Author's Response Reply to Dr. Terk.

Abstract

One part of our argument relies on the distinction between requesting inappropriate care (which, per AMA guidance, would make nonacceptance of potential patients permissible) and refusing appropriate care (which would not, by itself, make nonacceptance of potential patients permissible). Vaccine refusers are doing the latter, not the former. Dr. Terk claims this distinction doesn’t make a moral difference. We disagree. First, to be clear, by ‘appropriate care’ we mean the standard of care, defined as minimally competent care; by ‘inappropriate care’ we mean something falling below the standard of care. The distinction we draw—between physicians not offering inappropriate care and physicians tolerating parental refusals of appropriate care—corresponds to the asymmetric roles played by physicians and parents in pediatric decision making: parents are allowed to request and refuse any number of tests or treatments for their child, but how clinicians should respond to such requests and refusals depends on the nature of what is being requested or refused. They should never provide inappropriate treatments, but may sometimes tolerate parental refusal of appropriate treatments, such as when that refusal doesn't pose significant risk of serious harm to the child. Therefore, the mere fact that parents refuse some interventions that are the standard of care is not a sufficient reason to not accept those parents into one’s practice, nor does the clinician’s toleration of such parents constitute inappropriate care. With very few exceptions, the expected harms to a child from parental vaccine refusal are not high enough to justify nonacceptance.Dr. Terk also claims that a clinician who accepts vaccine-refusing families into their practice is “partly responsible for the morbidity or mortality that might arise” from doing so. We disagree. First, if it is lawful for a parent to opt out of one or more childhood vaccines, as it is in most states, it is not clear why the responsibility for the effects of a child being un- or under-immunized should be shouldered by clinicians, rather than by society more generally. Second, if we did consider clinicians to be partly responsible for the morbidity and mortality that might arise from accepting vaccine-refusing families, wouldn't clinicians who refused to accept these families also have to be held responsible for the morbidity and mortality that might arise by vaccine-refusing families going elsewhere? Vaccine-refusing families still send their children to school, take them to the playground, and have playdates. Refusal to accept vaccine-refusing patients essentially forgoes any possibility of changing parents' minds and improving their child's vaccination status. By making no effort, aren’t dismissing or non-accepting clinicians as culpably responsible (or even more culpably responsible) for facilitating transmission of disease than are those clinicians who accept such families in their practice and try to foster trust and behavior change?We thank Dr. Terk for engaging with our piece, and we agree about the fundamental importance of promoting vaccine compliance. We believe the continued acceptance of vaccine refusing families by primary care clinicians best promotes that goal.