Are immunization schedules negotiable?

Should parental belief trump the established vaccination schedule?
Should parental belief trump the established vaccination schedule?

With the recent hubbub about vaccinations highlighted in the presidential debate, I'm left to ponder the issue of vaccine schedule negotiation framed within the 4 bioethical tenets: autonomy, nonmaleficence, beneficence, and justice (The University of Washington has a wonderful resource about these and other bioethical principles1). It was disturbing to see 2 physicians on the debate stage waffle on the issue of delayed vaccinations, and I wonder how many of our PA/NP colleagues see vaccination schedules as negotiable.

It's always difficult to say “autonomy trumps justice” or “nonmaleficence trumps autonomy”. These kinds of black-and-white views of bioethics overlook the troublesome but necessary gray areas of ethics. With that noted, it seems reasonable to ask these questions:

  1. Does patient/parent autonomy compel a provider to negotiate with them about providing or delaying vaccines?
  2. If so, what about the infant patient? What about the provider's responsibility to help the patient and  do no harm, which are what nonmaleficence and beneficence are about?
  3. What role does justice play in this process, particularly for the patient who can't speak for themselves? The question becomes, justice for whom? For the public? For the parents? For the patient?
  4. Is it considered “harm reduction” for a provider to work with a skeptical family by compromising on the vaccine schedule for their child?

A timely piece called “Update on Routine Childhood and Adolescent Immunizations” was published in American Family Physician. From its abstract: “Despite the overwhelming success of vaccinations, vaccine delay and refusal are leading to pockets of vaccine-preventable diseases.”2

It's widely believed that many PAs, NPs, and MDs routinely delay the vaccination schedules of children based on the strong feelings of parents, even when the providers believe in the evidence supporting vaccine effectiveness. But is this a reasonable approach? Let's compare this to negotiating with a family that is nervous about antibiotics. Should a provider offer a lower dose if the family has concerns about antibiotics? In this analogy, it seems that such negotiating would be flirting with malpractice. Perhaps negotiating on proven vaccination schedules flirts with malpractice as well.

What makes this issue so complex is the long-held willingness of medical professionals to negotiate other evidence-based treatments based on patient or family beliefs. But as McCormick noted in 2008, even in these instances, there has been a precedent of providing treatment to children regardless of their parents' beliefs.3

This is a tough issue for PAs, NPs, and MDs. But even after considering all the gray area and ambiguity, it is difficult for any medical provider who is committed to science, the health of the patient, and the health of the public to make a strong case for delaying or withholding vaccinations.

Jim Anderson, MPAS, PA-C, ATC, DFAAPA, is a physician assistant in Seattle.

References

  1. McCormick TR. Principles of Bioethics. University of Washington School of Medicine. https://depts.washington.edu/bioethx/tools/princpl.html. October 1, 2013. Accessed October 15, 2015.
  2. Ackerman LK, Serrano JL. Update on Routine Childhood and Adolescent Immunizations. Am Fam Physician. 2015; doi: 15;92(6):460-468.
  3. McCormick TR. Ethical Issues Inherent to Jehovah's Witnesses. Perioperative Nursing Clinics. 2015; doi: 10.1016/j.cpen.2008.04.007.
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