Strong Beliefs About Vaccines Work Both Ways

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Sometimes, Dr. Andrew Lieber has to tell his patients that it just isn't working out.

When parents refuse to vaccinate their children in spite of his efforts to convince them of the benefits of immunity, he reluctantly lets them go.

"By four months, if I can't help you come to terms with the scientific fact that vaccines are helpful, then I've done my job educating you," Lieber, a pediatrician with Rose Pediatrics in Denver, told MedPage Today.

At that point, he'll tell them to find another doctor -- something he has to do "a couple times a year."

"I feel like I have a bigger responsibility to all the other kids walking through my waiting room," Lieber said.

Read this story on www.medpagetoday.com.

More pediatricians appear to be taking this hard-line approach, especially now that parents are making greater efforts to screen doctors for one whose vaccination philosophy matches their own.

According to a 2001 American Academy of Pediatrics survey, 23 percent of physicians reported that they "always" or "sometimes" tell parents they can no longer be the child's pediatrician if they won't get the proper shots.

The Academy doesn't have more recent survey data, but physicians say that they see plenty of their colleagues joining the ranks.

Lieber will sometimes work with parents to adjust the vaccination schedule -- "I'm willing to separate some vaccines by two weeks, whatever I can do to increase vaccination rates is good" -- but if an interviewer comes along wanting to cross all vaccines off the list, Lieber will show them the door.

Few physicians find that this practice challenges their ethics, especially in light of recent outbreaks such as pertussis in California and in certain communities within Brooklyn. Indeed, the American Academy of Pediatrics has in the past deemed it ethical to dismiss patients who refuse to get their children vaccinated, and offers a clinical guideline as well as an online toolkit on how to handle the pertinent issues.

"Physicians, like their patients, are moral agents," says Felicia Cohn, PhD, director of bioethics for Kaiser Permanente in Irvine, Calif. "Any physician may refuse an individual for moral reasons or may conscientiously object to providing particular treatments."

David Cronin, MD, a pediatrician with Medical College of Wisconsin in Milwaukee, says it's "entirely appropriate for a physician to refuse elective treatment to any patient. Being a physician does not obligate one to provide care to 'all comers.'"

Refusing to Treat: Unethical?

Yet others say refusing to treat because of vaccine preference is indeed unethical because it punishes the wrong party. Samuel Katz, MD, of Duke University, says it's not right to refuse seeing a child "because it is the parent who is the problem, whereas the child merits medical care."

Many doctors, like Lieber, reach a type of compromise, in which they take on the apprehensive parent and educate them on the science behind vaccines.

Rajiv Naik, MD, a pediatrician from the University of Wisconsin, said in his practice he's had success "in ultimately getting some of these families to change their minds and vaccinate their children."

But he notes that it required "building a relationship with the families and gaining their trust that I have the child's best interests in mind."

Even if a parent can be convinced to vaccinate, they may want to do so on their own terms, which involves adjusting a CDC and AAP-approved schedule.

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