Docs 'firing' patients for refusing to be vaccinated? What say you...

[BillKaneEMT]

I can understand your position on this issue Kiwimedic, though I don't personally feel the same. However. If the patient either contracts an illness or suffers ill effects from some problem which may or may not be related to a lack of vaccination you can bet that the parent or guardian will be filing a lawsuit against the child's doctor. The number of malpractice suits against docs and nurses, at least in my area, is insane. I wouldn't have a problem if they changed our rules to be similar to yours provided they abolished any legal recourse against medical providers based on a patients refusal of vaccines, necessary(in the doctor's view) treatments, failure to take meds, bad personal habits, etc.

My grandmother used to work for a judge at the Lake county courthouse before she retired and many of the lawsuits they had filed were far beyond ridiculous. Smoke 3 packs a day, hypertension, high cholesterol, drink like a fish, weigh 580 lbs? Time to sue your doctor because you're having a bimonthly AMI and he isn't making you better! Be sure to file against the cigarette companies, the fast food joints and your local distillery too! It's all their fault, right? Parents don't want to vaccinate their kids? Fine. If the kids get sick because of it then they should be prohibited from blaming anyone but themselves. Of course, taking responsibility for one's own decisions is probably a felony in these parts. I hope the PC police don't come a get me!!! *runs and hides*

[Kiwiology]

I wouldn't have a problem if they changed our rules to be similar to yours provided they abolished any legal recourse against medical providers based on a patients refusal of vaccines, necessary(in the doctor's view) treatments, failure to take meds, bad personal habits, etc.

Such legal protection could reasonably seen as infringing on a patients right to choice of treatment including lifesaving treatment. I understand your thinking there so let me explain how it works here,

New Zealand is unique as the only country in the world to have a totally no-fault compensation system, but we have given up the right to sue to get it. It is almost nearly impossible to sue a health care professional here, we have the Accident Compensation Corporation that is responsible for providing compensation, rehabilitation, support etc as appropriate for treatment injuries or medical misadventure as a result of health treatment (not failure to comply with it).

That is not to say we do not deal with practitioners who are negligent, we have the Health Practitioner Disciplinary Tribunal and Director of Proceedings (a spin-off of the High Court) as well as the appropriate health practitioner responsible authority for disciplining health practitioners up-to-and-including being banned from practising.

A civil suit against a health practitioner can happen for damages over and above what ACC gives you or for emotional anguish or something but it is so difficult to make it work it's totally not worth it.

You might be interested to know that Conrad Murray wouldn't have been able to get propofol here, because he would be registered in the vocational scope of "cardiology" and not "anaesthesia" or one of the vocational scopes approved to prescribe propofol. Michael Jackson would have had to hire a Consultant Anaesthetist or another vocational scope approved to prescribe propofol.

Oh just to add, here a criminal charge can be bought against a Doctor or another health care professional but that is a matter for the Police and the Crown Prosecutor.

My grandmother used to work for a judge at the Lake county courthouse before she retired and many of the lawsuits they had filed were far beyond ridiculous. Smoke 3 packs a day, hypertension, high cholesterol, drink like a fish, weigh 580 lbs? Time to sue your doctor because you're having a bimonthly AMI and he isn't making you better! Be sure to file against the cigarette companies, the fast food joints and your local distillery too! It's all their fault, right?

Such a person here would make a complaint to the Health and Disability Commissioner and they would investigate and be told no fault.

If they looked for medical lawyer to take the Doctor to Court they'd be told "that's $1,000 for my consultation now bugger off you have no case, can we get a forklift to help you down the stairs?"

Of course, taking responsibility for one's own decisions is probably a felony in these parts

Not sure mate, when I was living up large in the Great Nation of Indiana I was south of you, hmm ....

Edited February 18, 2012 by kiwimedic

[BillKaneEMT]

You've given me some great food for thought there Kiwimedic. I'd really enjoy seeing those rules put in place over here, even on a short term basis just to try them out. No doubt there'd be rioting by the poor, helpless, pure as the driven snow frivolous lawsuit crowd; but tear gas is cheap so it'd be a win-win.

Sorry if the end of my post last night came across as bitter. Between the news, internet "docs" whose sole source of info is their meth dealer and who persist in passing out advice, and some work issues...well. I was somewhat irritated last night. Still, I made it home alive and uninjured and now I get to sleep at least half the day away so things are looking up!

[Kiwiology]

You've given me some great food for thought there Kiwimedic. I'd really enjoy seeing those rules put in place over here, even on a short term basis just to try them out. No doubt there'd be rioting by the poor, helpless, pure as the driven snow frivolous lawsuit crowd; but tear gas is cheap so it'd be a win-win.

I am sure such sensible measures would be quickly discredited as "unconstitutional" and end up the subject of much piss-taking (mocking) by Jon Stewart.

Sorry if the end of my post last night came across as bitter. Between the news, internet "docs" whose sole source of info is their meth dealer and who persist in passing out advice, and some work issues...well. I was somewhat irritated last night. Still, I made it home alive and uninjured and now I get to sleep at least half the day away so things are looking up!

Not at all mate, don't worry about it but I must warn you, if you spot a funny talking Kiwi person who swans out the sky on the Lifeline helicopter (if it ever comes north to you) watch out, it might just be me, be sure to get the local farmers turned volunteer fire chief who is over talking to Earl the County Deputy to hog tie me like he does to his swine so I can't cause no trouble, you hear me boy? ....

On the topic at hand, I would be interested to see what our other member Physicians think of it.

[island emt]

I think it's a bit more complex than "whiney" parents in some cases however.

I say that because we have a subgroup of granola crunching isolationist here that don't have their kids vaccinated, Don't allow their kids to go to public schools, relying on "homeschooling or alternative schools, and tend to eat only homegrown foods in fear of contaminates.

Last year they had an outbreak of some mysterious illness among their community members that ended up being some toxic fungus that grew in their storage barrels of backyard ground flour. That incident nearly cost several of their kids lives.

While I have no problems with most of this. They had an outbreak of measles in their little playgroup last fall, and before that it was mumps and scarlet fever.

Why does a Dr. have the need to treat these kids whose parents shun normal medical practice?

Of course when these little darling are really sick they call 911 for us to deal with them and spread these contagious diseases far & wide.

Edited February 18, 2012 by island emt

[Kiwiology]

Why does a Dr. have the need to treat these kids whose parents shun normal medical practice?

Two reasons (1) a patient (or their parent if its a paediatric patient) has the right to decline treatment and/or care and (2) a Physician must not discriminate or deny health care to a patient based on their beliefs

Now depending on which international jurisdiction you are in the wordings and flavour of the above from regulators differ slightly but the same basic principles apply

Just because a patient chooses not to get vaccinated does not mean they are "shunning" medical care but rather they are making a choice about one aspect of the care they or their child receives and to judge them based solely on that choice is not appropriate.

I have admitted to my General Practitioner that I once did not fill a prescriptions she has given me; so should she refuse to see me any more; I mean how is that different than what we are discussing here?

[ERDoc]

I don't have much time to reply, but I will say that the doctor-patient relationship is a two way street. Everyone is entitled to their beliefs but it doesn't mean I have to agree with it and continue to treat you. A doctor and patient have a contract that can be broken by either side. There is nothing unethical about it.

As for the rest this is America, home of the entitled, land of the litigious.

[JPINFV]

Because it is the right of a patient or their parent in the case of a paediatric patient to refuse any treatment or care recommended, including lifesaving treatment?

Because the Physician has a duty of ethics in care towards that patient and must respect the wishes, opinions and beliefs of the patient (or their parents for a paediatric patient)?

Except no one is saying that the physicians should be able to tie down a patient and force administration of a vaccine.

However, why should I put my patients in danger by entertaining the possibility that one day one of my other patients could come in suffering from measles simple because they, or they're parents, drank the anti-vacc cool aid? Don't I have an ethical responsibility to protect my other patients waiting in the waiting room from someone with a communicable disease that could have easily been prevented with a vaccine?

The Medical Council of New Zealand, the Royal New Zealand College of General Practitioners, the Health and Disability Commissioner, the Health Practitioners Disciplinary Tribunal, the College of Kiwiologists and the Centre for the Advancement of Kiwiology in Medicine (1) have all agreed that a doctor-patient relationship may only be ended by the Physician if they are incompetent to treat the patient.

Except that's not what it says. Per your own link, the only requirment is to be able to justify it. There's nothing about the physician becoming incompetent. The only requirment regarding the patient is that the patinet must not need immediate care and has found another physician. That last part can also be wavied, given how the document is written, following a deadline and a breakdown of the patient-physician relationship. Patients cannot hold physicians hostage.

General Medical Council of the United Kingdom in Good Medical Practice (2,3) also states it is ethical only end a relationship with a patient when doctor-patient trust has been broken and only then in rare circumstances, specifically citing theft, assault or violence as specific appropriate examples; it goes to to specifically state that a patient must not be denied access to medical care or discriminated against based on their religion or beliefs.

Paragraph 8 in the first link is simply a standard non-discrimination clause. Discriminating againt patients who drink anti-vacc cool aid is not similar as discriminating against a patient because he is black. There's a legitimate public health risk involved here, including an unncessary risk to the physician's other patients. Furthermore, you're ignoring the last example given as a reason to terminate care, "has persistently acted inconsiderately or unreasonably." It's unreasonable to think that, despite all the evidence to the contrary, that vaccines cause autism.

Doctors' and Patients' Rights and Responsibilities as published by the South African Medical Association (4) also takes the same view; that a doctor has the right to choose their patients but must not discriminate against or decline medical care to a patient because their beliefs differ from their own and that a patient has the right to refuse any treatment if competent.

The physician also has a right to, "To have his/her life protected which includes the right not to be placed in disproportional life-threatening situations."

The Code of Ethics of the American Medical Association (5,6) supports the view taken by the funny-talking, national regulators mentioned previously. Specifically it states a patient may refuse any recommended health-care or treatment but here is where it gets interesting! It states that a physician has a right to end a doctor-patient relationship and does not specify the same cautionary notes as others.

"There may be times, however, when you may no longer be able to provide care. It may be that the patient is noncompliant, unreasonably demanding, threatening to you and/or your staff, or otherwise contributing to a breakdown in the patient-physician relationship."

http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/ending-patient-physician-relationship.page

Key word: noncompliant.

I am not arguing that a Physician should be able to end the relationship with a patient if it is truly necessary for reasons the UK GMC specifies and those like it i.e. assault, theft from the practice or clinic, if the patient is being threatening or if the doctor is retiring etc. Canada warns that such termination again must be "legitimate" and the natural test of such interpretation will come down to the disciplinary bodies or perhaps an additional civil suit in the US and a reasonable person, and indeed a reasonable Physician or at least all the ones I know, would say the reason "Little Molly's mommy didn't want her vaccinated" is not legitimate.

How many of these groups are legitimate disciplinary bodies? In the US, at least, the AMA does not license physicians. They can ask or demand what ever they want, but since my future license to practice medicine doesn't come from them, they can similarly go pound sand.

[systemet]

So many opinions, so little time.... this is a great thread:

* Discrimination is uh... wrong, m'key? A physician deciding not to see Afro-carribeans, HIV patients, or unvaccinated children because they dislike them based on their race, medical conditions, or personal life decisions is not ok. Especially when dealing with children, who don't get to make those decisions themselves but have them thrust upon them by their parents or the state (depending on the given country).

* That being said, if you're a pediatrician, or a pediatric oncologist, as two of the physicians were in the new report cited, and you don't want to risk someone's unvaccinated child bringing in measles (or, I guess, polio, does that still happen?) or mumps, because you have immunocompromised children, or pre-vaccination age children, then I don't think this is discrimination any more than signs at an ICU saying "Please don't visit today if you're feeling unwell". I think the difference between discrimination and sound medical practice is in the intent.

* In a similar vein, I hope that the physician who said "If you don't believe in the fundamental thing we believe in, then you need to go somewhere else", was selectively quoted or misrepresented. I share the frustration that people are willing to reject aspects of science / medicine and then turn immediately to it the minute there's a problem. But I think if someone who doesn't want to vaccinate their child makes the decision to seek medical help it should be provided without prejudice to their personal beliefs, as much as an individual scientist of physician might disagree with them.

* I think parents who don't vaccinate their children are ill-informed. I believe the media presents the anti-vaccine crowd as more credible than they are because it feels it has to present both sides of an argument in an attempt to appear "balanced". But I can respect that they feel they're doing what they feel is in the best interests of their children, as much as I might disagree with them. The kids don't get a choice, and if their parents are already preventing them from being vaccinated, we should do our best to provide care (in situations where other children's safety isn't compromised). I think there are reasonable arguments for rejecting the parents --- but their children shouldn't be doubly punished.

New Zealand is unique as the only country in the world to have a totally no-fault compensation system, but we have given up the right to sue to get it. It is almost nearly impossible to sue a health care professional here, we have the Accident Compensation Corporation that is responsible for providing compensation, rehabilitation, support etc as appropriate for treatment injuries or medical misadventure as a result of health treatment (not failure to comply with it).

As an aside, I don't know the specifics of the New Zealand system, but a number of the Scandinavian countries have similar systems, such as Sweden. There are both negatives and positives to this, as I see it, it enables the medical system to determine how resources should be allocated, and reduces the injury that occurs from unnecessary blanket tests that are designed to prevent against litigation. On the other hand, I think it may increase the risk for individuals with atypical presentations. It's good to be in an overly cautious system that does a lot of unnecessary expensive procedures if they catch your stroke or MI.

The compensation system also only works if you have good public disability care and medical care. It's no good to throw $50,000 at someone if they've now got to get their house retrofitted for a wheelchair, pay for a care aid for 40 hours a week, have a number of expensive follow-up procedures, deal with insurance issues, and live on poverty level disability pay. If your welfare system ensures decent disability care, decent living conditions for the disabled / long-term care, etc. it's easier to have a system like this.

Because it is the right of a patient or their parent in the case of a paediatric patient to refuse any treatment or care recommended, including lifesaving treatment?

This is also an interesting issue here. To what extent should a parent be able to decide for their child, and to what extent should the state be allowed to intervene? The North American tradition tends to be that the child is viewed as property of the parent, and the parent is allowed to dictate and restrict the care provided to a minor based on their religious beliefs and personal preferences. In other countries, including much of Europe, the state has greater rights to intervene, and can ultimately force parents to have their children vaccinated, whether they like it or not.

Both present problems. The state has the legal right to remove children from an abusive home environment, and has a moral obligation to protect them. But the parents also have a legal right to religious freedom, and a general desire to not have the state interfere in their daily lives, and those of their family. It gets very difficult where these two meet.

[Kiwiology]

Everyone is entitled to their beliefs but it doesn't mean I have to agree with it and continue to treat you

Now you know I have much respect for you mate, you seem like an excellent, model Consultant Physician (not like that Dwayne bloke, I don't respect him at all after he made me rescue him from the transvestite hookers in Las Vegas ...) but even you must agree we need to carefully balance the patients' right to choice in their (or their childs) healthcare and the right not to be discriminated against with whatever rights are applicable to you as a Physician in your respective jurisdiction around the subject of choice of patient and terminating having that patient on your book?

Don't I have an ethical responsibility to protect my other patients waiting in the waiting room from someone with a communicable disease that could have easily been prevented with a vaccine?

Sort of, but can't we say the same about Gramps in the waiting room who is hacking up flu droplets because he did not take the antibiotics for his lower lobar pneumonia?

Except that's not what it says. Per your own link, the only requirment is to be able to justify it. There's nothing about the physician becoming incompetent. The only requirment regarding the patient is that the patinet must not need immediate care and has found another physician. That last part can also be wavied, given how the document is written, following a deadline and a breakdown of the patient-physician relationship.

Patients cannot hold physicians hostage.

I provided the wrong link for which I apologise; the correct source is Cole's Medical Practice in New Zeal which does on page 40 state that a physician may terminate a relationship with their patient only when they are incompetent to care for the patient ; see here http://www.mcnz.org....0-%20george.pdf

NB termination of a relationship and discharge are not the same thing as I wondered about that but it seems they're separate

Physicians should not be subject to any law, rule or standard less natural or fair than any other member of the community and should not be "held hostage" but we must carefully balance the right of the patient to have their beliefs and choices respected and whatever right is applicable to the physician that would apply in this circumstance.

Paragraph 8 in the first link is simply a standard non-discrimination clause. Discriminating againt patients who drink anti-vacc cool aid is not similar as discriminating against a patient because he is black. There's a legitimate public health risk involved here, including an unncessary risk to the physician's other patients. Furthermore, you're ignoring the last example given as a reason to terminate care, "has persistently acted inconsiderately or unreasonably." It's unreasonable to think that, despite all the evidence to the contrary, that vaccines cause autism.

I couldn't find that reason on the GMC documents, perhaps I am not looking in the right place or you are referencing another?

Paragraph 38 of Good Medical Practice states a relationship may only be ended in "rare circumstances" citing theft, assault or violence as specific examples; see here http://www.gmc-uk.or...lationships.asp

To the subject of the non complaint patient, if a patient is persistently non compliant with all treatment and is making it impossible for the Physician to treat the patient then I think it is reasonable that the Physician be allowed to find another Physician for that patient because they (the first Physician) is actually incapable of caring for the patient because they are so non compliant.

Not taking a vaccination is not the same thing.

"There may be times, however, when you may no longer be able to provide care. It may be that the patient is noncompliant, unreasonably demanding, threatening to you and/or your staff, or otherwise contributing to a breakdown in the patient-physician relationship."

http://www.ama-assn....lationship.page

Key word: noncompliant.

if a patient is persistently non compliant with all treatment and is making it impossible for the Physician to treat the patient then I think it is reasonable that the Physician be allowed to find another Physician for that patient because they (the first Physician) is actually incapable of caring for the patient because they are so non compliant.

AMA does not license physicians. They can ask or demand what ever they want, but since my future license to practice medicine doesn't come from them, they can similarly go pound sand.

That's a bit snobbish is it not; if your professional association advises against something (whatever it may be) wouldn't is be a bit foolish to tell them to pound sand as you say?

Next minute .... tens of millions of dollars lawsuit; I need me a new private jet

* That being said, if you're a pediatrician, or a pediatric oncologist, as two of the physicians were in the new report cited, and you don't want to risk someone's unvaccinated child bringing in measles (or, I guess, polio, does that still happen?) or mumps, because you have immunocompromised children, or pre-vaccination age children, then I don't think this is discrimination any more than signs at an ICU saying "Please don't visit today if you're feeling unwell". I think the difference between discrimination and sound medical practice is in the intent.

That is a very difficult line to define

I think if someone who doesn't want to vaccinate their child makes the decision to seek medical help it should be provided without prejudice to their personal beliefs, as much as an individual scientist or physician might disagree with them.

I also agree with this and I think this is what various international medical ethics guidelines (or in the UKGood Medical Practice which is the standard) are trying to say. I also interpret that as being a fair standard.

I think there are reasonable arguments for rejecting the parents --- but their children shouldn't be doubly punished.

I think there is a reasonable argument for disagreeing with that parents individual choice but I don't think there is an argument for not providing care to that parents child. I could say oh international evidence supports my view and personally I think it does, but that is how I've chosen to interpret it, certainly the correct guidance from here and the UK seems to make it quite clear.

For some reason I couldn't quote all of systemet's post but regarding our compensation system, clinical need determines what you get here. The treatment injury or medical misadventure compensation provisions from ACC provide what would be awarded in a system which allows you to sue for damages and costs but rather does so in a way that avoids frivolous lawsuits and all that is entailed with that.

We have a pretty darn good system for public disability care which makes the system so much easier to work; a family member is in a wheelchair and got their house and bathroom converted; although they only require minimal assistance that is paid for, they are on disability for life (which is really generously paid here), gets rent assistance and help with any extra costs like new tires for the wheelchair etc. Every hospital appointment or procedure is free (but that's the same for anybody here) so it works very well

To what extent should a parent be able to decide for their child, and to what extent should the state be allowed to intervene?

This is a tricky subject here and there is no clear legal definition; more broadly speaking anybody can refuse care/treatment until found mentally incompetent

My personal view? It is the right of the parents to decide until such time as the child is reasonably capable of deciding for themselves

Oh and to sum up this entire issue, a good piss take .... remember that Pasteur said a disease only infects a susceptible host, so don't become susceptible and there is no need for a vaccine or this whole debate!

Edited February 19, 2012 by kiwimedic