Historically, the official American Academy of Pediatrics (AAP) position on dismissing vaccine-refusing families from a practice was, well, don’t do it. AAP policies aren’t binding, of course, and plenty of pediatric practices did show these families the door. But the Academy does carry a lot of weight, and the decision to proscribe dismissal policies was at least consistent with the sad fact that the AAP also allows anti-vaccine pediatricians to remain members in good standing. But that’s a different post.

An updated AAP position on dismissing vaccine-hesitant families

In September of 2016, the AAP issued a clinical report, “Countering Vaccine Hesitancy“, that discussed the varied reasons some parents have for refusing vaccinations and how to address them. It’s a nice summary of the issue, including some historical background, and I particularly appreciate the focus on the spectrum of parental hesitancy. It points out that only 3% of caregivers refuse all vaccines, while most hesitant caregivers are open to some or even all of them. Most can be reached with accurate information presented with thoughtful, respectful, non-confrontational, but personalized approach. Lumping everyone into either pro- or anti-vaccine piles isn’t helpful.

The last section of the report specifically discussed the dismissal of families who refuse some or all vaccinations. It acknowledges some of the ethical considerations involved in the decision to either dismiss these families or to keep them in a practice. It also points out that there is no published data on the effectiveness, or lack thereof, of dismissing families in regards to their eventual vaccine acceptance, however there are anecdotal reports that it can work after other efforts have failed.

It is important to note, and this is discussed in the AAP clinical report, that regardless of why a patient is being dismissed from a practice there are state laws in place to prevent abandonment. In general, families must be given some assistance in establishing care elsewhere and a reasonable amount of time to do so. They point out, correctly, that there are situations when dismissal is inappropriate even if it is a legally viable option, such as when a pediatrician practices in an area with no other qualified practitioners.

The report concludes its section on dismissal with a big change from previous iterations:

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.

But is dismissing these families fair to other practitioners and the community?

In an opinion piece in the latest JAMA Pediatrics, three medical ethicists discuss the fairness of dismissing vaccine-hesitant families. They worry about the erosion of “professional solidarity” because pediatricians are actually quite divided on the issue. I certainly know this to be true.

(For some personal perspective, I am strongly opposed to dismissing patients for the sole reason of vaccine-hesitancy or even blatant refusal. I think it’s wrong, and while evidence is lacking I am fairly confident that the practice will not improve vaccination rates. I think that it is a harmful and ethically questionable practice. This post isn’t really about my opinions, however, but if interested you can listen to a debate between myself and a fellow pediatrician on an episode of the podcast that I do with Grant Ritchey.)

The authors specifically 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. And because these discussions can be “emotionally and cognitively draining”, and frequently result in the uncompensated expenditure of added time and resources, dismissal policies might also unfairly shift a mental health and financial burden as well.

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. The authors of the JAMA Pediatrics opinion piece argue that dismissing vaccine-hesitant families isn’t ethically sound for this reason as well, and they worry that the updated AAP position is not in keeping with their commitment to public health and professional solidarity.

Conclusion: No easy answers regarding vaccine-hesitant parents

There are, in my opinion, better reasons to question the wisdom of dismissing a vaccine-hesitant family from a pediatric practice. But I agree with the authors of the JAMA Pediatrics Viewpoint article that it is probably a bit unfair to other pediatricians and their patients, and that it may increase risk to the community. Thankfully vaccination rates in the United States remain high, and the risk of serious outbreaks of dangerous diseases is low for the patients in any practice. But the risk is real and can’t be ignored. This is a complex issue and I’m confident that there are no easy answers.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.