Ethics Consult: OK for Docs to Fire Vax Refusers? MD/JD Bangs Gavel

Welcome to Ethics Consult — an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma in patient care, you vote, and then we present an expert’s judgment.

Last week, you voted on whether a pediatrician can ethically fire vaccine refusers. Here are the results from over 1,000 votes:

Is it ethical for the doctor to deny or dismiss unvaccinated patients?

Yes: 71%

No: 29%

Would your vote change if this is the only pediatrics practice in the community?

Yes: 25%

No: 75%

And now, bioethicist Jacob M. Appel, MD, JD, weighs in:

As a general principle, physicians outside the emergency and hospital settings are free to choose their patients with very few restrictions. They are also allowed to “fire” current patients as long as they afford them an adequate opportunity to establish care elsewhere. However, having the legal right to do so does not necessarily make all such decisions ethical. In this scenario, it might prove helpful to understand why the pediatrician has adopted such a policy.

One explanation might be concern that unvaccinated children will expose other pediatric patients to measles — such as in a waiting room setting. Some of the pediatrician’s patients may not yet be candidates for the measles vaccine due to immature age or medical comorbidities. Others may have been vaccinated but the vaccine did not “take” and they failed to generate the immunity necessary to ward off the virus. If enough children are vaccinated, even those in whom the vaccine does not work will be protected, because the odds of them coming into contact with infected people remain low.

The pediatrician may believe he or she has a duty to protect his most vulnerable patients from those whose parents choose not to accept a safe and effective public health measure. If he or she were to continue treating unvaccinated patients, he or she might even have an ethical duty to place signs in his waiting room warning other patients of this exposure risk. While he or she could certainly configure his office and schedule to ensure the children of “anti-vax” parents did not come into contact with others, rather than refusing to see them, few ethicists would argue that he or she has an obligation to do so. However, those that favor such accommodation of “anti-vaxxers” might argue that children should not be penalized for the poor choices of their parents.

Another explanation might be that the pediatrician wishes to pressure parents into accepting vaccination. Before doing so, he or she would be wise to inquire why parents are rejecting these vaccines. Overwhelming evidence supports pediatric vaccination: many of the scourges of past generations such as polio and diphtheria have nearly been eliminated, saving thousands of lives, and claims that the measles-mumps-rubella (MMR) vaccine is connected to autism have been widely debunked as fraudulent. But well-meaning parents may be misinformed, especially when celebrities and even the current president question the medically recommended vaccine schedule.

A pediatrician — especially the only one in a community — might have an ethical duty to attempt to educate these parents before refusing care to their children. At the same time, vaccines often do carry some rare risks to an individual child. This creates a “collective action problem” or “dilemma of the commons” in which self-interested parents, not acting in good faith, may try to freeload off the herd immunity generated by other families who have accepted such minor risks for the common good. Such behavior is deeply problematic. However, individual physicians are not ideally situated to play a coercive role in the implementation of public health measures.

What is most puzzling is why parents are allowed to refuse vaccination for their children at all when they are not allowed to reject other life-saving, health-preserving, or protective measures. While courts generally override parents who reject essential blood transfusions or chemotherapy for their offspring, opponents of compulsory vaccination often note that the acute risk of not vaccinating is lower than these interventions. A more fitting comparison might be to require that young children ride in car seats, wear bicycle helmets, etc. The most likely explanation for different approaches to similar risks is that no political will exists to force vaccination upon the large and increasing number of resistant parents. Unfortunately, while not using a car seat only puts one’s own child at risk, refusing vaccination places the lives of other people’s children in jeopardy.

Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College. Appel is the author of the recent book, Who Says You’re Dead? Medical & Ethical Dilemmas for the Curious & Concerned.

And check out some of our past Ethics Consult cases:

Should Christian Clinic Provide IVF to Lesbian Couple?

Is a COVID Human Challenge Trial Ethical?

Ethics of Testing Drugs on Down Syndrome Patients

*** This article has been archived for your research. The original version from MedPage Today can be found here ***