It's a situation Northern Virginia pediatrician James R. Baugh says he and his partners find themselves confronting with increasing regularity: A parent, usually a mother, refuses a scheduled immunization because she has read on the Internet that it could cause her baby to develop autism.
"My last patient just did it," said Baugh, who estimates he and his 11 partners each grapple with parents who refuse some or all immunizations about twice a month. Most recently, he said last week, the mother of a 2-month-old said she didn't want her daughter to receive the vaccine against measles, mumps and rubella or any other immunization federal health officials recommend to protect children from childhood diseases, some of them fatal.
Baugh said that in this case he did what he usually does when a parent refuses shots. He referred the woman to a Web site maintained by the Children's Hospital of Philadelphia, a source pediatricians regard as one of the most informative; reassured her that vaccines are safe; and reminded her that multiple studies by prestigious scientific groups have found no evidence that vaccines cause autism. Then he made a follow-up appointment, hoping the mother would change her mind.
"I used to get kind of angry" when parents refused to have their children immunized, Baugh said, "but I've evolved."
His equanimity in the face of what many pediatricians say are persistent myths that circulate on the Internet -- that mercury used as a preservative in childhood vaccines causes autism, that the dangers of immunizations far outweigh their benefits, and that there is a conspiracy by drug companies, doctors and vaccine makers to conceal the harm -- is not shared by other physicians. In a recent study, one of the first to explore the ethically explosive issue, a large number of pediatricians said they would consider "firing" a family that refuses some or all immunizations.
A team of pediatricians from three major Chicago medical centers surveyed more than 300 of their colleagues around the country about their attitudes toward vaccine refusal. Slightly more than half of pediatricians said that in the previous year they had encountered at least one family that refused all vaccines, while 85 percent said they'd had a parent turn down at least one shot.
More surprising to the authors were two findings: 39 percent of those surveyed said they would consider turning away a family that refused all shots -- researchers had expected the number to be about 20 percent -- while 28 percent said they'd think about severing a relationship with a family that refused some shots.
"I think it speaks to a level of frustration among pediatricians," said lead author Erin A. Flanagan-Klygis, a pediatrician and ethicist who practices at Rush Children's Hospital in Chicago. "There is not enough time in the world to address parents' fears in an office visit" -- or even several visits.
Equally surprising, according to the authors, whose study was published in the October issue of the Archives of Pediatric and Adolescent Medicine, were the similarities between "dismissers" and "nondismissers." They found no differences between the two groups in age, sex, number of years in practice or number of patients seen per week.
Finding parents who have been cut loose by their pediatricians for refusing vaccines is difficult. A publicist for Safe Minds, a group founded by parents of autistic children and dedicated to removing mercury from vaccines, said she couldn't locate any. And Barbara Loe Fisher, founder of the National Vaccine Information Center in Vienna, who claims vaccines are unsafe and that her son developed attention deficit hyperactivity disorder and learning disabilities after receiving a booster shot when he was 21/2, said "parents don't want to discuss it with the media because of harassment" by authorities.
Flanagan-Klygis noted that her study was of attitudes toward vaccine refusal, not of physician behavior, so it remains unclear how many pediatricians have actually dismissed patients. Several pediatricians said they had done so, not just for refusing vaccines, but when it was clear that trust had irretrievably broken down.
Termination, a touchy subject in medicine, is seen as particularly problematic in pediatrics because of the fear that helpless children may be deprived of care. Doctors are permitted to sever the relationship, according to the code of ethics promulgated by the American Medical Association, only after giving a patient sufficient notice and as long as other care is available.
"One of the reasons I think we haven't heard more from pediatricians is that [firing a patient] is not seen as a good thing to do," Flanagan-Klygis said. "It happens -- but it also takes a lot to get kicked out of a practice."
"I think [dismissal] should be a last resort," said Douglas S. Diekema, a Seattle pediatrician and chair of a committee on bioethics for the American Academy of Pediatrics. Several months ago the committee recommended that doctors ask parents who refused immunization to sign a waiver saying they have been informed of the risks.
Dismissal is permissible, the committee concluded, "when a substantial level of distrust develops, significant differences in the philosophy of care emerge or poor quality of communication persists."
One of the ironies, Diekema said, is that vaccines have been so successful that they have eradicated from the public memory the devastating effects of childhood illnesses: paralysis from polio, blindness caused by measles, deafness following mumps, and death that resulted from the overwhelming infection caused by Hemophilus influenza.
"I've lost patients to things we immunize against now," said suburban Baltimore pediatrician Daniel J. Levy, who graduated from medical school in 1975.
Flanagan-Klygis said that her interest in vaccine refusal was sparked by the two years she spent working in a private practice in suburban Chicago.
"This came up frequently," she said. One day she asked a family to bring her all the anti-immunization information on which they were relying. She said she sat down and read the books and scrolled through the Web sites. "I was blown away by how false it was," she recalled.
Flanagan-Klygis said she agreed to have a series of meetings with the parents to discuss their concerns and referred them to reputable sources of medical information.
"The upshot was that over a period of six months we talked about it and I told them I really felt strongly about vaccines," she said. Ultimately they worked out a compromise: a revised schedule of shots.
"By entering a dialogue, you allow parents to feel they're being respected," she said. "But what I did takes a lot of time and resources that practices probably don't have." Nor, she added, are insurance companies likely to pay for such appointments.
Baugh, who has offices in Herndon and Fairfax, said that when he asks parents to sign a waiver refusing vaccination, some acquiesce and permit the shots.
One reason he is less affronted by refusal than he might have been 20 years ago, he said, lies in the recent history of vaccines.
"There have been some catastrophes," he said, citing the 1999 withdrawal of RotaShield. The vaccine to prevent the gastrointestinal rotavirus was pulled after it was linked to cases of intussusception, a serious intestinal obstruction.
But that doesn't change Baugh's belief that vaccines are essential, one reason his practice tries to weed out parents who object to them during the prenatal visit. "If they say no vaccines," Baugh said, "we'll say, 'We're not the practice for you.' "
To comment on this article, send e-mail to email@example.com.