Practitioner Refusal to Treat Vaccine-Hesitant Patients in the Office Setting

Patti L. Ellis, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company, Part of TDC Group

Healthcare practitioners continue to face challenges in addressing vaccine hesitancy. Although many practitioners turn to patient dismissal, this action should be considered only as a last resort.

Measles Vaccination Trend

As an example of vaccination trends, declining measles vaccination rates have been correlated with the recent increase in measles infection rates and deaths. Although the U.S. measles endemic was declared eliminated in 2000, measles cases continue. According to the CDC, “During 2000–2022, estimated measles vaccination prevented approximately 57 million deaths worldwide. However, millions of children missed vaccinations during the COVID-19 pandemic, resulting in an 18 percent increase in estimated measles cases and a 43 percent increase in estimated measles deaths in 2022 compared with 2021.”

The most recent statistics reveal that between January 1, 2020, and March 28, 2024, the CDC reported 338 confirmed measles cases, with 97 cases (29 percent) occurring in just the first quarter of 2024. Almost all of these cases involved patients who were unvaccinated or whose vaccination status was unknown.

Despite morbidity and mortality associated with lack of vaccination for many diseases, there has been an increase in the number of vaccine refusals and delays by both adult and pediatric patients.

Ethical and Legal Concerns

Much controversy exists around healthcare practitioners refusing care or dismissing vaccine-hesitant patients and families, as evidenced by the number of articles written on the subject. Consider the ethical and legal implications prior to refusing care or dismissing a patient from your practice.

The American Medical Association (AMA) Code of Medical Ethics provides specific ethical principles for physicians to consider when determining whether to refuse care to an unvaccinated patient. (AMA) Code of Medical Ethics Opinion 1.1.2 Prospective Patients details certain limited circumstances in which a physician may decline to establish a patient-physician relationship with a new patient or to provide care to an existing patient. The opinion states that physicians should not decline patients solely on the patient’s infectious disease status.

The AMA Code of Medical Ethics Opinion 1.1.7 "Physician Exercise of Conscience" recognizes the rights of physicians to act according to their conscience while not violating their professional obligations—such as in the case of a medical emergency in which the physician is expected to evaluate and stabilize the patient regardless of the patient’s vaccination status or the inpatient/outpatient setting. Also, physicians must not discriminate against individuals when entering a physician-patient relationship with a new patient. Physicians have more substantial obligations to patients with whom they have had a long-standing physician-patient relationship.1

Some states have “Right of Medical Conscience” laws. For example, Florida Statute 381.00321 states that a healthcare provider has the right to opt out of participation in any healthcare service on the basis of a conscience-based objection. State laws may specify certain requirements that the practitioner must meet to be compliant.

Patient Safety Strategies

Consider the following strategies when addressing vaccine hesitancy:

  • Before refusing care to or dismissing a patient from the practice, discuss the patient’s (or parent’s or legal guardian’s) fears, answer any questions, and provide education about the importance of vaccination and the risks of not being vaccinated. The American Academy of Pediatrics (AAP), Immunize.org, and CDC.gov provide resources for healthcare professionals and patients/parents. Practitioners can also find free videos on the CDC’s “Immunization and Vaccines” playlist that address the importance of vaccination.
  • Document the discussions and education provided in the patient record.
  • If less drastic measures fail, patient dismissal should be carried out in a manner consistent with state laws to prevent claims of patient abandonment. Refusing care or patient dismissal may prove challenging in rural areas where there is no access to other qualified practitioners. (For more information on this topic, see our article “Terminating Patient Relationships” and our tool Quick Check: Patient Dismissal Process.)
  • If concerns necessitate taking actions to protect other patients and staff in the practice, consider making accommodations, such as patient screening, telemedicine visits (if applicable), curbside visits, scheduling the visit during certain hours of the day, having a designated exam room for unvaccinated patients using fully vaccinated practitioners and staff wearing personal protective equipment, and frequent disinfection of patient care areas.
  • For additional vaccine risk mitigation strategies, see our articles “Reduce Patient Safety Risks With Vaccinations, Including COVID-19” and “COVID-19 and Patient Safety in the Medical and Dental Office.”

Continue to engage with vaccine-hesitant patients, continue to provide other healthcare services, and attempt to modify opposition to vaccines before refusing to care for those patients and families.2

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.


References

  1. McLain EL, McKeon S. May a health care provider refuse to treat an unvaccinated patient? Summer 2022. USLAW Magazine. https://www.uslaw.org/wp-content/uploads/2022/09/USLAW-Magazine-Summer-2022.pdf
  2. O’Leary ST, Opel DJ, Cataldi JR, Hackell JM. Strategies for improving vaccine communication and uptake. Pediatrics. 2024;153(3):e2023065483. doi:10.1542/peds.2023-065483

Resource

  • Garcia TB, O’Leary ST. Dismissal policies for vaccine refusal among US physicians: a literature review. Hum Vaccin Immunother. 2020 May 3;16(5):1189-1193. doi:10.1080/21645515.2020.1724742

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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