By Sydney Spiesel For Slate
The latest incident of parents who don’t vaccinate their children impacting parents who do is unfolding in New York City, where the Health Department has confirmed a measles outbreak. Parents who don’t want their children immunized put pediatricians -- the great, great majority of us, anyway -- in a quandary. On the one hand, we profoundly believe in the value and importance of vaccines. On the other hand, we profoundly believe in the value and importance of caring for all children who need us, and some of those children have parents who refuse to vaccinate.
Probably most of my colleagues would be very annoyed to hear me say so, but if you were to take all the pediatricians and stuff them in a barrel and fling them over Niagara Falls, the world would not be so badly off, but the same cannot be said about vaccines: Getting rid of them would be a real disaster. Second only to providing clean water and properly dealing with sewage, the use of vaccines has contributed more to our quality and length of life than any other medical or public health intervention.
But not everybody understands that, partly because vaccines have been so successful at eliminating many serious infectious diseases that there is no longer any public perception of risk from the illnesses they prevent. But there are other forces at play that make some parents reluctant to have their children immunized, even though they care a lot about their children’s health. The Internet permits people to write anything they want, and apparently people do just that, authoritatively, no matter whether their positions are (or are not) sensible or rational. To complicate things, we are all influenced by a fascinating psychological mechanism that automatically imputes gravitas, wisdom, and authority to anything presented in Times New Roman, even if the same message would be dismissed out of hand if scrawled in chalk on a sidewalk. Googling “immunization” will give you lots and lots of hits that probably ought to have been written in chalk on a sidewalk.
Besides, we’ve all been manipulated and lied to for somebody’s political or parochial or financial benefit, and so it’s not hard to believe that we are all constantly being manipulated and lied to for somebody’s political or parochial or financial benefit. I cheerfully admit that I often feel that way, and it helps me to understand the sense of suspicion that affects the thinking of parents reluctant to allow their children to be vaccinated.
So here is where pediatricians find themselves: Even if we believe -- as virtually all of us do -- that immunization is tremendously important and valuable, what do we do about the parents who don’t want their kids to get vaccinated?
Different docs have different answers to that question, and each answer raises its own ethical issues. Probably the easiest to dispense with are the tiny, tiny minority of doctors who just don’t believe in immunization: They welcome reluctant parents with open arms, reinforce the reluctance, and keep everybody happy (except, of course, the rest of us). These doctors are adding, to some degree, to everyone’s risk. And that’s an ethical lapse, not just a medical one.
The great majority of doctors, however, apparently having paid attention in medical school, fully accept the value of vaccines and the very, very low rate of risk attached to vaccination. (Nothing in medicine or life is ever completely devoid of risk, but -- contrary to the chalk-scrawls -- vaccination is one of the safest treatments you will ever encounter.) What do we do about vaccine refusers? It’s a difficult question. If we don’t allow unimmunized kids in our practice, where will they get medical care? That’s the reason that many (though I’m not sure how many) pediatricians allow unimmunized kids in their practice. But others refuse to see any patients whose parents won’t vaccinate them. According to a 2012 Wall Street Journal story, “In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason.”
In 2005 the American Academy of Pediatrics issued a policy statement addressing the question of how to respond to parents who refuse to allow their children to be vaccinated. The document focused on how pediatricians ought to deal with vaccine refusal (with reason) and recommended that we do our best to educate parents about benefits and risks. Though there is a nod to the public health implications of immunization refusal, most of the attention is addressed to the medical needs of the child whose parents don’t want immunization. The policy, after a minor change in 2013, suggests that pediatricians should “endeavor not to discharge” patients whose parents refuse immunization.
Perhaps I am too heavily influenced by the beginning of my career, which was in public health, but I feel a strong commitment to the well-being of all the kids in the community and, even more strongly, to the health of all the children in my practice; not just the one I’m seeing right this minute. I know that doctor’s offices, like schools and shopping malls -- any place that children congregate -- pose an increased risk for disease transmission. It just seems unfair that one parent’s well-intended but perhaps not well-thought-out decision for her own child should add risk for the lives of other children I take care of. So, yes, I do have rules that apply to parents who refuse vaccination. But my rules differ a little bit from those of most pediatricians.
Personally, I draw the line at vaccines protecting against diseases that kids might catch from exposures in my office. If parents want to withhold protection from hepatitis B or cervical and oral cancer, I think it’s not so smart, but I’ll still care for their children because not even the friskiest teen is likely to transmit these diseases in my office. Measles? Whooping cough? These are another matter. My sense of responsibility to the health of the vast majority of kids coming to see me says “no.”
I didn’t come to this decision easily. After all, it’s the parents, not the children, who make the choice to avoid vaccines -- what is my responsibility to those kids? Maybe I’m deluding myself, but I sort of believe that my clear policy may be beneficial to them, too. It’s a statement of how important I think immunization is (and why I think so). It encourages families to think about responsibility to others in the community. And it sometimes provokes people to rethink the question. (I’ve had families who left my practice because of my policy, but later came back, perhaps in spite of it—or perhaps, finally, because of it.)
But I’m not entirely naïve. My decision is made easier because I’m lucky enough to live in a state, Connecticut, that is serious about requiring shots to attend school. In addition, there are plenty of fine practitioners around town, and the statistics suggest that if 30 percent of Connecticut’s pediatricians won’t see unimmunized kids, it must mean that 70 percent will take care of them. What would I do about vaccine-refusing families if I were the only doc around? That would be a hard one.
Sydney Spiesel is a pediatrician in Woodbridge, Conn., and clinical professor of pediatrics at Yale University's School of Medicine.