THE ETHICS COLUMN
NEW! WE WELCOME DR. JACOB APPEL TO EDUCATION UPDATE AS OUR REGULAR COLUMNIST ON ETHICS AND MEDICINE. Dr. Appel has a BA from Brown University, a JD from Harvard and an MD from the College of Physicians and Surgeons at Columbia University. He has taught Ethics at Brown University.
Unvaccinated Children & the Duty to Warn
By Jacob M. Appel, M.D., J.D.
Despite a strong scientific consensus favoring the health benefits of childhood immunization against serious infectious diseases, approximately 1 in 10 American children remains entirely unvaccinated. In New York State, for example, 89.3 percent of children had received the recommended Measles-Mumps-Rubella inoculation at the appropriate age in 2010—slightly below the national average. Although New York State requires such shots to attend the public schools, exemptions exist for parents who claim “genuine and sincere religious beliefs” against them. While New York does not compel these individuals to vaccinate their children, the choice of so many parents to opt out of well-established public health measures creates an ethical dilemma for physicians.
Shirley Wang of the Wall Street Journal recently reported on the growing trend of pediatricians refusing to treat patients opposed to childhood immunizations. According to Wang, this trend is growing: For example, 30 percent of Connecticut pediatricians surveyed have asked a family to leave care over vaccine refusal. The motivations of these pediatricians include the belief that vaccine refusers are likely to prove incompatible patients and the desire to take a stand on a matter of public welfare. Inevitably, this approach makes it more difficult for vaccinate refusers to find pediatric care at all. While physicians generally have a right to choose their patients, when a large number of doctors decline to perform a particular procedure or treat a particular group of patients, the discretion of practitioners is sometimes curtailed. In theory, if a family proves unable to find a new healthcare provider for unvaccinated children, the current pediatrician may have an ethical duty to continue care to avoid charges of abandonment.
What is rarely discussed with regard to this conflict—but should be—is the duty that pediatricians who treat non-vaccinators have to their other patients. Some children are too young to receive certain vaccines and a small number cannot receive vaccines for legitimate medical reasons. Other children are vaccinated, but the vaccines fail to “take”—leaving them susceptible to infection. If these innocent third parties share waiting rooms with unvaccinated children, they face an increased risk of contracting disease. (Unlike the general risk of exposure upon the streets or even in schools, the risk is likely higher at the doctor’s office—because people, including non-vaccinators, go to a doctor’s office specifically when they become sick.) Unfortunately, the average parent visiting a pediatrician rarely thinks: “I might be sitting next to an unvaccinated patient who will endanger my children.” And there lies the problem.
While parents have every right to endure these “waiting room risks”—which are indeed small—they are also entitled to know what risks they are accepting. Physicians who treat non-vaccinators have an ethical duty to inform all of their patients that they do so. A simple sign in the waiting room reading, “Both vaccinated and unvaccinated children are treated here,” might well suffice. Such a warning would enable all parents to make reasonable and informed decisions about risks and exposures. #
