Should doctors fire families who refuse to vaccinate?

We are currently in the midst of an epidemic. No, not the H1N1 epidemic, though that’s the most immediate threat. What threatens the long-term health of our nation, particularly our nation’s children, is an accelerating epidemic of ignorance. Vaccine rejectionism, the flat-earth theory of the 21st Century, previously the domain of the crazies, has gone mainstream.

Doctors are frustrated. As Dr. Nancy Snyderman angrily declared on her NBC show, we are just a “stone’s throw” from witnessing a return of polio to the US. Measles and pertussis (whooping cough) are already making a comeback. Although the absolute number of cases is still in the hundreds, the effects of vaccine rejection on medical practice extend beyond the number of children who are sick.

Pediatricians and family practice physicians are wasting extraordinary amounts of time counseling parents contemplating vaccine rejection. Counseling is, of course, part of any doctor’s job, and we routinely counsel against ignorance in other areas of medicine (HIV, sexually transmitted diseases, etc.). But in those cases we counsel against prejudice and lack of knowledge. What makes vaccine rejectionism extraordinary is that we are forced to counsel against the ignorance deliberately disseminated by professional vaccine rejectionists.

Within the medical community, doctors are beginning to debate the possibility of “firing” families who refuse to vaccinate their children for deadly illnesses like polio and pertussis. Dr. Gary Marshall speaking at a recent American Academy of Pediatrics conference explained that it is both legal and ethical to refuse care:

In the middle of treatment, you can’t just say, I’m done, …

But if it becomes obvious that you and the family will never see eye to eye on a specific issue, there’s no reason not to “fire” them, providing you follow the steps necessary to avoid charges of abandonment. Those include providing written notice that you will no longer treat their children and giving them a set time frame — at least 30 days — to find another physician.

Doctors are and have always been legally entitled to refuse to care for specific patients as long as they did not abandon them in the midst of an acute event. This drastic step is usually reserved for patients who are difficult, disruptive or openly disrespectful. It is an acknowledgment that every doctor is not right for every patient.

It is rarely used merely because patients disagree or are non-compliant. Patients have every right to disagree with recommendations or to ignore them. Non-compliance is a serious problem, but it is often a case of “the spirit is willing, but the flesh is weak.” Smokers know they need to quit and generally make good faith efforts to do so. Alcoholics are often more distressed about their conditions than their doctors, but they are addicted and have great difficulty doing what they know is right.

There is something fundamentally different about vaccine rejectionism because it is a rejection of the principles of science and medicine. It is illogical and “evidence resistant.” When the patient does not agree with the doctor on the absolute requirement that medicine should be based on science, there is no common ground. And since vaccine rejectionism depends on absurd conspiracy theories regarding the financial motives of doctors and vaccine manufacturers, it destroys the trust necessary in the doctor patient relationship.

While individual doctors are certainly free to legally “fire” families who reject vaccination, it is a poor way to address the problem. It places children at risk for being unable to obtain good medical care in a crisis. Those most likely to suffer, the children, are not the ones who made the foolish and uneducated decision. Moreover, at this point, the problem has grown too large to be solved by physicians acting individually.

This is a public health problem of the most basic kind, and should be solved with government based public health measures. The government should more strictly enforce vaccination policies. Technically children cannot go to school if they are not vaccinated, but it has become all too easy to obtain vaccination waivers on the grounds of religious or personal beliefs. The government should end the policy of allowing philosophical exemptions.

All children should be fully vaccinated against fatal childhood infectious diseases as a requirement for being allowed to attend school. It makes particular sense to apply a vaccination requirement to attending school because schools are where non-vaccinated children posed the greatest threat to other children.

In an effort to placate parents with religious and philosophical objections, the government has fueled the epidemic of ignorance. It is time to address that ignorance head on. If you want your child to go to school, your child must be vaccinated. Period.

The time for endless discussions about irrational, non-scientific claims is over. The rest of the population deserves to be protected from the effects of this ignorance. Individual doctors cannot, and should not be expected to, handle this serious problem alone. The government must step in and put an end to this nonsense.

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