Parents refuse vaccines? Ethical response needed
Many pediatricians feel some distress over parents who refuse to vaccinate their children, says Douglas S. Diekema, MD, MPH, attending physician and director of education at the Treuman Katz Center for Pediatric Bioethics at Seattle (WA) Children's Hospital and professor in the Department of Pediatrics at the University of Washington School of Medicine, also in Seattle.
About 10% of parents refuse at least one vaccine, about 20% either defer or refuse at least one vaccine, and 1-2% refuse all vaccines, estimates Diekema.
Of the 13% of parents following an alternative vaccination schedule, most refused only certain vaccines and/or delayed some vaccines until the child was older, while 17% reported refusing all vaccines, according to a survey of 750 parents of children aged 6 years and younger.1
Health care providers feel an obligation to protect the children in their practice from health risks, and they worry that when a parent refuses to vaccinate a child, they put the child at increased risk of contracting a vaccine-preventable infectious disease, Diekema explains.
In addition, these parents place other children at risk should their own child contract a communicable illness, he says, and there is a sense that these parents are not doing their part to contribute to the protection against the spread of infectious diseases within the community.
Many pediatricians believe that vaccination is one of the most important things a health care provider can do to protect the health of children, and that if a child's parent is unwilling to accept the physician's recommendation about something that central to the practice of pediatrics, "they have essentially rejected the most important thing the provider has to offer," adds Diekema.
Autonomy is issue
It is important for physicians to remember that the medical community and the community of parents who refuse vaccinations are probably thinking similarly about this issue, says Jennifer C. Kesselheim, MD, a pediatric hematologist-oncologist and the chair of the Ethics Advisory Committee at Dana-Farber Cancer Institute in Boston.
"Both parties want to minimize harm and maximize benefit for each child," she says. "In this way, parents and clinicians are on the same page, ethically speaking."
While clinicians usually view the risk of potentially life-threatening infections to be the greater harm, some parents conclude that this risk is quite low since many of these infections have become rare due to the success of vaccines, says Kesselheim.
"Parents therefore come to believe the larger risk of harm may be due to side effects from the vaccines themselves, leading them to refuse immunizations," says Kesselheim.
Providers must remember that ethical decision-making hinges not only on the balance of benefits and harms but also on the principle of autonomy, stresses Kesselheim. "Respect for persons leads us to place high value on the autonomous decision-making of parents on behalf of their children," she says.
Refusal of treatment
A parent can refuse treatment or preventive care for a child as long as the decision to do so does not place the child at substantial risk of serious harm, notes Diekema.
The physician's role when a parent refuses treatment on behalf of a child is to assure that the parent understands the potential consequences of the decision, continue to counsel the parent with the child's welfare as the central concern, and to involve child protective services if the parent has refused a treatment in a situation where doing so places the child at substantial risk of serious harm, he explains.
"The physician has an ethical and legal obligation to independently assure that children do not come to serious harm as a result of parental decisions in the health care realm," he says. Generally speaking, refusing a vaccine does not place a child at substantial risk of serious harm, adds Diekema.
This is the case in a reasonably well-immunized community where there is some degree of herd immunity and where the likelihood of contracting a vaccine-preventable illness is still fairly low, or where the likelihood is that the child would recover from the disease without any lasting harm, says Diekema.
Clinicians do not force parents to accept immunizations and cannot administer them without parental permission, largely to honor the parental right of autonomous decision-making, says Kesselheim.
That said, clinicians are also granted a right to autonomy, says Kesselheim, and are ethically justified in protecting their own professional integrity.
"For this reason, some clinicians refuse to provide care to families who do not immunize," she says. "Just as the clinician cannot compel the parent to accept vaccines, the parent cannot compel the physician to provide care in a setting in which he or she feels unprofessional."
Reference
- Dempsey AF, Schaffer S, Singer D, et al. Alternative vaccination schedule preferences among parents of young children. Pediatrics 2011;128(5):848-856.
Sources
- Douglas S. Diekema, MD, MPH, Director of Education, Treuman Katz Center for Pediatric Bioethics, Seattle (WA) Children's Hospital. Phone: (206)-987-4346. Email: [email protected].
- Daniel S. Kamin, MD, Staff Gastroenterologist, Boston Children's Hospital. Phone: (617) 355-7964. Email: [email protected].
- Jennifer C. Kesselheim, MD, Associate Ethicist and Chair of the Ethics Advisory Committee, Dana-Farber Cancer Institute, Boston. Phone: (617) 632-2423. Email: [email protected].
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