Many pediatricians say they would not continue care for families who refuse vaccines

October 03, 2005

CHICAGO - More than one-third of pediatricians say they would dismiss a family from their practice for refusing all vaccinations, according to a study in the October issue of the Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

The rate of unvaccinated children has risen significantly since 1995, according to background information in the article. While most parents continue to believe that vaccination is important, a large number express concern about vaccine safety. Although most parents depend on their pediatrician's advice and counsel in their decision to vaccinate their children, when a parent refuses one or all vaccines the relationship between parent and pediatrician may be weakened. Some pediatricians may choose to end their participation in the care of children whose parents refuse vaccinations, the authors suggest.

Erin A. Flanagan-Klygis, M.D., of Rush Medical College, Chicago, and colleagues surveyed pediatricians who provide routine vaccinations in a primary care setting. The survey included questions on the pediatrician's experience and type of practice; a question asking the pediatrician to rate the importance of the seven most common vaccines; and a set of questions about parental vaccine refusal and the pediatrician's response, including reasons for dismissing a family from the pediatrician's practice.

Of the 302 pediatricians completing the survey, 85 percent (256) reported encountering a family refusal of at least one vaccine during the previous 12 months, the researchers report. Fifty-four percent (162) of pediatricians reported encountering a parent who refused all vaccines. Pediatricians reported that parental reasons for both partial and full refusal of vaccines were similar. The most common reasons were safety concerns, concern at giving multiple vaccines at once, philosophical reasons and religious beliefs.

"In the case of parents refusing specific vaccines, 82 (28 percent) said that they would ask the family to seek care elsewhere; for refusal of all vaccines, 116 (39 percent) of pediatricians said they would refer the family," the authors write. The most important factors for pediatricians in the decision to dismiss families who refuse vaccines were lack of shared goals and lack of trust. There were no significant differences between pediatricians who would dismiss families for vaccine refusal and those who would not with respect to age, sex, number of years in practice or number of patients seen per week.

"Does the practice of family dismissal, in fact, promote or undermine immunization for particular children or children as a group?" the authors write. "Might family dismissal generally damage relationships between pediatricians and families such that parents become less likely to seek or successfully obtain other needed primary preventive services or care for acute or chronic illness? Given the changing climate of confidence in childhood vaccination, future research should address these and other potential implications of practice dismissal in the face of parental vaccine refusal. The answers obtained may provide insight into the influence physician behavior has on the health and welfare of children and communities for many years to come."

(Arch Pediatr Adolesc Med. 2005; 159:929-934. Available pre-embargo to the media at www.jamamedia.org.)

Editorial: Does Immunization Refusal Warrant Discontinuing a Physician-Patient Relationship?

In an editorial accompanying the article, J.W. Hendricks, M.D., of Pediatric and Adolescent Care, L.L.P., Tulsa, Okla., writes: "Dismissing a patient is a rare occurrence for most physicians. I have found a vaccine refusal fowm to be helpful in continuing a relationship with a family who refuses some or all vaccined. The form doesn't (and can't) address issues like 'mutual trust' or 'lack of shared goals for the child.' Although subjective, these two factors often weigh heavier than a simple refusal of recommended care. I feel a straightforward immunization refusal does not by itself damage trust, breach shared goals, or necessarily lead to a 'my way or the highway' confrontation. This is supported by a recent clinical report from the American Academy of Pediatrics Committee on Bioethics. A future survey to tease out these issues would be helpful."

(Arch Pediatr Adolesc Med. 2005; 159:994. Available pre-embargo to the media at www.jamamedia.org.)

For more information, contact JAMA/Archives Media Relations at 312-464-JAMA (5262) or email mediarelations@jama-archives.org.

Media Advisory: To contact Erin A. Flanagan-Klygis, M.D., call Mary Ann Schultz at 312-942-7816. To contact editorial author J.W. Hendricks, M.D., e-mail jwh@pac.pcc.com.
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