommend reading them if you have the time. Among other things, they discuss the financial incentives (and disincentives) of encouraging vaccinations.
This is a very thought provoking discussion. Another aspect is the legal liability of doctors, too. Can a doctor be sued if an unvaccinated patient with measles infects a baby too young to vaccinate? (Something that has happened in the past, with bad consequences, though no lawsuits happened that I know of). Can a doctor be sued for not counseling a family strongly enough to vaccinate if a child gets a disease (I do know of some of those)?
But this is a really, really tricky issue, and I appreciate the comparison to lawyers. I think doctors, too, need to seriously consider the duty to the patient – especially when it's a child. Is it fair to refuse the child other medical care because the parent is wrong on vaccines?
What if somebody cites Masterpiece Cakeshop and argues that the Doc is violating his Free Exercise rights by not treating his kid? The Doc is discriminating against religion? Here is another question. What happens to all that case law that forces religious parents to obtain medical treatment over their objections usually at the hands of a court?
I prefer to keep the lines of communication open, so I work with parents and try to get their children at least partially vaxxed.
My office has a single waiting room, but 2 month and younger patients, and immunocompromised are brought back to a room immediately. I also try to get the front desk to bring back any un/underimmunized Child with fever/rash as quickly as possible.
Since there are children with true medical exemptions to getting vaccinated, it is likely that every pediatrician accepts and sees unvaccinated children.