Avis Meeks Day, a pediatrician at the Austin Regional Clinic in Texas, examines a girl. Last year, the clinic announced it would no longer accept new patients who aren’t getting fully vaccinated. (Courtesy of Austin Regional Clinic and Leindani Creative)

Pediatricians around the country, faced with persistent opposition to childhood vaccinations, are increasingly grappling with the difficult decision of whether to dismiss those families from their practices to protect their other patients.

Doctors say they are more willing to take this last-resort step because the anti-vaccine movement in recent years has contributed to a resurgence of preventable childhood diseases such as measles, mumps and whooping cough. Their practices also have been emboldened by families who say they will only choose physicians who require other families to vaccinate.

But the decision is ethically fraught. Doctors must balance their obligation to care for individual children against the potential harm to other patients. They must respect parents’ right to make their own medical decisions. And they need to consider the public health consequences of a refusal to treat, which could result in non-vaccinating families clustered in certain practices, raising the risk of disease outbreaks.

Until recently, the American Academy of Pediatrics considered it unacceptable to refuse families for not vaccinating.

Here are some of the most common arguments for and against vaccination. (The Washington Post)

At the large Salem, Ore., pediatric practice where Mark Helm is a partner, clinicians eventually felt that their top priority was to protect their many medically fragile patients, including children with cancer or weak immune systems and infants not yet old enough to be fully vaccinated. Last year, Childhood Health Associates of Salem became the first practice in Oregon to require all of its families to vaccinate their children fully and on schedule for the diseases most easily spread from person-to-person contact.

“Our policy happened because it simply did not seem ‘just’ to permit the kids who could not be vaccinated to face dire risks because another child’s parent ‘disbelieved’ vaccination,” Helm explained. “We did not want anyone to get measles because they passed through our waiting room.”

In response, about a dozen families out of several thousand chose to leave the practice, Helm said. But other doctors’ groups in the community followed Childhood Health’s lead and adopted similar measures. The overwhelming majority of Childhood Health’s families have supported the move, blurting out thanks in person, on the practice’s website and Facebook page.

“These are young parents and they’re saying, ‘I’m so glad about your policy. . . . I don’t understand why people don’t vaccinate their kids,’ ” Helm recalled. “That kind of spontaneous comment did not used to happen.”

After years of meeting hesi­ta­tion or reluctance from parents, he said, “it’s just nice to hear parents say that — that they want their children to be vaccinated.”

Some of the heightened appreciation of vaccines grew out of a 2015 measles outbreak that started at Disneyland in California. A single, unvaccinated child with measles led to the infection of 131 people, many of whom also were unvaccinated. One infected adult who visited several hospitals ended up exposing 98 infants, 14 pregnant women and 237 hospital employees, according to the California Department of Public Health.

Following the Disneyland outbreak, California passed a law that requires almost all schoolchildren to be fully vaccinated to go to school, allowing only some medical exemptions. The debate over the bill helped raise awareness of the dangers of measles and other preventable diseases.

For years, the official position of the AAP was not to dismiss vaccine-resistant families. But recently, the AAP recognized what many individual pediatricians have been wrestling with on an ad hoc basis. This summer, it announced for the first time that dismissal is now an acceptable option if doctors have exhausted counseling efforts.

“We found there was a lot of resentment at the AAP for hanging those of us who did choose to dismiss [patients] out on a limb with no institutional support,” said Jesse Hackell, a Rockland, N.Y., pediatrician and an author of the AAP report. “We felt that it was time for the AAP to recognize that there were many members who did choose this route, and that we were good pediatricians and loyal members.”

The AAP found that pediatricians are increasingly likely to dismiss families who refuse vaccinations. In 2013, nearly 1 in 8 pediatricians reported that they always do so, twice as many as in 2006, according to a study comparing the survey results published this summer in Pediatrics.

Pediatricians say this more systematic and open acceptance of dismissing vaccine refusers is evident in email discussions and in one-on-one conversations at meetings. In addition to the public-health impact, there is also the personal frustration and burnout among providers who have repeated unsuccessful conversations with vaccine refusers, Hackell said.

The changing landscape of vaccine hesitancy is also evident at professional gatherings. At a recent meeting of infectious-disease specialists in New Orleans, experts said many uninformed families are educable if pediatricians take the time to address their specific concerns. Only a “card-carrying minority of anti-vaccine activists who try and convert you” are unlikely to be persuaded, said C. Mary Healy, a pediatrics infectious-disease expert at the Baylor College of Medicine.

Still, only a minority of the several dozen audience members said they would dismiss those families.

“That’s one of the hot-button issues right now,” she said. “While I can see situations where that is the only option, it really should be kept as a last-ditch option.”

(Source: Immunization Action Coalition)

Nevertheless, some doctors say more families seem to want pediatricians to take a firm stand. Gary Marshall, a pediatric infectious-disease expert at the University of Louisville, said the university-run pediatric clinics have been getting telephone calls asking if “we fire patients who refuse vaccines,” he said, because they say if there are unvaccinated children nearby, “they don’t want to bring their kids to the clinic.”

“It’s possible,” Marshall said, “that the tide is turning.”

The modern anti-vaccine movement began in 1998, when a medical journal published a study suggesting a link between vaccines and autism. The study was later revealed to be an elaborate fraud, and scores of studies from around the world since then have shown conclusively that vaccines do not cause autism. Every relevant scientific and medical organization has examined the evidence and concluded that vaccines are safe and effective and that the real danger lies in skipping or delaying them.

Conspiracy theories against vaccines tend to be strongest in politically extreme communities suspicious of modern medicine, such as fundamentalist conservatives or back-to-nature liberals. Green Party presidential candidate Jill Stein has made ambiguous comments about vaccines, and during a televised Republican primary debate, President-elect Donald Trump claimed that vaccines cause autism. Neurosurgeon Ben Carson, who has been mentioned by Trump as a potential secretary of Health and Human Services, has said he would consider alternate vaccine schedules from the current protocol.

Still, the vast majority of parents vaccinate their children fully, leading to a dramatic decline in the rates of severe illness and death from infectious disease.

In Austin, where anti-vaccine sentiment is fierce and the number of students with nonmedical exemptions to school immunization laws has soared statewide in the last decade, one of the area’s largest medical providers adopted a policy in July 2015 requiring pediatric patients to be immunized.

The Austin Regional Clinic is a large, multispecialty practice that includes 70 pediatricians. Relatively few families left the practice as a result, said Alison Ziari, chief of pediatrics. Many families made a point to say how grateful they were. Growing parental awareness of disease risks led one mother to frantically call the clinic, on short notice, to get her son’s immunization records last summer. The boy, not yet old enough to attend kindergarten, was going to a birthday party. The mother hosting the party required all children coming to the party to bring proof of immunization.

Knema Rezaei Bazazidad, a pediatrician at the Austin Regional Clinic, examines Evolet Garcia before updating her immunizations. The Austin Regional Clinic cares for about a third of the pediatric patients in the Texas region. (Courtesy of Austin Regional Clinic and Leindani Creative)

Doctors are finding that having a dismissal policy “forces the tough discussion” with families, and that, in turn, can often change minds, said Claire McCarthy, a pediatrician at Boston Children’s Hospital and a spokesperson for the AAP.

“When you draw this line in the sand — vaccinate or get out — they realize how seriously we feel about it that we’re willing to sacrifice our patients and revenue,” Hackell said.

Part of the underlying problem is that many clinicians and patients are too young to have experienced the deadly illnesses that were common before vaccines were available.

When McCarthy and Helm were in training, for example, a potentially life-threatening bacterial infection known as epiglottitis was common, and often associated with croup, a hacking cough. After effective Haemophilus influenzae type b vaccines were licensed in the late 1980s, “we don’t see epiglottitis any more,” McCarthy said.

Jessica Roth is a firm believer in immunizing her children, now 4 and 2. Roth, 36, the development director for a children’s theater in Louisville, is expecting her third child in March.

“It gives me pause,” she said, referring to parents who refuse to immunize their children, including a distant family member. “I believe in modern medicine and the scientific process. I want to do what I can so my children have the best option for a healthy life.”

When Roth sees mothers in her Facebook moms group asking for doctors who will accept patients who aren’t immunized, she says she makes a mental note “never to go that doctor” if she ever has to change pediatricians.

Her pediatrician, Heather Felton, part of the University of Louisville practice, says doctors are still trying to figure out what their policy should be for vaccine refusers. So far, clinicians have been able to convince reluctant families.

When parents are unsure or reluctant to get their children vaccinated, Felton says her most powerful argument may come from her status not as a doctor, but as the mother of a 2-year-old and a 6-month-old baby.

“I tell them I have two little girls,” Felton said. “I get them all their shots, and I get all of them on time.”