(co-written by Susannah Rose and Jalayne Arias)
Should pediatricians be able to refuse to treat children who are not vaccinated for measles? This issue was raised by Carey Goldberg [here], in which she describes the basic considerations needed to answer this question. Briefly, she reports that several national studies indicate that some pediatricians do discontinue caring for non-vaccinated children, but there is wide variation in this practice. Considering whether pediatricians should be permitted to refuse patients based on vaccination decisions raises a host of questions: Would refusal constitute patient abandonment? Do a clinician’s obligations to this patient outweigh his or her obligations to protect other patients? Does refusing to treat a patient constitute discrimination? Does the refusal infringe on parental authority?
A physician’s decision to refuse patients based on vaccination decisions depends largely on the vaccination under consideration. For example, the MMR carries different risks and benefits (including public health benefits) than the HPV vaccine. The MMR vaccine raises unique public health and individual health concerns, given that measles is highly infectious, the low risk and high efficacy of the vaccine, and the potentially tragic outcomes of the disease (which are wide-ranging, and include pneumonia, encephalitis, death and others complications [here]).
We argue that under certain circumstances pediatricians should be able to refuse to treat non-vaccinated patients, based upon non-medical reasons. However, an individual pediatrician’s decision to refuse treatment should come only after certain factors are considered and circumstances must be met.
1. Transparency and Disclosure: All patients (and their families) should be notified of the physician’s decision not to treat non-MMR vaccinated patients. Disclosure should be made universally and to all patients, regardless of the decision related vaccination. This can be done through letters to current patients, statements on the practice’s website, and/or verbally, either in-person or over the phone, with new patients or current patients scheduling appointments. This disclosure should be clear, and the reason for the decision provided. It is important that patients and their families don’t perceive the decision to refuse to treat as discrimination based on their particular value system or as a threat to consent to vaccination. Offering the disclosure in a transparent mechanism and done appropriately will enhance trust, rather than diminish it.
2. Accommodations and Physical Practice Environment: Prior to refusing to treat patients the physician should consider other mechanisms of protecting others from exposure to vaccine preventable diseases. This may include offering separate waiting rooms or facilities for non-vaccinated children or home visits. This supports the parent’s decision and protects other patients while continuing to treat unvaccinated children. These decisions also protect unvaccinated children from potential risks.
3. An Offer to Refer: If a patient is dismissed from a practice, then every effort should be made to locate a provider who will treat the patient in as safe a way as possible. This may lead to increased referrals to providers who can specialize in the needs of this population, perhaps increasing the quality of care they receive.
Despite these measures, there remain challenges with our proposal. First, transparency is easier said than done. Not only is this a potentially challenging topic to discuss with patients and their families, it opens the door for discrimination based on a patient’s beliefs (versus the decision), and increases administrative costs to develop and distribute materials. And, even with the best communication, pediatricians run the risk of alienating non-vaccinated patients, potentially increasing the risk of harm to these individuals. Second, having separate waiting rooms may be impractical (and expensive), but may also serve to further marginalize such patients. Finally, finding physicians who will treat unvaccinated children may be difficult, if not impossible, particularly in rural environments. Ultimately, a physician’s decision to refuse to treat may be supported by public health arguments – provided the physician can refuse without causing harm by alienating and abandoning patients – specifically patients who did not make this decision for themselves, such as children.