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

Abstract

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.

Vaccine Refusal and What to Do About It: a Systematic Review of the Ethical Literature

“…The best interests of the child are also invoked extensively to argue that non-vaccinating families should not be dismissed from medical practices (98, 104,26,75). Here authors note that an unvaccinated child is more vulnerable to vaccine preventable diseases (9,49), practice dismissal limits opportunities to access health care (31,52,56,79,116) and the increased risk of harm from vaccine preventable diseases is transferred to other practices (9,47,49). One paper makes an argument about the consequences of treating non-vaccinating families for general practitioners, suggesting that practices caring for unvaccinated children should disclose this to other patients to minimize medicolegal risks, and should receive legal protection to account for the increased liability and risk of caring for these patients (40).…”

“…These include a health professional's obligation to provide healthcare in the best interest of the child despite the parent's decisions, and to deal with infectious disease as a part of their role (9,26,45,47,56,101). Authors also argue that physicians' obligations exclude enforcing parental accountability through dismissal, especially if that means the child is held accountable for the actions of their parents (47), and that continuing to provide care to a non-vaccinating family does not make the physician complicit in their decision (116).…”

Characteristics of Oklahoma Pediatricians Who Dismiss Families for Refusing Vaccines

“…5,17 Still, some families will not be persuaded to vaccinate, and some physicians have resorted to cease or decline to initiate care for families who wish to refuse or delay vaccines. This practice of patient dismissal is controversial among the medical community, and experts argue against this on public health, ethical, and legal grounds [18][19][20][21][22][23][24][25][26] ; however, patient dismissal continues to be practiced by a significant percentage of pediatricians. 27 There is little literature investigating the behavior and characteristics of physicians who dismiss those who refuse or delay vaccines.…”

Caring for the Vaccine-Hesitant Family: Evidence-Based Alternatives to Dismissal

“…14,15 This is occurring even though many have argued strongly against the widespread adoption of this practice on ethical, legal, and public health grounds in the US and Canada. [16][17][18][19] In 2016, the American Academy of Pediatrics' (AAP) Report "Countering Vaccine Hesitancy" characterized dismissal as acceptable only after careful consideration of the situation, transparency with parents about the risks to their child, and openness about practice policies. 20 Although we are unaware of any recent studies measuring practice dismissal, pediatricians' willingness to embrace dismissal may be increasing after the 2019 measles epidemic.…”

“…First, it is unclear where children go after dismissal, especially given the shortage of primary care providers in North America. 19,20 Second, practice dismissal may paradoxically increase the risk of outbreaks. As increasing numbers of unvaccinated patients cluster in practices tolerant of vaccine delay or refusal, the risks of vaccinepreventable diseases in those practices and communities only increase.…”