Parental Refusal of Vaccination: What Should the Pediatrician Do?
There may be many reasons for parents to refuse a physician's advice to have their child vaccinated for significant diseases which can be acquired in childhood or later. But what is the pediatrician or family physician to do next after the refusal. Certainly the doctor should, after explaining the benefit of vaccination to the child but also the benefit to the community and any realistic risks involved, ask questions to the family about what they understood as the value and risks and then why they are continuing to refuse vaccination. But what if the refusal is not based on some personal financial or some medical or scientifically proven contra-indication but on a religious or some personal idiosyncrasy? Should the physician then discharge the patient from further care and tell the parents to find another physician? Should the physician report the parents to the appropriate governmental child protective agency or the health department? Or is it professional and ethical for the physician simply to accept the refusal as a parental right and continue caring for the child?
If you were the pediatrician.. what would you do? ..Maurice.
posted by Maurice Bernstein, M.D. @ 12:44:00 PM
2 comments
2 Comments:
I want to preface my response by saying I am old enough to remember the polio epidemic. I understand the value of vaccination and would probably choose to have my child vaccinated. I think the key word here is choice. Is choice real or is it just an illusion. If, as a physician, you offer parents the "choice" to vaccinate their children, then drop them as patients if they don't make the right "choice", you are really telling parents they have to vaccinate their children.
Again, I want to be clear that I understand the public health implications of an unvaccinated population. Polio was wiped out overnight by a vaccine. Because we have not had an epidemic of that severity since, many don't understand what an epidemic can do.
Still, I believe parents should have the right to choose. Some states require children to be vaccinated in order to enter school. I have far less issue with that. I think the government has a public health role to play, and that they should be allowed to (in VERY rare circumstances where the immediate health of an entire population is at risk) insist on certain vaccines that serve to protect the entire population.
I assume that along with explaining the risks and benefits of a vaccine itself, you also find a way to learn what the parent's concern is. Is it financial? It may be that the family won't be able to eat that day or week if they vaccinate their children. Is the concern with the safety of the vaccine? The drug companies have behaved shamefully in knowingly pushing unsafe drugs into the US market. As you well know, the decision to take any medication is a question of whether the risks of the medication outweigh the benefits. Shouldn't the parent make that decision freely?
I think the implications of dropping a family for not vaccinating children are frightening. Parents should not have to feel that if they bring their child to a doctor, they then have no choice but to do everything the doctor says. Either the parents have the right to choose or they don't.
Again, the public health concerns belong with public health departments. I suspect you have a concern about the welfare of vulnerable children and I sympathize. Still, I think it is becoming far too easy to interfere with patient autonomy. If you believe parents want what is best for their children, you must respect their choices.
MB
The implications of parental refusal to immunise relate to the degree of harm that might occur in the absence of such an immunisation.
Let me illustrate this by describing a recent case presented to our ethics advisory group. A mother who is hepatitis B positive was about to give birth to a baby. She refused to have Hepatitis immune globulin and also refused to have hepatitis B immunisation.
The risks to the baby of becoming a chronic carrier of hepatits B in this situation are very high. In addition, with the infection being congenitally aquired the child would be very unlikely to clear thie virus
In addition these perinatal issues, there are long term risks for the child to develop liver cirrhosis and liver cancer.
There is short window of opportunity for effective prophylaxis against acquiring hepatitis B (about one week)
Given these circumstances, a court order was obtained in order to administer the preventive programme, but the mother took the child away and the opportunity to give protection to the child was lost.
The mother is pregnant again and there is the dilemma as to whether a further court order should be instituted in order to protect the interests of the child by allowing the administration of a protective programme that will benefit the child in the long term.
The interests of the child and long term risks to its health seem to outweigh the parental decision not to allow an immunisation programme to occur.
In addition, society needs to think about the potential long terms risks ( and financial costs) incurred in event of these liver complications arising.
Parental choice about whether immunisation should or should not be administered have to relate to the degree of damage incurred by not allowing immunisation to occur.
In this case parental choice is trumped by potential damage to the child.
Such a stance is not without risk to the extent that the mother might not avail herself of optimal maternal services because she might feel that her independence and autonomy might be limited by the threat of a court order.
This raises issues of confidentiality about the care of the mother, how far should one go to protect the child of this second pregnancy at the expense of breaking confidentiality arrangments for the mother and her next pregnancy.
Again, all things considered, the welfare of the child is paramount.
Any comments welcomed !
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