A new survey shows more pediatricians are experiencing vaccination refusal among patients, and while the reasons are evolving, they still often result from misinformation. An increasing proportion of doctors are kicking these families out of their practices if they can’t change minds and behavior, but is that ethical? Whose rights are paramount—the unvaccinated child or the rest of the practice?
- Dr. Kathryn Edwards, Professor of Pediatrics, Vanderbilt University and member, Committee on Infectious Diseases, American Academy of Pediatrics
- Dr. Nathan Boonstra, pediatrician, Blank Children’s Hospital, Des Moines, IA
- Dr. Art Caplan, Director, Division of Medical Ethics, Langone Medical School and Co-Director, Project on Vaccine Ethics and Policy, New York University
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16-43 Vaccination Refusal
Reed Pence: A hundred years ago, it was sadly common for children to die from infectious diseases like measles, or become disabled for life as a result of polio. Today most of us don’t give those diseases a second thought. But it’s not as if they disappeared on their own. Vaccinations are what protect our kids today. But only if we use them. And according to a national survey of pediatricians, that doesn’t always happen.
Dr. Kathryn Edwards: There are more people refusing vaccines and more people that are choosing to use alternative schedules to vaccines and so there is more reluctance.
Pence: That’s Dr. Kathryn Edwards, professor of pediatrics at Vanderbilt University and a member of the committee on infectious diseases at the American Academy of Pediatrics. She says that according to the survey, 87 percent of pediatricians have had parents in their practice refuse immunizations for their children. Dr. Nathan Boonstra, a general pediatrician at Blank Children’s Hospital in Des Moines, Iowa, is one of them.
Dr. Nathan Boonstra: I do see families where they are somewhat hesitant to vaccinate and I see a few families where they don’t vaccinate at all. The reasons can be extremely varied. So there can be anything from some kind of emotional experience that they’ve had or something that they’re read or something that has bothered them where they have talked to somebody and made them hesitant. There’s kind of that aspect of things. There are families that believe certain myths about immunizations or have done reading or gone into websites that have really led them away from the idea of vaccinating. So there’s a lot of different reasons why families refuse or at least are nervous or hesitant about immunizing.
Pence: One of the myths often promoted by websites is the claim that vaccines cause autism or other diseases. It’s a charge that’s been debunked repeatedly…yet it was the biggest reason for vaccine refusal 10 years ago, and today, it’s still number two — cited by nearly two-thirds of parents who won’t let their kids be immunized.
Edwards: It’s very frustrating and my perspective is that I have seen children die of these vaccine preventable diseases. I understand the power of these diseases and I also understand how difficult it can be to eliminate myth information and false information. Repeated studies have shown over and over and over that the vaccines are not associated with autism, but in spite of that people continue to believe that they are. It also is frustrating because if we need to continue to do the same studies proving that autism isn’t related to vaccines, then we divert money that could be used for meaningful research in terms of what does cause autism and how can it be managed.
Pence: But that’s not the only myth doctors need to combat to get some children immunized. The most common reason for vaccine refusal today, according to the survey, is the belief that vaccines aren’t necessary.
Edwards: One of the problems that we have, we have such effective vaccines that we have eliminated a number of the diseases that used to infect young children. So parents don’t really know about them, they don’t know about measles. They don’t know about meningitis because those vaccines have largely eliminated those diseases. I have seen these diseases that are virtually eliminated now that we have vaccines. So the last night I was a pediatric resident four decades ago I stood by and was totally helpless as a baby died of homophyllis meningitis. Now that disease is virtually gone because we have a vaccine. I mean, people are short sighted. When something is gone they forget that it’s a threat. It’s just easier to say, well it’s not here, so I’m not going to worry about it. And I think that is something that we have to continue to try and educate people about.
Pence: One thing many people don’t understand is that nearly everyone needs to be vaccinated to create what’s called “herd immunity.” Otherwise those who can’t be immunized because of cancer treatment or other medical factors won’t be protected. And there are always a few children—perhaps five percent–whose vaccines are not completely effective. Without universal immunization, they’re not protected, either. So Edwards says parents who choose not to vaccinate are making a decision for other children as well as their own.
Edwards: If we have a 4-way stop and three people stop and one doesn’t, we’re just fine. But if we have two people that don’t stop or three people, I mean the more that we do not adhere to the vaccination guidelines the greater risk we have for those immunized people to be infected. So we do have a burden. The Supreme Court has upheld on a number of occasions the mandatory vaccination of individuals for the protection of the entire public good. We do have a responsibility to others if we’re living in a society and if we’re not vaccinated then certainly we put children that are vaccinated at risk and we put children who have immuno- compromised who can’t get vaccinations at risk as well.
Dr. Art Caplan: When a parent says I don’t want to, sometimes it can be that they know that others are and they’re acting as a free rider. They’re kind of depending on you to vaccinate your kid so they don’t have to do it with their kid. I think that’s morally wrong. It’s wrong to take a benefit without participating in the procedures necessary to secure that benefit.
Pence: Dr. Art Caplan is director of the division of medical ethics at the Langone Medical School of New York University and co-director of its project on vaccine ethics and policy.
Caplan: Some parents do it because they’re worried about safety and I think again that’s bogus. Vaccines are very very safe. They’re not 100 percent, but the risk of disease to their own kid is higher than any risk from vaccination. The autism myth is false, that’s just not something you have to be concerned about. We know that isn’t the cause of autism clearly established by study after study after study. And then you roll around to the, so do you have an obligation to help others. And I think you do. What does it mean to be a member of a community, a good neighbor, a responsible citizen? Well, part of it is I don’t just look out for my kid, I look out for your kid. I don’t just look out for me, I look out for your sister who just had an organ transplant or your grand mom who’s getting cancer therapy and their immune systems are weak and they could get the flu or some other contagious disease. I think we expect our neighbors to keep an eye out for our kids, make sure they don’t fall in the pool or injure themselves doing something and I think vaccination is like that.
Pence: So what should doctors do when a parent refuses to have their child immunized? Most of them talk to parents first. Boonstra tries to answer their concerns and perhaps get them to change their minds.
Boonstra: I think a lot of talking to a family about immunizing begins with the relationship that the physician has with the parent. So the first thing to do is to listen and try to figure out where they are coming from. What kind of experience have they had that brought them to the point that they are? And then you can go from there. And sometimes it’s a long conversation. It’s not necessarily something that you can make them confident about in a 15-minute physician’s visit. Sometimes it takes multiple conversations, sometimes it takes e-mail communication so that you can look at the kind of resources they’re using and give your opinion on that. And sometimes the conversation doesn’t work out in the end. Sometimes I just have to do the best I can and give my recommendation and if they don’t take my advice we work on other things. I try to make sure that this child gets the best health care that they can, even when I think that the decision that the parent has made is not the best for that child.
Pence: If parents won’t budge, an increasing number of pediatricians dismiss the family from their practice. And the policy of the American Academy of Pediatrics, which Edwards helped to formulate, now says that that’s okay, as long as there’s another doctor in the area to take them. It’s a decision Edwards says doctors wrestle with.
Edwards: I have listened to pediatricians and the anxiety and the frustrations that they have and the true concern that they worry about their other patients. This is not something that pediatricians are doing without incredible angst. Obviously pediatricians want the best for their patients, as do parents. Parents are not refusing vaccines because they want to hurt their children; they just don’t understand the implications or don’t see things in the same way. So these decisions are really hard ones for pediatricians and are never taken lightly.
Pence: But is it ethically okay for a doctor to dump a patient? Caplan says it’s a close call.
Caplan: I understand why they do it. They basically say, look, if you can’t follow my advice I can’t really be your doctor. If you can’t do what I think is medically appropriate you shouldn’t come to me; you need to go to somebody else. And some of them are saying too, there’s even the threat in the waiting room if your kid isn’t vaccinated they could infect other kids. These actually are situations where children are there to get vaccinated, they may not have their vaccines. If your kid comes in infected with something and isn’t symptomatic, well you could be a danger to the other kids in a small confined space. But in thinking about it and thinking about it, well, I understand why pediatricians and family docs might want to say no. I don’t think that’s the right answer. I think the kids can’t protect themselves against bad choices by their parents. I think you’ve got to try to work with the parents, convince the parents somehow or another or win them over, do your best, keep seeing them.
Pence: That’s what Boonstra does. He makes no secret of his view that all kids should be immunized. But he doesn’t kick out those that refuse. He says he has an obligation to the unimmunized child, as well.
Boonstra: When it comes down to it I think it’s important to make sure that every child gets good pediatric care even when their parent is not making necessarily the healthiest decision for their child. I understand the reasons that a lot of physicians choose to dismiss and they’re looking out for their patients as well. They’re looking out for their waiting rooms. They don’t want to bring contagious disease into their clinic. They want to make sure that they have a good relationship with their parents and their patients, that they are building that relationship on trust. The other thing is that I feel like I can’t change minds if I don’t see those kids. If they are going to go somewhere else they might go to a physician who doesn’t spend as much time educating about vaccines or has a different philosophy about vaccines that’s not evidence based. Or they might start not bringing their child to a medical provider. These are all things that I worry about with kids if I’m not going to be willing to see them in a practice.
Pence: Few of these dilemmas would exist if states eliminated non-medical immunization exemptions for school children. That’s what the American Academy of Pediatrics advocates, and in states where waivers for religious or personal objections don’t exist, vaccination rates are much higher. Caplan says no major religions object to immunization, so states shouldn’t bend over backwards to grant exemptions. Then it’s up to doctors to educate parents to protect their kids… and everyone else.
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I’m Reed Pence.