Agreeing to Care for Unvaccinated Children
March 1, 2025
By Philip R. Fischer, MD, DTM&H
Synopsis: Many primary care clinicians choose not to enroll pediatric patients in their practices when the parents disagree with standard childhood immunization. However, such refusal to provide primary care raises significant controversy and ethical concerns.
Source: Cheung A, O’Leary ST, Temte JL. Deciding whether to accept an unvaccinated child into a pediatric practice. N Engl J Med 2025;392(5):510-512.
A family contacts a primary care physician’s office with the hope of transferring the care of their children to that clinician. Based on parental concern about measles-mumps-rubella (MMR) vaccine and autism, the family has not and will not allow their children to receive MMR vaccines. In addition, the children have and will use a limited schedule for other standard vaccinations.
If you were that primary care clinician (or were advising that primary care clinician), would you accept these children into your practice?
Two experts were asked to evaluate evidence in support of a response to this scenario. The two very different expert opinions were published together in an effort to help clinicians make their own decisions.
Sean T. O’Leary from the University of Colorado points out that this is a common scenario and that approximately half of U.S. practices have a policy for refusing such patients. However, Dr. O’Leary believes there is not good evidence to support excluding unvaccinated patients from a practice.
Specifically, there is not evidence to show: whether children denied care would be more likely to subsequently accept vaccination, where children who are denied care actually would end up receiving care, the effect of refusing to care for the child on the ongoing trust of the denied family in the medical care system, and the effect of denied care on vaccination and vaccine-preventable diseases on the overall community and population. O’Leary reminds readers that the primary obligation of the clinician is to consider the child. Denying care for the child could allow the child to receive no care or inadequate care. Deciding to care for the child could maintain an ongoing relationship that actually might lead to the family eventually accepting vaccines; indeed, there are data showing that vaccine hesitancy and vaccine refusal can be modifiable behaviors. O’Leary also points out that, outside of a known outbreak, allowing an unvaccinated child to be around other children in a waiting room is very unlikely to cause measles to be spread to other children within the clinician’s practice.
Thus, O’Leary agrees with the American Academy of Pediatrics in discouraging exclusion of vaccine-refusing families from a practice, especially prior to endeavoring to engage families in a trusted fashion that might help alter the families’ decisions about vaccination. Thus, O’Leary encourages acceptance of new, non-vaccinating patients into practices based on a lack of actual evidence to the contrary and based on ethical and practical concerns supporting continuing to work to help children and families over time.
On the other side of the discussion, Jonathan L. Temte from the University of Wisconsin supports denying non-vaccinated children from acceptance into a practice. Temte’s opinion is based on ethical standards about one’s duty to care for patients being coupled with consideration of public health, risk to other vulnerable patients, and the social consequences of measles.
Temte thinks back 25 years to his service on a Centers for Disease Control and Prevention (CDC) panel declaring that measles had been eliminated from the United States as a direct result of widespread immunization. Then in 2012, Temte was on a panel that acknowledged the threat to ongoing measles elimination posed by increasing non-vaccination that easily could sustain endemic transmission of measles after measles was introduced from an international traveler.
Measles-containing vaccines are safe and effective; they do not cause autism spectrum disorder or other neurodevelopmental conditions. However, measles illness can have major influences on a population’s morbidity and mortality. Young and immunocompromised children who have appropriately not received MMR vaccine easily could be at risk of measles transmission via aerosol spread in a physician’s waiting area. Temte advises that we consider our ethical responsibility to vulnerable children who could be seriously harmed by another family’s vaccine refusal.
Temte reminds us that the aftereffects of accepting unvaccinated children into a primary care practice can alter the safety of other patients, the quality of care being delivered, professional advancement, job satisfaction by clinicians, moral injury, and burnout. In light of this, Temte says declining care to an unvaccinated patient can be ethical, and, in consideration of clinician outcomes, necessary.
Commentary
Should intentionally unvaccinated children be accepted into a medical practice, primary care or otherwise? Experts disagree; evidence is lacking. The major pediatric professional organization in the United States suggests non-acceptance of these patients be considered only as a last resort. While half of American primary care practices (in one survey) have policies to decline care to non-vaccinating families, fewer clinicians actually have dismissed such patients from their practices.1
In fact, there are several layers to the scenario presented. First, this scenario involved a parent deciding what was best on behalf of a child. For adults deemed incompetent to make medical decisions (as are all young children), courts sometimes impose care for psychiatric and geriatric patients. In addition, the 1984 “Baby Doe Rules” in the United States stipulated that neither parents nor physicians had a right to withhold life-saving care from a child.2
Second, the scenario involved preventive instead of curative care. The preventive use of seat belts and car safety seats is broadly accepted, regardless of parental agreement. At least one state has extended the legal interpretation of the Baby Doe Rules to impose preventive treatment (vitamin K to present hemorrhagic disease of newborns) regardless of parental desires.2
Third, the scenario involved a condition (non-vaccination) that has broad public health implications beyond merely the care and outcome of the specific patient involved. Indeed, as seen during the COVID-19 pandemic, many societies regulate personal behaviors for the good of community health.
Fourth, the scenario involved a primary care practice, and specialty care would be different for specialists providing illness-focused care when preventive interventions sometimes are beyond their scope of practice. Nonetheless, it would seem strange for an infectious disease subspecialist not to express opinions about and even to advocate for standard vaccines.
Fifth, there is an issue of physician autonomy. Should a physician be empowered to decide which specific treatments to endorse and apply? In the context of shared decision-making with patients and families, clinicians can accept a care plan that is reasonable but not the clinician’s preference. Agreeing to care a clinician considers unreasonable or even wrong is more difficult, and Temte points to the moral injury and career dissatisfaction that such agreement might engender. In disparate situations, including antimicrobial stewardship, non-vaccination, abortion, gender-transition surgery, and medically assisted death, there can be discordance between physician beliefs, practice/institution policies, and patient desires. Legal and ethical issues surrounding conscientious provision of care and conscientious objection to care continue to be debated.3
However we each peel away the layers and decide for whom we will care, someone will end up providing at least some care for vaccine-averse patients. Clinicians should have good strategies in mind for how to provide that care in good fashion. A recent study focused in California identified clear gaps in understanding between clinicians and vaccine-hesitant patients.4 Some of these gaps could be bridged by clinicians listening more and by the use of a discussion style known as motivational interviewing.4
Philip R. Fischer, MD, DTM&H, is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
References
- O’Leary ST, Cataldi JR, Lindley MC, et al. Policies among US pediatricians for dismissing patients for delaying or refusing vaccination. JAMA 2020;324(11):1105-1107.
- Isennock SM. The legal limits of parental autonomy: Do parents have the right to refuse intramuscular vitamin K for their newborn? HCA Healthc J Med 2023;4(1):5-11.
- Brummett AL, Hafen T, Navin MC. Principled conscientious provision: Referral symmetry and its implications for protecting secular conscience. Hastings Cent Rep 2024;54(4):3-10.
- Purcell N, Usman H, Woodruff N, et al. When clinicians and patients disagree on vaccination: What primary care clinicians can learn from COVID-19-vaccine-hesitant patients about communication, trust, and relationships in healthcare. BMC Prim Care 2024;25(1):412.
Many primary care clinicians choose not to enroll pediatric patients in their practices when the parents disagree with standard childhood immunization. However, such refusal to provide primary care raises significant controversy and ethical concerns.
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