Monday, October 31, 2011

Discharging Unvaccinated Patients From a Practice

By Jason V. Terk, MD

As the phenomenon of parents declining or delaying routine vaccinations has grown, so have occurrences of physicians discharging patients from practices over this issue. Why is this happening, and is the response of these physicians appropriate and defensible? As a practicing general pediatrician with some expertise in the area of vaccines, I will offer some of my perspectives.

Public fears about vaccine safety date back to the 1700s, when the members of the well-educated and well-to-do among the population expressed reluctance about receiving vaccination against smallpox. The vaccine was made using the closely related cowpox virus that Edward Jenner had discovered could confer immunity to smallpox, which killed thousands of people in episodic epidemics at the time. Jenner found that milkmaids infected with the harmless cowpox virus did not get ill during lethal outbreaks of smallpox. However, when vaccination against smallpox became widely recommended by public health officials and required by some local and state laws, it was derided by these contrarians as against the will of God and an affront to the sanctity of humanity. Rumors flew that one could actually sprout cows from one’s body after receiving inoculations with the cowpox virus. And so, a conflict between individual liberty and public welfare began that continues to this very day.

The most recent outcry about vaccine safety arose from a now-discredited study by Dr. Andrew Wakefield and colleagues published in The Lancet in 1998, which purported a possible link between the MMR (measles, mumps, rubella) vaccine and risk for developing autism. Although it has been fully retracted by the journal and described as a public fraud intended to enrich the author of the study, its effect on the public health has been profound. Thousands of parents have come to the conclusion that they have more to fear from vaccines than from the diseases that those vaccines prevent. Over the 13 years since this study was published, millions of children have had recommended vaccines delayed by their parents or withheld entirely. And, this same period of time has seen the resurgence of previously controlled diseases, with multiple outbreaks of measles, whooping cough, and vaccine-preventable forms of meningitis — all due to the creation of pockets of vulnerability where rates of vaccination have fallen. Preventable deaths have occurred, and hundreds of thousands of public tax dollars have been spent to control outbreaks that should have never happened.

Because vaccination of each individual forms the fabric of the public health safety net, each person who refuses to be vaccinated contributes to the risk that deadly outbreaks will occur. And so, at the point care, a physician encountering a patient or parent who refuses recommended vaccines must make a choice to consent to continue to care for that patient or not. This is indeed an important decision to be considered because no thoughtful physician would want to deny access to needed care without very good reason. And for those physicians who decide to terminate the doctor-patient relationship in this situation, very good reasons can be found.

Good physicians try to practice medicine according to what is considered to be appropriate standards of care that are based upon validated research and evidence-based recommendations. The quality of the supporting evidence underlying recommended vaccinations for children is very strong and validated over the years. So, a physician who would fail to follow these recommendations would be practicing medicine below accepted standards of care, and adverse events arising from this poor care would be cause for liability for the physician.

But more importantly, a physician takes an oath to do no harm. In the practice of any given physician who cares for children in an outpatient setting, the number of times that a more vulnerable patient will come in for care is very high. Some infants are too young to have received any vaccines, and some children have compromised immune systems because they are being treated for cancer. Some may have undiagnosed conditions that put them at increased risk to vaccine-preventable diseases. All of these patients come together in a physician’s office when they need care. A physician who allows patients to go unvaccinated in his or her practice becomes complicit in the increased risk that such a choice creates and allows that risk to be hosted within the walls of the practice. All of those vulnerable patients are potential innocent victims to another person’s misinformed choice that the physician enabled by keeping that person in the practice. I personally could never live with an outcome of serious preventable disease or death that I contributed to in any way.

So for me, as long as our libertarian culture abides individual choices that put the rest of society at risk, I view my responsibilities as educating and respectfully answering questions and addressing concerns to achieve what is recommended for children. If, however, vaccines are refused after a thoughtful discussion, then my responsibility shifts to protecting the rest of my patients from the ill-advised and dangerous choice of the individual who refuses vaccinations.

1 comment :

Ray M Johnson, MD said...

Some parents are difficult, if not impossible, to convince about the safety of vaccines. Discharging them from your practice is not a viable option to me. I have them sign the AAP refusal form and try to convince them the next time. These patients require a lot of time that many physicians are not willing to give. Not attempting to educate the patient because of the time, is unacceptable. I provide copies of articles, I direct them to what are considered good websites for information and ask them to return in a week or two so that we can discuss what they have learned.
I have only had one family continue the refusal mode, but I continued to see their children and kept trying to convince them of the safety of the vaccines.
Texas laws make it too convenient for families to refuse vaccines. I utilize articles written about families who refused to authorize the a vaccine such as HIB, and then had the child develop HIB meningitis. One such article was published in "Time" magazine several years ago. Another was published in Pediatrics as an online review of vaccines. I try to utilize every weapon I can gather to convince the parents.
I have watched patients die of measles encephalopathy, pertussis and meningitis before the vaccines became available. The one disease for which we have not developed a good vaccine is responsible for 30% of the cases of meningicoccal diseases, Type B.

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