As the number of measles cases from the recent outbreak that began at Disneyland continues to grow, so too does the debate surrounding it.
Parents who refuse vaccinations for their kids are no longer alone in facing hard choices about how best to care for these unvaccinated children.
Increasingly, doctors are finding themselves caught between their professional oaths to care for all sick children and standing by the recommended schedule for measles vaccination. They must also protect the health of other children in their offices, including infants too young to be vaccinated.
In the past week, the debate dipped into murkier waters as pediatricians contemplated dropping patients whose parents refused to have them immunized according to the recommended schedule. The Centers for Disease Control (CDC) says kids should get the first dose of the measles, mumps, and rubella (MMR) vaccine at 12 to 15 months of age and the second dose at 4 to 6 years of age.
In one case, Los Angeles pediatrician Charles Goodman posted a notice on Facebook announcing that his office “no longer accepts NEW PATIENTS who have decided not to immunize their children.”
Other physicians are considering the same action, with some hoping to change the minds of anti-vaccine parents and others who may question the safety and effectiveness of modern vaccinations.
It’s difficult to know exactly how many offices have “fired” patients. But a 2011 study found that 30 percent of 133 pediatricians in Connecticut surveyed had asked a family to leave their practice for refusing to have their children vaccinated.
The Ethical Dilemma of Vaccine Refusal
Medical officials say it’s sometimes difficult to know what’s right or wrong when it comes to how doctors should handle unvaccinated children.
“It’s an ethical dilemma in the sense that there are two choices and neither of them are optimal choices,” said Dr. Eric Kodish, a bioethicist and pediatrician at the Cleveland Clinic.
The easier question to answer is what to do when a child shows up at a clinic with measles. The disease typically begins with a high fever and cough. Three to five days after the symptoms begin, patients develop the characteristic red measles rash.
“Of course doctors need to see patients with measles,” said Kodish. “It can lead to pneumonia. It can lead to other serious complications. Pediatricians and family doctors are obligated to care for children that are sick.”
Although measles is quite contagious, medical offices can use well-established isolation procedures to protect other unvaccinated children in the waiting room or other exam rooms. According to the American Academy of Pediatrics, if you are unvaccinated, your chance of getting measles after coming near an infected person is 90 percent.
The same isolation procedures can be used for children who have been exposed to measles but have not yet developed symptoms. Children with measles pose little risk to children and adults who have been vaccinated because the vaccine is 93 to 97 percent effective.
Should Doctors Refuse to See Unvaccinated Patients?
Where it gets tricky is deciding how to handle unvaccinated children who don’t have measles and have not been exposed to the disease.
Some doctors are concerned these children pose a risk to their other patients. This includes children too young to be vaccinated or other children who can’t be vaccinated, such as those with compromised immune systems — like cancer patients — and those who are allergic to ingredients in the vaccines.
The American Academy of Pediatrics provides the following guidance to doctors: "In general, pediatricians should avoid discharging a patient from their practices solely because a parent refuses immunizations for the child.”
The guidelines do suggest a physician encourage a patient to see another provider if the relationship with the patient becomes “unworkable.” In the case of children, this relationship also includes the parents. However, this guidance still leaves room for debate.
“What I ask as an ethicist is would [dropping a patient] be the right thing to do and under what circumstances,” said Kodish. “How exasperated does a pediatrician need to be before she says, ‘That’s it, I’m not going to see your child anymore?’”
For pediatricians like Goodman who have drawn a line in the sand, the frustration appears to stem from parents’ continued doubts about the safety of vaccines.
“Vaccines are safe and effective. Global warming is a reality. The Earth is not flat. THESE ARE THINGS OF WHICH I AM CERTAIN!” reads another post on his office’s Facebook page.
In many carefully controlled studies, scientists have shown there is no connection between the MMR vaccine and the development of autism or other developmental problems. A now-retracted study from 1998 purported to show a link between vaccines and autism, but the researcher behind the report was later found to have manipulated evidence. In fact, the only significant side effect of the MMR vaccine is a slightly increased risk of seizures in kids younger than 7.
The Downsides of a Hardline Stance on Vaccines
The hardline approach may convince some parents to agree to vaccinations or perhaps begin the long search for another pediatrician who is more accepting of their views. But this path is not without its own problems.
“Personally, I wouldn’t encourage [firing patients] because I think I have a duty to help any patient,” said Dr. Margarita Cancio, an infectious disease physician with Tampa Community Hospital, an HCA West Florida hospital. “Just because I don’t agree with them, I don’t think I should be disrespectful.”
Practicing medicine is not just about treating illness and helping people stay healthy. Cancio said it also involves building a strong doctor-patient relationship. In this case, that includes the parents. It’s this trust that often suffers the most when doctors try to forcibly change patients’ minds.
“A pediatrician or family doctor who is more absolutist and takes a hardline stance on vaccination loses that opportunity to build a kind of trusting relationship [with the patient and parents] and do what’s right for the kid, which is to get them immunized,” said Cancio.
There is also the danger that if parents are forced out of a practice because of their anti-vaccine views, they may have difficulty finding another pediatrician to treat their child. This could lead to even more problems if the child catches measles because the they would no longer have a primary care physician.
“At the end of the day the parents are not your patient, it’s the child,” said Cancio.
Can Doctors Change Parents’ Minds?
The other option for pediatricians is to keep seeing unvaccinated children in their offices. Parents often put a lot of effort into finding a pediatrician they trust. This provides doctors with a unique opportunity to educate parents about the importance of vaccination.
“The pediatrician is uniquely capable of influencing the decision of the parent,” said Cancio. “Not by ordering them but by answering their questions.”
In addition, pediatricians can spend more time trying to understand the parents’ objections to vaccines. Finding this face-to-face time may be difficult in an era of fast-paced medicine, but other staff in the office may be able to take this on as well.
“Good doctors make the diagnosis before they embark on a treatment,” said Kodish. “And understanding where the parent is coming from can bring parents along toward vaccination.”
Some parents are concerned vaccines cause autism, something that has been widely discredited. Others, like the Amish, object to vaccines on religious grounds. Still other parents may embrace a “natural lifestyle” that limits the use of chemicals.
This issue won’t go away anytime soon. Even after the outbreak has faded from the headlines, questions about whether or not to mandate vaccines for children will remain.
“I’d like the public to have a more sustained attention to [this issue] and for us to really think both about the individual good and the public good,” said Kodish. “And to remember that children are not the property of their parents, but they’re also not the property of the state. They’re children.”