Re: immunization refusal

From: jack syme <>
Date: Wed Nov 16 2005 - 06:59:12 EST

While it is true that part of this issue regards "herd immunity", and how those that refuse immunization are still protected because everyone else takes risks that they are not willing to take, I do not think that is the predominant reason for pediatricians to dismiss families from their practice for doing so.

I think those pediatricians that dismiss families from their practice do so simply out of frustration. The parents that refuse immunization are not neglectful parents, they are well intentioned, well read, and mis-informed, and it is having to battle, over and over again, disinformation regarding vaccines that is the cause of the pediatricians frustration.

And this points to a couple of larger issues. First of all, in the current reimbursement climate, most pediatricians have to see 30 or 40 patients a day just to make ends meet, so do not take the time, or do not have the time, to discuss these issues in greater detail. However, according to this study, there was no significant difference in dismissal between pediatricians based on age, sex, number of patients they see a day, etc.

The other bigger issue is, I think, the erosion of respect for authority in general, and physicians in particular. With so many sources of information out there it is easy to find information that contradicts what the doctor says. The most common reason cited for dismissal was "lack of trust" and "lack of shared goals".

For the record, I do not think that dismissal is an appropriate response to refusal of vaccination.
  ----- Original Message -----
  From: Mervin Bitikofer
  Sent: Tuesday, November 15, 2005 11:20 PM
  Subject: Re: immunization refusal

  The common perception of this seems to be that those foregoing vaccinations are making a selfish decision to avoid personal risks while still enjoying the benefits of living in a society that is largely immunized -- a similar situation to that illustrated by the 'prisoner's dilemma' which itself would make a great discussion here with its possible application to evolution and morality. So if the pediatricians' reasoning for dismissal is to provide extra motivation, hopefully minimizing the numbers of people choosing to refuse it -- this would certainly make sense. But I wonder if the common perception will turn out to be a good one in the long run on these issues. I'm certainly not always singing the praises of modern medicine in general, and I have a hard time dismissing as 'second-class' those who deliberately opt out on this. (And I'm not just saying that because I happen to have a sister whom I believe has not immunized her large family -- for what I assume are probably religious reasons.) When we were getting our own immunized some years ago the DPT shots could cause quite the medical maladies. I think they have since softened the most mischivous ingredients involved. But we didn't make the decision to do it lightly. And it's only in hindsight that we can contentedly know our kids 'survived' that hurdle. 'What doesn't kill you makes you stronger' is an aphorism that applies to a lot of things in life a lot riskier than vaccinations. But I still don't think I could look down on someone who makes that decision differently than we did.

  Isn't there some pretty good research now showing that Native Americans were a pretty healthy bunch over here until the filthy and disease ridden Europeans came over with their army of microorganisms that ended up doing their dirty work for them? The Europeans probably had merciless immune systems necessitated by survival in cities of open sewage compared with a relative healthy and lazy set of immune systems in their native isolation on this side of the puddle. Don't get me wrong -- I still wash my hands like mother taught me, and I'm glad doctors do the same now. But I still have to wonder how much of a long term favor we really are doing our civilization when we aspire to make everything as sterile and disease free as possible. And yet -- what else could we possibly want?


  jack syme wrote:
    I was serious about my question about what were appropriate topics for this forum. I did not imply that what Glenn posted was not appropriate, I was asking what is or is not.

    Michael Roberts suggested medical ethics. I chair our hospital ethics committee so I am always looking into some ethical issue or another. But I had never thought to bring up the issues here, I never really thought they were appropriate. I could bring these issues up from time to time now that I think about it.

    So, to give this a whirl, this is what we discussed at our last hospital ethics committee meeting. Admittedly, there are other medical ethical issues that would be more appropriate for this forum, this is just the most recent issue we were dealing with.

    Many pediatricians say they would not continue care for families who refuse vaccines
    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."
Received on Wed Nov 16 07:02:07 2005

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