News & Views: What to Do About Non-Vaccinating Families in Practice

The recent outbreaks of measles have renewed the national discussion about non-vaccinating families and what to do. Many of the media discussions have focused on legal aspects of this question as well as public opinion. Caught in the middle, and now also revisiting their policies because of these pressures, are providers.

We have been asked about what providers should do, and while we are not responsible for making policies, we thought it might be useful to share our position on this with a wider audience than those who specifically requested our input.

To frame the discussion, we will start with two scenarios:

Scenario #1: A parent brings in her child who is visibly ill; you diagnose bacterial pneumonia and prescribe antibiotics. The parent then tells you that she does not believe in the use of antibiotics and is not willing to treat the child.

Scenario #2: A parent brings in her 2-month-old infant who is due for several vaccinations. She tells you that she does not believe in vaccines and does not want her child to be immunized.

What would you do?

In scenario #1, you know that without treatment, this child will likely suffer — possibly even experience long-term sequelae or death. In fact, 1 in 3 children who don’t get antibiotics in this scenario will die. So, chances are you would do everything in your power to change this parent’s mind. Failing that, you would probably call child services.

But what about scenario #2? Would you be as forceful in your arguments? Statistically speaking, the chance of the child getting a vaccine-preventable disease is minute compared to the 1 in 3 chance of death without antibiotics. So, while you might disagree with the parent’s decision, you might not be as forceful in trying to change her mind, and you certainly wouldn’t consider calling child services. In fact, in most states in this country, you wouldn’t have a valid legal reason to do so. Indeed, 48 of 50 states in the U.S. allow religious or philosophical exemptions or both. However, we would argue that your response to scenario #2 should be no less forceful than it would have been in scenario #1 with the difference being that you would not employ legal means to accomplish your goal.

Why stand firm about vaccinations with families who prefer not to vaccinate?

Let’s continue with scenario #2:

This parent brings her child back for the 4-month and 6-month visits during which she continues to refuse immunizations for the child. At 1 year of age, you are notified that the child is hospitalized with pneumococcal meningitis. The child is on life support and although she is expected to survive, she will be severely mentally impaired. She will likely spend the remainder of her life institutionalized as a result of her infection. The last thing you find out is that the strain of pneumococcus that grew from her cerebrospinal fluid is one contained in the vaccine.

This sounds scary, but it is just a hypothetical situation, right? Wrong. This happened. The child ended up at The Children’s Hospital of Philadelphia. The child was born completely healthy; she could have been protected from this infection had she had her vaccinations. Her parents refused immunizations at the 2-, 4- and 6–month well visits. Her life now no longer holds the potential it did on those three occasions when she was seen by a pediatrician who allowed her parents the choice of whether or not to vaccinate her.

The chances are small; it is not likely that you would be this pediatrician. But on that day, someone was. Every single missed opportunity for immunizations is another entrance into the game of Russian roulette. It is for this child — and other children like her — that you are just as forceful as you would be in scenario #1. For the pediatrician who let this child’s parent repeatedly make a bad decision, this child’s face will be one of the faces that will never disappear.

Parents should not have the right to make bad decisions for their children, and given the breadth and depth of data supporting the safety of vaccination, allowing a child to be unimmunized could be argued to be the same as allowing the child to ride in the car unrestrained. Further, when you allow a child to remain unimmunized in your practice, you are in a sense, at least tacitly, agreeing with the parent’s choice. Because vaccines are safe and because unvaccinated people are at greater risk of disease, the oath to “first do no harm” compels vaccination.

What do I say or do to address this issue?

These conversations are tough; a parent who doesn’t want to immunize can be difficult to get to change his or her mind, but here are some tips:

• Be consistent – Make it clear that in your practice choosing not to vaccinate is acting against medical advice. If you have a form, make it a “declination of treatment” form, not an “acknowledgement” of having had vaccine education or discussion.
• Be passionate – Explain that this is what you do for your children or grandchildren, that you are trying to take care of their children, and vaccination is the best way to do that. Explain that anything less is substandard care.
  
  “Let me love your children.”
  
  “Please don’t ask me to send them out into a world that is progressively becoming more dangerous with diseases like measles, pertussis and mumps.”
  
  “Please don’t ask me to practice substandard care.”
• Refuse to continue seeing the child – Every time you see the child and allow the child to leave without the protection of vaccines is one more time that you are sending that child out into the world unprotected. Data suggest that for many parents, a strong position is enough for them to grasp the importance of this issue for you and value your attempts to protect their children. Indeed, one doctor recently shared the following story:
  
  As a practice, we had finally decided to dismiss non-vaccinating families. I had one family who I had been seeing for quite a while trying to convince them to vaccinate. We had discussions every time they had an appointment; I had tried everything I could think of to convince them. The day of their appointment, I was dreading the visit. One of my colleagues and I had talked about the appointment and how much I was dreading “the break-up discussion.”
  
  When the time finally came, I told the mom that our practice had recently made this policy and unfortunately, the family was going to have to find another practice because I was no longer able to see families that did not vaccinate. The mom asked me, "Are you saying that I can’t bring my kids to you anymore?" I responded that yes, unless they were vaccinated, I could no longer see them. She immediately asked me to help get her kids vaccinated. I could not believe it. I had literally tried everything I could think of to convince this family during prior visits. Nothing, I mean nothing, had worked, and then just that fast, when faced with the prospect of finding another practice, she changed her mind.

Medically, vaccines are the best we have to offer. History shows this, statistics show this. Vaccines have saved millions of lives and every time we have looked, we have been reassured that they are both safe and effective. To this day, in Africa some parents still don’t name their children until they have survived measles — too many of them don’t. Vaccines have allowed parents in the U.S. to live without that worry. Be proud of your part in that.