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.

There's no evidence that vaccines are more efficacious on a different schedule, and there's certainly no data on whether this could reduce rates of adverse events, researchers say.

Indeed, it lengthens the time a child could be vulnerable to a disease, or could be a carrier -- a problem for other young patients in a physician's waiting room.

"Some children who are in the waiting room may have not started their vaccination schedule because they are too young or still completing the schedule and so could be exposed to a child who may get the disease due to lack of vaccination," said Siva Subramanian, MD, hospital ethicist and pediatrician at Georgetown University Hospital.

Many doctors blame the ado largely on British researcher Andrew Wakefield, whose studies linking the MMR vaccine with autism were recently discredited.

Lieber says Colorado is particularly troubled as its vaccination rates are among the lowest in the nation, a fact likely attributable to a culture that promotes alternative medicine.

Vaccinations: Great Medical Advance

On the other hand, few Americans see the larger story when it comes to vaccinations -- which researchers agree are one of the greatest medical advances of our time.

"Vaccination has provided relief of diseases such as polio, smallpox, and the various viral -- chicken pox, measles, mumps, rubella, pertussis -- and bacteriologic -- pneumonia, flu, meningitis -- diseases that once plague small children and has contributed in immeasurable ways to the improvement of humanity," Cronan said.

Lieber says he enacted his policy about 11 years ago, "after an unvaccinated family walked into my waiting room with chicken pox." Last week's incident in which a woman with measels flew through Denver put more fuel on the fire for him.

Yet he emphasizes that he's not refusing to see patients.

"I'm begging to treat the patients," he says, "but the parents are refusing to let me."

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