To dismiss or not to dismiss: Practice policy on vaccine-refusing families

Issue: December 2015

While the majority of pediatricians across the United States may believe they have an ethical and professional obligation to treat patients regardless of their vaccination status, a significant minority refuse to treat vaccine-refusing families due to a perceived threat on patient health.

“Families who choose not to vaccinate are by definition going against medical advice. And, we have to set a limit,” Christoph Diasio, MD, FAAP, chair of the Section on Administration and Practice Management for the AAP, said during a session at the 2015 AAP National Conference and Exhibition in Washington, D.C. “If they’re not going to believe the mountain of data, if they’re not going to accept the science … we make clear that when we boot them out for this, that they are choosing a fringe position.”

According to Natasha Burgert, MD, FAAP, of Pediatric Associates Kansas City, this approach is not only wrong, but clashes with the ethical standards of being a pediatrician.

“Closing your doors to vaccine-rejecting families may allow you to feel like you’re helping your community, and it may even make you feel more power to do your job,” Burgert said during the presentation. “But ultimately for all of us, our feelings don’t matter. We are physician scientists who are held to the highest levels of professionalism. And as a physician, before we refuse care to a group of individuals, we have to be able to strongly justify that decision with both scientific evidence and ethical merit.”

The belief that vaccines are paramount to the protection of children worldwide is at the core of both Diasio’s and Burgert’s perspectives on this issue. Although Diasio believes that concise action is required to educate families on the seriousness of vaccine compliance, Burgert said a long-term relationship with vaccine-refusing patients is critical to increasing vaccination rates.

“I found that my relationships with initially vaccine-refusing families have led to a lot of vaccinated children,” Burgert said. “I feel like I have a special touch with those families that validates my time and effort.”

According to Diasio, however, he has attempted the long-term approach and said it lacks efficacy when compared with setting an ultimatum.

“I’ve tried it … the let’s talk and talk and talk and never set a limit approach,” Diasio said. “But, once we set a limit, those people who we were talking and talking and talking to did finally come around to vaccinate. It really did work.”

According to Burgert, it is a matter of dedication to public health and of determination to educate refusing families on the importance of vaccines.

“Parents who challenge vaccines for their children are certainly not easy,” Burgert said. “It takes a special level of dedication, awareness and finesse in order to work with these families. And, I will be the first to admit, when I see certain families on my day sheet, I am mentally preparing for a tussle, but I do it. And, I believe that all of us who provide direct patient care should do it, because it is our ethical duty and our obligation as physicians to care for all children.”

Diasio said that his dedication to public health is exactly what motivates him during conversations with vaccine-refusing families.

“Once we started to tell families, ‘If you don’t get vaccines, you’ll have to go somewhere else,’ the families thanked us,” Diasio said. “They came back and thanked us. We put signs on the back of every door saying this is our new policy, and families would stop me in the hall to say, ‘Thank you for doing this.’ Because, at the time we did this, we were getting into a very dangerous place in America.”

Diasio cited contamination of waiting rooms and office spaces as a reason to dismiss vaccine-refusing families; Burgert, however, feels this will ultimately create optimal conditions for vaccine-preventable disease outbreaks.

“If an increasingly high percentage of providers refuse to see undervaccinated children, they’re going to be forced into waiting rooms with a limited number of providers,” she said. “Now, you’re creating situations where unvaccinated kids are clustering together and potentially a bigger health problem. Undervaccinated kids need to be more evenly spread out to where they’re less likely to spread disease to other undervaccinated individuals.”

According to Diasio, once the conversation with parents about routine vaccination begins, pediatric expertise holds more weight than parental concern.

“When I say to a parent, ‘You have to get these vaccines in order to remain in this practice,’ they’re kind of no longer in charge of that decision anymore,” Diasio said. “I think this is an effective policy that works well and does change behavior, and we have experiential data to show that.”

Burgert countered that she believes the practice of dismissing vaccine-refusing families undermines the care of individual children and is an impractical solution to the problems related to vaccine compliance.

“I know it’s not ideal, it’s not how we want it to work,” Burgert said. “We want all of our kids protected before these diseases present themselves. But, practically, that’s not going to happen. It hasn’t happened in the history of vaccination. And, for the sake of the kids who are going to become victims of their parent’s choices, we cannot shut our doors.” – by David Costill

Disclosure: The researchers report no relevant financial disclosures.