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Responding to parents who refuse childhood immunizations

Deem, Michael J. PhD

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doi: 10.1097/01.NURSE.0000526899.00004.b9
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CHILDHOOD immunization programs have successfully prevented large-scale outbreaks of vaccine-preventable diseases and reduced the rates of severe morbidity and mortality associated with these diseases.1 Despite the clear public health benefits of such programs and the policy mandates that promote them, nurses working in pediatric care continue to encounter parents who refuse recommended childhood vaccines for nonmedical reasons.

Vaccine refusal can be frustrating for nurses, particularly after they've had lengthy discussions with parents about the benefits of keeping a child up to date with immunizations. At times, nurses may wonder if parents who persistently refuse one or all recommended childhood vaccines are calling their clinical competence into question—or perhaps even their commitment to the child's well-being. This can lead to tension in the relationship between pediatric healthcare professionals and families, which can adversely affect the child's care.

Vaccine refusal for medical reasons, such as having a child who's immunocompromised or who's experienced a documented adverse reaction to a particular vaccine, is generally not controversial. But how should we respond to parental refusal of immunizations for nonmedical reasons, such as a religious objection to immunization or a belief that too many vaccines are administered during a single wellness visit? This article reviews some of the ethical questions that arise when parents refuse some or all recommended childhood vaccines for nonmedical reasons, and discusses ways in which nurses and other healthcare professionals can respond ethically and effectively to vaccine refusal.

Should nonimmunizing families be referred to another provider?

When faced with parental refusal of recommended childhood vaccines, some primary care providers (PCPs) are inclined to dismiss the family from their practice or refer the family to another provider. A 2005 study showed that 28% of surveyed PCPs in the United States indicated that they'd dismiss families who refuse specific recommended vaccines, and 39% indicated that they'd dismiss a family that refuses all recommended vaccines.2 A 2011 European study showed similar results: 27% of surveyed PCPs indicated that they believe that parents who refuse all recommended childhood vaccines should seek another provider.3 These data indicate that a significant proportion of PCPs are inclined to dismiss nonimmunizing families, particularly after educational interventions have failed.

We currently possess little data on the perceptions and attitudes of nurses as a distinct group, despite the fact that pediatric nurses frequently counsel families about the benefits of vaccination, administer vaccines to children, and engage in conversation with parents who refuse specific or all recommended vaccines. Accordingly, nurses and primary care teams face decisions about whether to continue to care for a child despite parental vaccine refusal or to discharge the family from practice. While a clinical nurse specialist or NP might be a primary decision maker regarding dismissal of nonimmunizing families, clinical nurses also have important voices in decisions regarding a practice's policy on handling vaccine refusal.

What ethical considerations speak in favor of dismissing nonimmunizing families from one's practice? Perhaps the most compelling reason for dismissal is that continuing care for these families increases the risk of transmission of vaccine-preventable diseases to other patients visiting the clinic's offices, patient rooms, and waiting areas.4 Patients who are too young to receive certain vaccines or who can't receive vaccines for medical reasons are particularly vulnerable. As advocates for the well-being of all their patients, nurses have an obligation to promote a clinical environment that's as safe as possible; continuing to provide care for nonimmunizing families might compromise that effort.

Another concern is that vaccine refusal might lead to tension and distrust between vaccine-hesitant parents and the healthcare team, especially nurses who've invested time, emotion, and effort in establishing this relationship. Frustration over persistent refusal, especially when compounded by anxiety about the well-being of the nonimmunized child and risks to other patients, might adversely affect the nurse's ability to provide a high quality of care to a child.5 In such cases, one might think that it's best for the nonimmunizing family to find another practice.

But is dismissal ethically justified?

There are, however, strong ethical reasons not to dismiss nonimmunizing families from the practice. First, it's important to consider that the focus of care is primarily on the child, who's not responsible for the decisions parents make about immunizations. Cases of vaccine refusal aren't like situations in which a patient is belligerent, abusive, or otherwise poses a serious safety risk to a healthcare professional. In these scenarios, severing the patient-clinician relationship might be warranted. But in cases where parents refuse vaccines, clinicians must remember that the patient isn't the source of frustration in the clinical relationship and that risks are being imposed on the unvaccinated or undervaccinated child. The clinician arguably has even weightier obligations of care to the child, given the child's increased vulnerability.

In addition, the dismissal of a nonimmunizing family won't necessarily lead to better care for the child. Parents might seek out a “vaccine-friendly” provider, or one who shares many of their values. If the child remains unvaccinated or undervaccinated, the dismissal won't have solved the root problem.

Another possible effect of dismissal is the erosion of parents' trust in healthcare professionals, because they might view the dismissal as a breach of professional commitments to patient advocacy and nonabandonment. Feelings of betrayal may disincline parents to seek any other provider for the child, potentially leaving the child without proper pediatric care. Comprehensive pediatric care provides many benefits beyond immunizations, including physical examination and health screening, management of illnesses that are unrelated to vaccine refusal, and early intervention for behavioral or developmental conditions. The exclusion of unvaccinated or undervaccinated children from a practice might have the unintended effect of leaving a child without these additional benefits.5

Broader considerations of justice and professional obligations to healthcare colleagues are also relevant to decisions about whether to dismiss a nonimmunizing family. While dismissal might reduce the risk of transmission of communicable diseases within one's own practice, if that family is established at another practice, this risk is merely transferred to another pediatric population. The transfer of risk, moreover, shifts the clinical burdens associated with care of nonimmunizing families to one's colleagues. In geographic regions with severe shortages of PCPs or comparatively low immunization rates, that burden can be significant.

When we consider the various ethical and practical issues surrounding parental refusal of vaccines, it seems that dismissal of families strictly because of persistent vaccine refusal is neither ethically justified nor professionally responsible.

How do we mitigate risk?

Clinicians are nonetheless justified in believing that parents who refuse specific or all recommended vaccines are denying some benefit to their child while imposing a risk of harm on the child and other patients in the practice. While continuing care for nonimmunizing families, clinicians have a duty to mitigate this heightened risk of harm, even though the risk is only incrementally increased where regional immunization rates are high and disease prevalence is low. To mitigate this risk, some healthcare providers have suggested that unvaccinated and undervaccinated children wear masks while in a clinic's waiting area, or that these patients wait in a vehicle until an examination room is ready.5 While this might reduce other patients' risk of exposure to vaccine-preventable diseases within the clinic, and perhaps even push parents toward vaccine acceptance, clinicians should consider whether such measures would adversely affect the child emotionally and socially, as well as damage the trust between the family and the healthcare team. Perhaps there are other ways to mitigate the risk to other patients that are less likely to produce these harms to nonimmunizing families.

Do we just need to educate?

A common reaction to vaccine-hesitant parents is to view them as needing education about the safety and benefits of vaccines, with the assumption that educational interventions will nudge these parents toward vaccine acceptance. While some vaccine-hesitant parents have misconceptions about vaccine safety, risk, and effectiveness, recent studies show that vaccine-hesitant and vaccine-refusing parents tend to possess more knowledge about the manufacturing, composition, and risks of vaccines than parents who readily accept routine immunization.6,7 Moreover, some evidence shows that vaccine-hesitant parents tend to become less inclined to vaccinate after purely educational interventions, suggesting that vaccine refusal isn't always, or even commonly, the result of a deficiency in knowledge about immunizations.8 These data suggest that a much broader strategy than mere educational intervention must be deployed to advance families toward vaccine acceptance. Let's consider some ways that nurses and other pediatric care professionals might more effectively address vaccine refusal.

Building trust

Trust is often cited as being among the most important factors influencing vaccine acceptance.6,9 When we put aside assumptions about ignorance driving vaccine refusal and choose instead to attune ourselves to individual families' concerns, fears, and beliefs about vaccines, we're likely to have more opportunities for building trusting relationships.

We shouldn't assume that vaccine-hesitant parents already distrust healthcare professionals and aren't open to building a trusting relationship. Instead, we should recognize that a baseline of trust is already present. After all, the parents, however hesitant, are present in the clinic and entrusting healthcare professionals with the care of their child.

Effective and ethical care for children of vaccine-hesitant parents, then, requires an approach tailored to addressing the reasons for vaccine hesitancy applicable to each family. The tailored approach advocated here requires the following skills and competencies.

Carefully listen to parents' concerns. A willingness to listen to parents' concerns about vaccines, as well as taking the time to identify whether these concerns stem from lack of knowledge, confusion, misconception, fear, or previous experience with vaccine injury, will signal to them that the nurse is committed to fulfilling a role of care to their child. Studies of parental attitudes toward vaccines show that vaccine refusal stems from diverse perspectives, including religious beliefs, political views, cultural influences, individual risk assessment, and personal experience of or acquaintance with previous vaccine injury.9,10 Nurses who approach all vaccine-hesitant parents as if they were simply ignorant and in need of education about immunization may come across as condescending, insensitive to parents' real concerns, or dismissive of parents' values. Rather than moving parents toward eventual vaccine acceptance, this education-only approach might instead have the effect of alienating them and weakening bonds of trust between provider and family.

Recognize aligned goals. Parents who refuse some or all vaccines likely share many of the nurse's goals of care for the child. While vaccine refusal might be a rejection of a particular means of promoting a child's well-being and health, nurses can continue to work with vaccine-hesitant parents to promote many other goals of pediatric care.

Practice mindful communication. Effective communication about vaccine benefits and safety goes beyond merely providing information. Tone, body language, and information framing affect how parents receive this information. Maintain an awareness of how you come across to families in these conversations by asking yourself: Am I framing my comments and questions in ways that are judgmental or disapproving of parents' views? Am I condescending or abrasive in my tone? Does my body language signal compassion and concern, or closed-mindedness?

Consider when and how often to educate. A tailored approach to addressing vaccine hesitancy involves discerning when and how often educational interventions should occur. Some vaccine-hesitant parents already know a lot about vaccine benefits, risks, and safety; others don't. The frequency, intensity, and content of vaccine education should vary depending on a family's knowledge base, reasons for refusal, receptiveness to information, and capacity for understanding medical information. Eventual vaccine acceptance might rely more on a family's response to a nurse's compassion and effectiveness in providing comprehensive pediatric care than on a cognitive response to a steady stream of vaccine information at every visit.

Trust that you're being heard. Don't assume that vaccine-hesitant parents are impervious to influence. Many parents who initially refuse specific or all recommended vaccines indicate that their views on vaccination evolve and that they're constantly reevaluating their decisions.10 By building trust with these parents, the nurse's impact and influence on this process may become stronger over time.

The takeaway

While there are grounds for optimism about advancing nonimmunizing and vaccine-hesitant families toward vaccine acceptance, we have no magic bullet against vaccine refusal. Effectively and ethically responding to vaccine refusal doesn't require dismissing families from practice, nor does it involve overlooking the risks that refusal poses to an individual child and to other patients. By showing compassion, patience, and respect to vaccine-hesitant families, and recognizing the actual concerns that result in vaccine refusal, nurses can create a clinical environment in which these families grow more confident in the benefits of childhood immunization.


Head to to catch up on the previous two installments of our new column, Ethics in Action.

Putting ethics into action

Moral distress: A case study


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