Physician Dismissal of Families Who Refuse Vaccination: An Ethical Assessment

Strategies for Improving Vaccine Communication and Uptake

Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.

The Dizziness of Freedom: Understanding and Responding to Vaccine Anxieties

The rise in vaccine hesitancy in high-income countries has led some to recommend that certain vaccinations be made compulsory in states where they are currently voluntary. In contrast, I contend that legal coercion is generally inappropriate to address the complex social and psychological phenomenon of vaccine anxieties.

Kansas Family Physicians Perceptions of Parental Vaccination Hesitancy

Introduction

In the past few decades, patients expressing the idea that vaccines are unsafe or unneeded have been experienced increasingly by physicians and other healthcare providers. Discussions with patients regarding their reasons for vaccine refusals are important, as it may provide information that can be utilized in an intervention to increase vaccination rates and combat the spread of diseases that are making a resurgence in the United States. The main objective of this study was to explore the perceptions of family physicians as to why parents in Kansas may be vaccine hesitant.

Methods

An electronic survey was distributed to family physicians in the State of Kansas via the University of Kansas School of Medicine-Wichita Family Medicine Research and Data Information Office (FM RADIO). Several aspects of physician perceptions regarding patients’ vaccine hesitancy were measured in this study, including vaccines that are most often refused, reasons for refusing vaccinations, as well as what responses physicians employ when presented with vaccine concerns.

Results

The majority of physicians surveyed have experienced vaccine hesitancy or refusal in their practice, and the human papillomavirus (HPV) and flu vaccines were reported to be the primary vaccines refused for children. In addition, physicians reported frequently employing various practices in response to vaccine refusals, including requiring parents to sign a form (40%) and dismissing families from their practice (1.5%). Physician perceptions on the reasons as to why parents/guardians refuse vaccinations also were measured, and the most common response was that parents possess a fear of long-term complications for their children as a result of vaccines (74%). Additionally, the three most commonly refused vaccines were HPV, influenza, and measles, mumps, and rubella.

Conclusion

Physicians must not only deal with time constraints that vaccine hesitant discussions require, but also must try and implement discussions or interventions suited to the varying reasons why parents/guardians refuse vaccines to convince parents of their safety. The results suggested that vaccine refusals by parents/guardians seemed to be affecting Kansas family physicians’ clinics in more than one way. This study could be a useful tool to help physicians better understand why vaccine refusals occur and be able to combat unwarranted concerns about vaccines.

Nurses' Perspectives on the Dismissal of Vaccine-Refusing Families From Pediatric and Family Care Practices

PURPOSE

Dismissal of families who refuse mandated childhood vaccines from pediatric practices has become more common among US pediatricians over the past 2 decades. While nurses (registered nurses [RNs] and advanced practice registered nurses [APRNs]) often are the first health-care professional to encounter parents' vaccine hesitancy and serve as a primary source of information, there are no published data on nurses' perspectives on dismissal as a response to vaccine refusal. This study examined nurses' perspectives on dismissal of vaccine-refusing families from primary care practices.

DESIGN

Cross-sectional survey administered electronically from February to September 2018. Data analysis was conducted from November 2018 to March 2019.

SETTING

Data were collected electronically from a national sample of nurses.

SUBJECTS

A convenience sample of 488 primary care nurses (74% APRNs) was recruited and enrolled in the study through collaboration with 4 professional nursing associations.

MEASURE AND ANALYSIS

A cross-sectional survey was conducted from February to September 2018. We explored correlates of nurses' (n = 488) attitudes toward dismissal by modeling attitude scores as a function of practice and respondent characteristics. We also modeled odds of encountering vaccine refusal and odds of reporting dismissal of a vaccine-refusing family in the last 12 months, each as a function of respondents' practice characteristics.

RESULTS

Eighty-four percent of respondents encountered vaccine refusal in the previous 12 months, and 22% reported that their practice had dismissed a vaccine-refusing family within the previous 12 months. Twenty-eight percent agreed/strongly agreed that they would dismiss or support a decision to dismiss families who refuse all vaccines, and 12% supported dismissal of families for refusal of some but not all vaccines. Thirty-nine percent of respondents disagreed/strongly disagreed with dismissing families who refuse all vaccines, and 50% disagreed/strongly disagreed with dismissal for refusal of some but not all.

CONCLUSION

Almost all nurses working in primary care encounter vaccine refusal, and most consider all Centers for Disease Control and Prevention-recommended childhood vaccines to be important to public health. There is significant polarization of nurses' attitudes toward the appropriateness of dismissal as a response to vaccine refusal. We recommend the development of professional nursing guidelines for responding to vaccine refusal. However, because there are no data on the community health impact of dismissal policies, we recommend further research on outcomes of dismissal policies to inform such guidelines.

Dismissal policies for vaccine refusal among US physicians: a literature review

Childhood vaccination is one of the greatest public health achievements of the 20th century, yet increasingly, parents question the safety of and need for vaccines. This has led to increased rates of vaccine delay and refusal and outbreaks of vaccine-preventable diseases. Physicians struggle with how to respond to families who refuse vaccines, as there are few known effective interventions to convince a family to vaccinate. In the United States, the practice of dismissing families for vaccine refusal appears to be increasing as a strategy for dealing with vaccine refusal. In this review, we review the literature surrounding this controversial practice, starting with the impact that vaccine-refusing families have on medical practices, followed by a review of dismissal policies of US physicians, and ending with a discussion of the ethics of this practice.

Ethical position of medical practitioners who refuse to treat unvaccinated children

Recent reports in Australia have suggested that some medical practitioners are refusing to treat children who have not been vaccinated, a practice that has been observed in the USA and parts of Europe for some years. This behaviour, if it is indeed occurring in Australia, has not been supported by the Australian Medical Association, although there is broad support for medical practitioners in general having the right to conscientious objection. This paper examines the ethical underpinnings of conscientious objection and whether the right to conscientious objection can be applied to the refusal to treat unvaccinated children. The implications of such a decision will also be discussed, to assess whether refusal to treat unvaccinated children is ethically justifiable. The best interests of both existing and new patients are crucially important in a doctor's practice, and the tension between these two groups of patients are contemplated in the arguments below. It is argued that on balance, the refusal to treat unvaccinated children constitutes unjustified discrimination.

Perspectives of public health nurses on the ethics of mandated vaccine education

BACKGROUND

Since 2015, Michigan has required parents who request nonmedical exemptions (NMEs) from school or daycare immunization mandates to receive education from local public health staff (usually nurses). This is unlike most other US states that have implemented mandatory immunization counseling, which require physicians to document immunization education, or which provide online instruction.

PURPOSE

To attend to the activity and dispositions of the public health staff who provide "waiver education".

METHOD

This study reports results of focus group interviews with 39 of Michigan's vaccine waiver educators (37 nurses), conducted during 2016 and 2017, and analyzed in 2018.

FINDINGS

Four themes emerged from analysis of the transcripts of these interviews: Participants had (1) complex and nuanced observations and evaluations of parents' judgments and feelings about vaccines and vaccine education; (2) sympathetic attitudes about alternative vaccine schedules; (3) critical and supportive evaluations of institutional policies and the background political context of immunization education; and (4) consistent commitments to respect parents, affirm their values, and protect their rights.

DISCUSSION

These results show that public health nurses are sensitive to the burdens mandatory immunization education places on families, the motivations for parents' requests for nonmedical exemptions, and the values implicated by personal immunization decisions and government immunization policies. In light of the unique training, experiences, and public reputation of nurses, there is good reason for additional investigation into the roles that nurses can play in immunization education and in vaccine mandate policies, more generally.

Is physician dismissal of vaccine refusers an acceptable practice in Canada? A 2018 overview

Despite robust evidence that routine immunization is effective and safe, some parents refuse some or all vaccines for their children. In 2007, concern that Canadian paediatricians and family physicians might be considering dismissal of vaccine refusers from their practices prompted an ethical, legal, and public health analysis which concluded that dismissal was professionally problematic. We now reassess this important issue in the Canadian context updating ethical, legal, and public health considerations highlighting changes since 2007. In light of the recent strengthening of Ontario's school immunization requirements that include stiffer steps to qualify for a medical, conscience, or religious belief exemption, physicians and health care workers may be under more pressure from vaccine refusers in their practice leading some to contemplate dismissal or even consider no longer offering immunizations at all in their practice. Given the challenges that vaccine refusers may present, we offer an overview for managing vaccine refusal by parents/patients in a medical practice.

Voluntary vaccination: the pandemic effect

Justification of a voluntary vaccination policy in England and Wales rests on tenuous foundations. Two arguments against voluntary vaccination are gaining ground. The first is that globalisation necessitates preparedness strategies for pandemics. Assuming sufficient supply, compulsory vaccination of adults and children constitutes a potential policy option in the context of a severe, vaccine-preventable pandemic outbreak. The second argument is that children have a right to preventive medicine and thus to vaccination. The influence of the UN Convention on the Rights of the Child and its emphasis on parents as the trustees of their children's best interests, and the increasingly global nature of our collective and individual responsibilities with respect to the transmission of vaccine-preventable disease present challenges to the right to refuse vaccination on our own behalf and on behalf of our children. Exploring methods of compulsion and persuasion utilised across Europe, the USA and Australia, this paper argues that necessity and proportionality must be reassessed, and national public health law and policy setting out a graduated and proportionate approach to compulsory vaccination developed as a matter of priority.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.