Op-Ed: Treating Families That Don't Immunize

Many doctors complain that the few patients who refuse immunizations put all patients at risk, and some refuse them treatment. New York Times Ethicist Ariel Kaminer addresses the question of whether it's ethical for pediatricians to refuse routine care to families with unvaccinated children.

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NEAL CONAN, HOST:

And now the Opinion Page. Frightened by false reports of the risks of vaccines, some parents decide not to get their children's shots. Frightened by outbreaks of preventable diseases like measles and whooping cough, some pediatricians don't want unvaccinated kids in their waiting rooms. In her latest column, New York Times Ethicist Ariel Kaminer responded to the question: is it ethical for pediatricians to refuse routine care to families that do not immunize their children?

So, pediatricians, what do you think? Give us a call: 800-989-8255. Email us: talk@npr.org. You can also join the conversation on our website. That's at npr.org, click on TALK OF THE NATION.

Ariel Kaminer is the Ethicist at The New York Times magazine. We've posted a link to her latest column "Armchair Ethicist, Flu Season Edition" at our website, and she joins us now from a studio at the newspaper. And nice to have you with us on TALK OF THE NATION today.

ARIEL KAMINER: Thanks. Nice to be here.

CONAN: And like any good dilemma, there seem to be arguments - good arguments - on both sides here.

KAMINER: Indeed. This is a very complicated question. I respond to readers' questions, and sometimes they come in and they seem straightforward, but this is one of those that really opened up, unraveled to reveal a great deal of complexity.

CONAN: And, indeed, the reader could have turned it around. Do pediatricians have an ethical obligation to bar unvaccinated children from exposing the unvaccinated - the vaccinated kids in their waiting rooms?

KAMINER: Indeed, and that gets to one of the primary questions involved here, which is to whom is the pediatrician primarily obligated? Is the pediatrician obligated to each individual patient or to all the patients in his or her practice?

CONAN: And there is the other question of the greater good.

KAMINER: And the greater good, indeed. Thank you. That's another important consideration that the community as a - at large, the community outside the doors of the clinic.

CONAN: And so it is clearly a parent's choice if they choose to - not to immunize their children, but they then take on the role of what you described and others have as free riders. They take advantage of the immunizations that everybody else takes.

KAMINER: That's right. You know, these childhood diseases used to be a daily fact of life, or I guess I should say, fact of death, because burying young children was a common thing. Sometimes a few in each family. Now these diseases are kept at bay, and that is because of vaccines, which don't just keep the individuals safe, they keep the community safe by eliminating the vectors of possible transmission. But it only works if everyone pitches in. Studies show that unless, I believe, it's 95 percent of a population gets the shots for measles, then that disease, even if it's been eliminated in a - in some area, it starts to creep back in.

So whether you believe that vaccines carry a risk of autism or not - and I say believe, because this is not something that's backed up by any scientific findings, but, OK, people do believe that and we have to deal with it. Anyway, whether you believe that or whether you just believe that vaccines are a pain in the neck to get - they make your kid cry and they leave your arms sore and your legs sore, and they might bring on a fever and they take time, you have to take time off from work and all of that, whichever of those camps you're in - we can all agree that there is a very small but real risk inherent with vaccinations. That's true of any medical procedure. It's not - that's not in doubt.

But there's still a much, much, much, much greater risk inherent with huge epidemics, and nobody doubts that, couldn't possibly, you know, hundreds and hundreds of millions of people killed by these diseases that were once so prevalent.

So as a reader wrote in, as a reader said, parents that don't immunize are - they're gaming the system. They're banking on other parents shouldering the risk, while reaping the rewards of herd immunity - risk-free. That's the quote from one of my readers, which I thought was very smart. That, to me, is unethical. It's like enjoying the benefits of national security but just assuming that somebody else can go ahead and put his life on the line to keep you safe which is, by the way, an ethical lapse which I am, myself, guilty.

CONAN: There is also then the question, what is the pediatrician trying to accomplish, presumably trying to persuade those free riders into taking up their burden.

KAMINER: That's right. And I think, in this part of the question, we unfortunately have to get into a bit of speculation, and so leave the realm of statistics and hard evidence and get into speculation. How can a pediatrician be more persuasive? Is it by keeping somebody in her practice and trying to help the family to make a better informed decision and building up a, you know, years, possibly years or more than a decade of trust in the care of a child?

Or is it by making clear to the family that there are real consequences for their actions? And that if they don't - if they don't take these, sort of, minimal safety precautions, then they're not welcome in the practice. And I don't think it's possible, really, to say.

CONAN: And there is then the real consequences. We've seen outbreaks of whooping cough most recently, I think, in Connecticut.

KAMINER: That's right. We've seen outbreaks of these diseases that we once thought were in check. And some of those outbreaks have been traced back very specifically to families that chose not to immunize their children, that then went traveling and got exposed to, in California, there's a case of measles. A kid came back from a trip sick with measles but didn't yet know what it was, went to the doctor, and in the doctor's office came into contact with people who had not themselves been immunized.

I don't know - I'm sorry - I don't know if that's because they had opted out of immunization or because they were not eligible because they had immune problems or whether they were tiny infants who, you know, who were too young to be immunized. But in any case, several of those people came down with measles, which is highly, highly, highly contagious, and they had to be hospitalized. So we have very direct evidence that this does happen and it happens right in the doctor's office.

CONAN: Well, let's get some pediatricians in our conversation. 800-989-8255. Email: talk@npr.org. We'll start with Nina. And Nina's on the line with us from Birmingham, Alabama.

NINA: Hi. I'm actually a family physician, but I treat children in a rural practice in Alabama. And I oftentimes come across parents who don't want their children vaccinated, usually at an early age. Mostly their concern is that too many shots at too little an age just has to be wrong. And it's a topic that's really dear to my heart since I went to medical school in a third world country, and I've seen the consequences of non-vaccination. My approach has been very successful.

Usually, my response will be respectful. I'll tell them that I do respect their decision. They are the parents. They get to make that choice. However, I send them home armed with a lot of data. My resource is usually the CHOPS vaccine education program in CDC. I tell them that if they choose to continue to bring their children to the practice that they will get the same questions at the same visit, and I will remind them at the same - at every visit that they need to be vaccinated.

And I have - I had an overwhelming success within the next well child visit, those parents will come back and choose to get their children vaccinated. So I think for me, it's just being respectful and understanding their concern but being very emphatic at the same time has really been successful.

CONAN: So it works for you?

NINA: It's really worked for me, absolutely. I don't believe children should be non - should not be vaccinated. I - like I said, I've seen a lot of bad consequences. But giving them a little breathing room for maybe a month, a few weeks oftentimes works in our favor.

CONAN: And - go ahead, Ariel Kaminer.

KAMINER: I'm sorry. I think that's interesting also from a perspective of ethics because it kind of points up that it is possible to be - it's possible and desirable to be respectful of other people's choices even when they are not the same as yours without descending to a kind of just total relativism where we say that every choice is equally good. In this case, you think this sounds like you'd think that the choice of non-vaccinating families is not equally good to the choice of vaccinating families.

But you are respectful in the way that you deal with these families and you don't call them kooks, and you don't tell them that they're crazy. And as a result, you win their trust, and they begin to listen to your ideas in addition to whoever suggested to them that they shouldn't be getting a vaccine.

NINA: Exactly. It's more about - I think it's more about making them feel that they're being empowered to make the decision whether - rather than being me being paternalistic and making this decision for them even though I'm really the one who initiated it. So it's worked. It's worked wonderfully.

CONAN: Well, Nina, congratulations. Thanks very much.

NINA: Thank you.

CONAN: Let's go next to - this is Hilda. And Hilda's with us from East Lansing in Michigan.

HILDA: Hello.

CONAN: You're on the air, Hilda. Go ahead, please.

HILDA: I think Nina has the heart of the matter in her. Of course, respect for patients is important. I just wanted to make the point that physicians really are obligated to care for all their patients. It's certainly not the child's fault if the parents have not vaccinated. The child needs the care. But what the physicians might also think about doing is having a separate waiting room if this is a problem of infecting other patients in the waiting room. And, you know, in some countries, pediatricians make house calls. How would that be?

CONAN: Some pediatricians might find it, well, either the idea of another waiting room or house calls is inefficient, so they can't serve as many patients as they can, though I'm sure they would like to.

HILDA: That's right. But that - if that's what it takes to keep their patients healthy, then they might have to think about taking fewer patients.

CONAN: Ariel Kaminer...

KAMINER: I agree. I think that would be - the sort of the simplest solution would be to have separate waiting rooms. But I think that for many doctors, I mean, I know I live in New York City where real estate is always at a premium, and I think many doctors just can't really undertake that. But that would be great if they could.

CONAN: Would it work if you had a infectious day? You know, if you don't take vaccines, everybody could show up on Thursday morning or something like that?

KAMINER: I think the problem is when people come - people who haven't been vaccinated come because they're feeling under the weather suddenly, but - excuse me. I'm coughing. But they don't yet know why they're sick or really if they're sick.

CONAN: Take a moment, Ariel Kaminer, if you will, and clear your throat. We swear to you all she's had her vaccinations. Hilda, thank you very much for the phone call. We're talking about The Ethicist column that appeared in yesterday's issue of The New York Times Magazine. You're listening to TALK OF THE NATION from NPR News. And let's see if we can go next to - this is - we'll try to get Ariel Kaminer back on the line. She's the...

KAMINER: I'm right here.

CONAN: Oh, there you are.

KAMINER: So sorry.

CONAN: And that's quite all right. This happens to everybody. The - is this comparable at all to the situation of, you know, a doctor? There are a lot of patients - doctors tell you, you're doing things that are bad for you. You're drinking too much. You're eating too much.

KAMINER: It's an excellent question, and that's one that a lot of readers raised when we had an online forum about this. I think that this is an inherently different situation than a doctor saying I won't treat you unless you get on a healthier diet or I won't treat you unless you get this or that surgery that I recommend because I absolutely believe that individual patients have the right to make decisions about their own health, and nobody should ever be obligated blindly to follow a doctor's recommendation if it doesn't feel right. That's if it's a matter of their own health.

But vaccinations are not just a matter of your own health. I mean, in this case, of course, it's - directly, it's a matter of your child's health. But even beyond that, it is a matter of community concern. This is a public health issue, and the decision that you make can very, very easily - as we've seen with those cases of measles in California or, as you mentioned, the outbreak in Connecticut can very easily become - have an effect on lots of people around you, especially the very, very young, the very, very old people who are most vulnerable.

CONAN: Let's go next to Fozy(ph), Fozy with us from Fort Smith, Arkansas.

FOZY: Well, hi.

CONAN: Hi.

FOZY: Yeah, I just had a, you know, I'm an emergency room doctor. I'm not a pediatrician (unintelligible) and I don't read The Ethics column in New York Times. My thing is I think pediatricians should see all the kids like the previous caller said. They can separate and put them in different rooms. But what - if we start doing this, I think we need to do the same for flu vaccine, too, and I'm comparing apples to oranges here. But a lot of people don't get them. We recommend it, and they can do the same waiting room, sit, and, you know, they can infect others too. I'm not sure, you know, how good is that. I don't know if your expert can answer that.

CONAN: Well, ethically, is there any difference between the, you know, measles, whooping cough and rubella vaccine and flu?

KAMINER: Well, I'm not an epidemiologist and so I can't really speak to the comparative rates of transmission. But I can say that though for most people, flu, at least in the last few - last many years, flu is generally just a terrible inconvenience, and it's just something really yucky that you get through OK. Obviously, there have been strains of influenza that has killed many, many millions of people.

FOZY: Absolutely.

KAMINER: So, you know, I think that it is important to remember that that, too, is a life-threatening condition.

CONAN: Fozy, thank you.

FOZY: OK. Thank you.

CONAN: Email from Beth. MDs don't punish people for their bad life decisions, i.e., smoking, drugs, et cetera. They will still treat them when they have health issues, even though we all know the risks. Why not in this situation too? Again, because it's not just an individual situation. You're risking the health of others.

KAMINER: Right. I think that this is really a question of trying to keep the community safe in a - sort of in a secondary way but in the primary way. The first question here is, can a doctor choose to limit the exposure that takes place in her own office of her vulnerable patients to potentially life-threatening diseases? And so I don't really think that it's the same as saying I won't treat somebody who smokes because smoking is a known health risk. Or, I won't treat somebody who drinks too much because that's a known health risk. That's just endangering yourself. This is endangering the other patients, and then beyond that, the community at large.

CONAN: You came down on the theory that the patient had to be treated because it's no fault of theirs. What's been the reaction?

KAMINER: Well, the column hasn't been published yet, but we did - prior to the publication of the column, we did have a live online forum in which few hundred readers piled on to talk about the different issues, and I was amazed, as usual, by how many different insights they were able to spring to the issue, but also even within the community of pediatricians. Many, many pediatricians wrote in, some of whom said there is no question that a pediatrician's obligation is to treat a patient like this, and many others who said there is no question that a pediatrician's obligation is to keep somebody like that out of their office where other vulnerable people, patients might be.

CONAN: Ariel Kaminer, The Ethicist for The New York Times. You could find a link to her latest column at our website. Go to npr.org. Click on TALK OF THE NATION. She joined us today from a studio at the newspaper there in New York. Thanks very much for being with us.

KAMINER: Thank you so much.

CONAN: Tomorrow, Joseph Epstein and the value of gossip. Join us for that. It's the TALK OF THE NATION from NPR News. I'm Neal Conan in Washington.

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