The Right to Not Treat

[StephBee]

http://shine.yahoo.com/channel/parenting/pediatricians-turn-away-kids-who-arent-vaccinated-2509592/

Long story short for those who don't want to read the whole article: some docs are refusing to treat kids who aren't vaccinated.

Thoughts?

I actually had a simular discussion in a ethics in the health professions.
As caregivers (or future caregivers) do we have the right to refuse to treat someone? Especially in this case, considering it's not the children who refuse to be vaccinated but the parents who refuse. I had this argument with my aunt recently who is still convinced vaccinations cause autism (which, frankly, I think is rediculous.).

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[KindofBlue]

With the ever rising costs of medical liability insurance, hell yeah..

 

[theseeker4]

http://shine.yahoo.com/channel/parenting/pediatricians-turn-away-kids-who-arent-vaccinated-2509592/

Long story short for those who don't want to read the whole article: some docs are refusing to treat kids who aren't vaccinated.

Thoughts?

I actually had a simular discussion in a ethics in the health professions.
As caregivers (or future caregivers) do we have the right to refuse to treat someone? Especially in this case, considering it's not the children who refuse to be vaccinated but the parents who refuse. I had this argument with my aunt recently who is still convinced vaccinations cause autism (which, frankly, I think is rediculous.).

There is absolutely the right to refuse treatment. With the exception of certain emergencies (and the law varies by locality I am sure) there can and should be no OBLIGATION to treat anyone. We are not talking about being on an airplane and you are the only medical professional who can help someone suffering a heart attack; this is routine care for mild illnesses and well-child checks that these parents will have to find another doctor for. The child is not making a choice to not be vaccinated, but the parent's decision is putting all other patients at that practice in danger, so doctors should absolutely exercise this right to refuse treatment.

 

[autotroph]

I see this as kosher from a logistics perspective:

Look at a doctor's office--lots of kids in and out every day. Any kind of heavily trafficked area is probably going to be a melting pot for contagious diseases. Now imagine kids without their MMR. One comes in with a case of measles and another catches it at the office and brings it back to school with 25 (out of 100) kids don't have their MMR either. You've got a small epidemic at that point. So what is better: treating 1 kid that gets measles because of misinformed parents, or prevent 25 kids from getting measles because of 26 misinformed sets of parents and a clinician that sees patients without MMRs.

Note: Numbers used are completely made up, and are used to demonstrate my point. Unless you can cite more meaningful numbers, don't argue me on them.

 

[theseeker4]

I see this as kosher from a logistics perspective:

Look at a doctor's office--lots of kids in and out every day. Any kind of heavily trafficked area is probably going to be a melting pot for contagious diseases. Now imagine kids without their MMR. One comes in with a case of measles and another catches it at the office and brings it back to school with 25 (out of 100) kids don't have their MMR either. You've got a small epidemic at that point. So what is better: treating 1 kid that gets measles because of misinformed parents, or prevent 25 kids from getting measles because of 26 misinformed sets of parents and a clinician that sees patients without MMRs.

Note: Numbers used are completely made up, and are used to demonstrate my point. Unless you can cite more meaningful numbers, don't argue me on them.

You also can't forget that the vaccinated are also put at risk by the un-vaccinated. While vaccines are extremely effective, they are not 100% effective. Some percentage of vaccinated individuals are still vulnerable to the illness. When the vast majority of individuals are vaccinated, the vulnerable individuals who are either resistant to the vaccine (for lack of a better term) or un-vaccinated are protected because so many people around them are safe from the disease, they are never exposed. When the number of un-vaccinated individuals increases to a point that exposure to someone who is not protected becomes commonplace, epidemics are possible. This makes a decision not to be vaccinated (either because one with no science background still insists it causes autism, or a conspiracy theorist believes drug companies are gouging them for that $10, etc.) dangerous not only for the individual who is not vaccinated, but to everyone, vaccinated or not.

 

[LizzyM]

Physicans do have a right to refuse to take specific patients, or to "fire" patients although they may not discriminate against a class of patients (e.g. announce that they will no longer treat Muslims or Mexicans).

I do see the point of requiring/strongly urging vaccination of all children in the practice according to the guidelines promulgated by the American Academy of Pediatrics and the CDC but I can not for the life of me figure out why the HPV vaccine would need to figure into the mix.... if the pediatric patients are transmitting that in the waiting room, you have a serious problem that won't be solved with immunizations.

 

[Flamen04]

Related question: Do doctors have the right not to treat dangerous criminals (ie. rapists, serial killers, mass murderers) ?

 

[brandonh4]

Maybe we should also refuse to treat black people because they have higher incidence of TB...

I would love to see some actual research showing that non-vaccinated patients demonstrate an actual health risk for other patients in practices... till then, sounds like we are trying to punish the people who went against our conventional dogma.

 

[theseeker4]

Maybe we should also refuse to treat black people because they have higher incidence of TB...

I would love to see some actual research showing that non-vaccinated patients demonstrate an actual health risk for other patients in practices... till then, sounds like we are trying to punish the people who went against our conventional dogma.

Unless you buy the hysteria that vaccines are a scam and don't work (and that many of the diseases that killed millions less than a hundred years ago magically declined on their own, just by random chance coinciding with the introductions of vaccines) do you really need actual research, as opposed to simple common sense, to see why vaccines protect people? I certainly hope there are not documented cases of outbreaks at doctor offices, since we are too late if that has started already. The point is to prevent these outbreaks from occurring, and encouraging vaccination of patients in your practice is the best way to do this. Once a patient refuses to protect themselves, they are putting all of your patients at risk, and as such a doctor has every right to "fire" them from their practice.

As to comparing declining to treat those who refuse vaccination with refusing to treat blacks, that is a race-bating straw man argument. No one is saying "group A on average refuses vaccination more than group B, so no one in group A can be treated here." It is saying on an individual basis, if you refuse vaccination you are a risk to other patients, so you can either be vaccinated or find another doctor.

 

[KinasePro]

Maybe we should also refuse to treat black people because they have higher incidence of TB...

I would love to see some actual research showing that non-vaccinated patients demonstrate an actual health risk for other patients in practices... till then, sounds like we are trying to punish the people who went against our conventional dogma.

Ever hear of "herd immunity"? There's nothing dogmatic about it.

 

[brandonh4]

Unless you buy the hysteria that vaccines are a scam and don't work (and that many of the diseases that killed millions less than a hundred years ago magically declined on their own, just by random chance coinciding with the introductions of vaccines) do you really need actual research, as opposed to simple common sense, to see why vaccines protect people? I certainly hope there are not documented cases of outbreaks at doctor offices, since we are too late if that has started already. The point is to prevent these outbreaks from occurring, and encouraging vaccination of patients in your practice is the best way to do this. Once a patient refuses to protect themselves, they are putting all of your patients at risk, and as such a doctor has every right to "fire" them from their practice. - The children you're refusing didn't make any such decision.

As to comparing declining to treat those who refuse vaccination with refusing to treat blacks, that is a race-bating straw man argument. No one is saying "group A on average refuses vaccination more than group B, so no one in group A can be treated here." It is saying on an individual basis, if you refuse vaccination you are a risk to other patients, so you can either be vaccinated or find another doctor.

The effect is the same, whether you are turning away groups or individuals within a group. I know no one wants to sympathize with parents who have refused vaccinations, but if this does become a nationwide trend, a relatively sizable group of people will suffer without health care. To make it worse, the compromised patients are children who made no wrong choices in life except having parents with eclectic beliefs.

And if you're gonna do that, it would at least be ethical to support your actions with research.

 

[KinasePro]

The effect is the same, whether you are turning away groups or individuals within a group. I know no one wants to sympathize with parents who have refused vaccinations, but if this does become a nationwide trend, a relatively sizable group of people will suffer without health care. To make it worse, the compromised patients are children who made no wrong choices in life except having parents with eclectic beliefs.

And if you're gonna do that, it would at least be ethical to support your actions with research.

http://www.pbs.org/wgbh/pages/frontline/vaccines/view/

In that short documentary, there are examples of long eradicated diseases being re-introduced into "eclectic" Oregon communities because parents refused to vaccinate their children.

 

[LizzyM]

Maybe we should also refuse to treat black people because they have higher incidence of TB...

I would love to see some actual research showing that non-vaccinated patients demonstrate an actual health risk for other patients in practices... till then, sounds like we are trying to punish the people who went against our conventional dogma.

http://www.minnpost.com/healthblog/..._linked_to_misplaced_vaccination-autism_fears

http://www.reuters.com/article/2011/06/23/us-indiana-measles-idUSTRE75M76L20110623

If a kid gets sick and is brought to the doctors' office or the emergency department and while there exposes other children, some with weakened immune systems, what do you think will happen?

What kind of evidence do you require and how would you get that evidence in an ethically acceptable manner?

 

[brandonh4]

http://www.pbs.org/wgbh/pages/frontline/vaccines/view/

In that short documentary, there are examples of long eradicated diseases being re-introduced into "eclectic" Oregon communities because parents refused to vaccinate their children.

I'm off to class so I can't watch it atm =(, but if it is about what you say it is - what I wanted to see was research demonstrating that non-vaccinated patients are health risks to other patients in the waiting room, which is different than what you provided...

 

[brandonh4]

http://www.minnpost.com/healthblog/..._linked_to_misplaced_vaccination-autism_fears

http://www.reuters.com/article/2011/06/23/us-indiana-measles-idUSTRE75M76L20110623

If a kid gets sick and is brought to the doctors' office or the emergency department and while there exposes other children, some with weakened immune systems, what do you think will happen?

What kind of evidence do you require and how would you get that evidence in an ethically acceptable manner?

Observations of so-called "waiting room outbreaks." And obviously, it will be difficult to ultimately attribute it to non-vaccinated patients.

So in the end we're all just guessing, but as a future physician I'd rather take that risk than (at the risk of sounding repetitive) turning away children who did nothing wrong (without evidence).

Edit: And besides, you just made the case for turning away kids with ALL contagious disease...

 

[rxlea]

Just sat in on a meeting at the WHO on global issues of influenza/influenza vaccines...

there is plenty of research out there that indicates adults/children who are not vaccinated can pose a threat to others, particularly immunosuppressed patients. remember that some vaccines do not protect you for your entire life hence the need to be re-vaccinated as an adult with Tdap. Even Hep B titers show a decline in protection over time and some people need to be re-vaccinated for that, too!

 

[theseeker4]

The effect is the same, whether you are turning away groups or individuals within a group. I know no one wants to sympathize with parents who have refused vaccinations, but if this does become a nationwide trend, a relatively sizable group of people will suffer without health care. To make it worse, the compromised patients are children who made no wrong choices in life except having parents with eclectic beliefs.

And if you're gonna do that, it would at least be ethical to support your actions with research.

I am sorry, but I would absolutely risk the individual's ability to find another doctor before I put ALL of my other patients at risk. In the same way, if I had a patient I diagnosed with TB, and despite all my efforts they absolutely refused any treatment for the TB, I would absolutely ban them from my office because of the risk they posed to my other patients, the ones who would actually accept treatment for their conditions. I would do the same if a child had TB and the parents refused to allow them to be treated for it (though I would obviously exhaust all legal options for compelling the parents to have their child treated for the TB).

It is not about punishing the children for the parent's beliefs; I am not talking about turning a child away from an ER even though they have a broken arm. These are routine office visits at primary care practices, and more harm can come to more patients by allowing non-vaccinated patients to mingle with those willing to get vaccines than turning away those who choose to put everyone at risk.

Regarding research, start here http://www.cdc.gov/vaccines/. If you don't think that is sufficient, sorry, I have no interest in spending the time necessary digging up journal articles for you.

 

[BA11]

I have no problem with this

 

[brandonh4]

I am sorry, but I would absolutely risk the individual's ability to find another doctor before I put ALL of my other patients at risk. In the same way, if I had a patient I diagnosed with TB, and despite all my efforts they absolutely refused any treatment for the TB, I would absolutely ban them from my office because of the risk they posed to my other patients, the ones who would actually accept treatment for their conditions. I would do the same if a child had TB and the parents refused to allow them to be treated for it (though I would obviously exhaust all legal options for compelling the parents to have their child treated for the TB).

It is not about punishing the children for the parent's beliefs; I am not talking about turning a child away from an ER even though they have a broken arm. These are routine office visits at primary care practices, and more harm can come to more patients by allowing non-vaccinated patients to mingle with those willing to get vaccines than turning away those who choose to put everyone at risk.

Regarding research, start here http://www.cdc.gov/vaccines/. If you don't think that is sufficient, sorry, I have no interest in spending the time necessary digging up journal articles for you.

That is your guess. And of course it's your right to guess it.

And once again, stop saying that the PATIENT CHOSE ANYTHING. They're kids... mommy and daddy made those decisions.

 

[LizzyM]

Observations of so-called "waiting room outbreaks." And obviously, it will be difficult to ultimately attribute it to non-vaccinated patients.

So in the end we're all just guessing, but as a future physician I'd rather take that risk than (at the risk of sounding repetitive) turning away children who did nothing wrong (without evidence).

Edit: And besides, you just made the case for turning away kids with ALL contagious disease...

So, you are fine with kids transmitting infections to other kids in daycare, in school, and to Auntie's newborn as long as you have evidence that the transmission is unlikely to have occurred in your waiting room? Providing an incentive to parents to have their child vaccinated on schedule (the alternative being that they have to find another provider) keeps kids safe not just in the waiting room but everywhere. We have observations that kids transmit disease "out in the world". What more do you need?


And for turning away kids with contagious disease -- in fact, pediatrician offices do that routinely. If you call and say that your kid has been exposed to chicken pox and now has a lesion, you will be told to KEEP YOUR KID HOME. You will be told not to bring your child to the office. I can so clearly remember the horror of the pediatric staff when word came in one day that a pediatric heart transplant recipient had been exposed to chicken pox (this was before the vaccine was widely available) and was being admitted. The kid was in need of care but there was also a need to keep the kid away from other children to avoid spread of the disease to a very vulnerable population.

 

[theseeker4]

That is your guess. And of course it's your right to guess it.

And once again, stop saying that the PATIENT CHOSE ANYTHING. They're kids... mommy and daddy made those decisions.

If the semantics are that important to you, then feel free to read "the child whose parents chose" as it is obvious that is what we are discussing. I thought it went without saying any more explicitly than I have already that I understand that pediatricians treat children, and children's medical decisions are made by their parents and not by themselves.

 

[brandonh4]

So, you are fine with kids transmitting infections to other kids in daycare, in school, and to Auntie's newborn as long as you have evidence that the transmission is unlikely to have occurred in your waiting room? Providing an incentive to parents to have their child vaccinated on schedule (the alternative being that they have to find another provider) keeps kids safe not just in the waiting room but everywhere. We have observations that kids transmit disease "out in the world". What more do you need?


And for turning away kids with contagious disease -- in fact, pediatrician offices do that routinely. If you call and say that your kid has been exposed to chicken pox and now has a lesion, you will be told to KEEP YOUR KID HOME. You will be told not to bring your child to the office. I can so clearly remember the horror of the pediatric staff when word came in one day that a pediatric heart transplant recipient had been exposed to chicken pox (this was before the vaccine was widely available) and was being admitted. The kid was in need of care but there was also a need to keep the kid away from other children to avoid spread of the disease to a very vulnerable population.

No, I never said I was "fine" with children not getting vaccinated. And yes, I agree there should be incentives for parents to vaccinate their children. But there are probably better ways to do it than turning them away from basic care. And by the way, this sounds like an excellent way to have non-vaccinated children start popping up in emergency waiting rooms for basic care, where I expect there will be an even more vulnerable waiting room.

 

[KinasePro]

Observations of so-called "waiting room outbreaks." And obviously, it will be difficult to ultimately attribute it to non-vaccinated patients.

The burden of proof that pandemic, infectious diseases are highly contagious has already been met and does not need to be extended to the confines of a waiting room. What additional relevant information would such a study provide? We know many of these diseases are communicable in close proximity, be it a playground, the grocery store, a waiting room, or the lunch table. The burden of proof has already been satisfied.

So in the end we're all just guessing, but as a future physician I'd rather take that risk than (at the risk of sounding repetitive) turning away children who did nothing wrong (without evidence).

Also, I don't think turning away these children will actually prevent them from receiving the care they need. Someone will treat them, even if it means taking an expensive trip to the ER. The net effect will just give their parent's a headache by requiring them to a) find another provider and more importantly b) re-evaluate their decision not to vaccinate.

Edit: And besides, you just made the case for turning away kids with ALL contagious disease...

I disagree. All thing considered, a small number of contagious diseases are entirely preventable by vaccination. I think a more accurate analogy would be to refuse providing care for tobacco users (which is still a weak analogy)

 

[autotroph]

No, I never said I was "fine" with children not getting vaccinated. And yes, I agree there should be incentives for parents to vaccinate their children. But there are probably better ways to do it than turning them away from basic care. And by the way, this sounds like an excellent way to have non-vaccinated children start popping up in emergency waiting rooms for basic care, where I expect there will be an even more vulnerable waiting room.

Look at it this way: Those providers are saying "If you don't take steps to help protect the rest of my clients, you are not welcome as one my my clients."

Also, for those of you who don't know--the research that predominantly fueled the anti-vaccine movement (linking vaccines to autism) was retracted because of large-scale fraud and manipulation of data.

 

[Geekchick921]

http://www.minnpost.com/healthblog/..._linked_to_misplaced_vaccination-autism_fears

http://www.reuters.com/article/2011/06/23/us-indiana-measles-idUSTRE75M76L20110623

If a kid gets sick and is brought to the doctors' office or the emergency department and while there exposes other children, some with weakened immune systems, what do you think will happen?

What kind of evidence do you require and how would you get that evidence in an ethically acceptable manner?

Lizzy took the words right out of my mouth (my fingers?)

 

[oldbearprofessor]

I encourage those interested to read this free article in its entirely. I support its message throughout. I do not have a general pediatric practice so I am not affected directly by it in terms of refusing treatment. A family that doesn't want their child immunized in our NICU is not tossed out.

Regardless, the AAP committee on Bioethics does not support discharging a patient from a pediatric practice for this reason.

I think the net benefit to keeping these children in one's practice while working to convince them to immunize their children is the best one. Others disagree and I certainly think they have the right to refuse to treat such children (barring an emergency, etc).

 

[MeowMeowCAT]

Related question: Do doctors have the right not to treat dangerous criminals (ie. rapists, serial killers, mass murderers) ?

Probably, but considering that prisons inmates receive quality free healthcare I am guessing there are plenty of doctors that do not mind.

 

[brandonh4]

I suppose in closing my suggestion would be this:

1) Is there a clearly defined health risk for patients exposed to other non-vaccinated patients in the waiting room? To my knowledge, this data has not yet been presented. It would certainly be a difficult question to answer, but more complicated questions have been answered in the past.
2) If there is a health risk, can it be minimized by certain control procedures: separating patients with greater communicable potential, more consistent and thorough wipe-downs of waiting rooms, etc?
3) If the health risk is absent, not clearly defined, or can be minimized with control, then refusal of treatment is justified only in saying that you are incentivizing parents to vaccinate children. For me, this would not be an acceptable reason to refuse treatment.
4) If there is a clear health risk, should we automatically move to refuse treatment? Would more expansive public education be a better alternative?