Parental rights and decision making regarding vaccinations: Ethical dilemmas for the primary care provider

Authors


  • Disclosures
    The author reports no competing interests.
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Alison Fernbach, RN, MSN, CPNP, Pediatric Oncology, Developmental Therapeutics Program, Columbia University Medical Center, 161 Ft. Washington Ave–IP 7, New York, NY 10032.
Tel: 212-305-7212;
Fax: 212-305-5848;
E-mail: aef2120@columbia.edu

Abstract

Purpose: To discuss the ethical dilemma that a primary care nurse practitioner (NP) must face when parents refuse to have their children immunized.

Data sources: Review of published literature on the topic.

Conclusions: By listening carefully to their concerns, responding honestly, and providing clear information about the risks and benefits, NPs may be able to build trust and to convince once hesitant parents to have their children immunized. For those parents who refuse, NPs may feel uncertain on how to respond. By considering the ethical principles to which they are bound, autonomy, beneficence, and non-maleficence, NPs can work with the parents to decide what treatment is best for the child.

Implications for practice: Providing truthful information to parents and utilizing public awareness through recent discussions in the media and on the Internet may be able to obviate many of the concerns of parents, which may be getting in the way of universal immunization.

On March 7, 2008, CNN Headline News (2008) reported that for the first time in history, the federal government had compensated the family of Hannah Poling, a child with autism, who had recently received her routine childhood vaccines. This case implied that immunizations might have been connected to her development of autism. Hannah Poling was a normal infant and toddler who became ill with viral-like symptoms after receiving nine routinely scheduled immunizations when she was 18 months old. Shortly thereafter, she began displaying signs of autism. Although multiple studies have found no causal relationship between autism and immunizations, and although the federal government has supported these findings, the government agreed that there might be a connection in the Poling case. Emotionally charged situations frequently receive massive attention in the media, engendering the fear that particular immunizations may be linked to lifelong disorders in children.

The purpose of this review of the literature is to explore the reasons parents refuse to vaccinate their children, the ethical issues surrounding the prophylactic immunization of children, and provider strategies to handle parental ambivalence. The epidemiology of vaccine-preventable diseases, immunization statistics, parental reasons for refusal of vaccinations, ethical principles, role of the nurse practitioner (NP), and effective responses to parental refusals will be explored. An extensive review of literature retrieved from Google Scholar, Cochrane, and Pubmed that encompassed the years 2002–2009 is the basis for this review. Keywords used in the search included immunization, ethics of immunizing, parental refusal of immunizing, decision making in immunizing, herd immunity, bioethical principles, and physician attitudes.

Epidemiology

According to the Centers for Disease Control (CDC; National Immunization Program [NIP], 1999), immunizations are one of the 10 greatest public health achievements of the 20th century. For almost 100 years, the United States has utilized immunizations to prevent many of the most common and most harmful infectious diseases. Because of the worldwide implementation of the first effective vaccine, smallpox has been eradicated from the earth (NIP, 1999). As a result of the use of the rubella immunization, congenital rubella syndrome, which may cause heart disease, deafness, and blindness, has become very uncommon. Children with the stereotypical gait, leg braces, iron lungs, and sequelae of poliovirus infection are not seen anymore and parents no longer need to fear this virus. As recently as 15 years ago, the common childhood illness varicella was still causing children to miss school for up to a week and parents to miss valuable workdays. Today, the incidence of this virus has reached a record low thanks to the vaccination (NIP, 1999). In 2006, an immunization was approved to reduce rates of the human papilloma virus (HPV) in girls and young women 9–26 years of age and was the first immunization created to prevent a specific type of cancer (see Table 1 for rates of morbidity from vaccine-preventable diseases).

Table 1.  Impact of vaccines on infectious diseases
DiseasePrevaccine baseline dataAverage annual baseline cases2002 CasesaPercent decrease
  1. aChildren under age 5.

  2. bChildren under age 2.

  3. Note. Adapted from “Childhood Vaccine Finance and Safety Issues,” by Giffin et al. (2004), Quality and Access.

Diphtheria1920–1922175,885   1100.0
H. influenzae Type B1985 20,000 16799.2
Measles1958–1962503,282  37100.0
Mumps1968152,209 23899.8
Pertussis1922–1925147,2718,29694.4
Invasive pneumococcalb1998–199913,330   2700 80.0 
Poliomyelitis1951–1954 16,316   0100.0
Rubella1966–1968 47,745  14100.0
Congenital rubella syndrome1998   823   399.6
Tetanus1922–1926  1314  2298.3

Immunization statistics

Low rates of diseases and high rates of protection against common illnesses would not be what they are today if the majority of the population was not immunized. The CDC (2008) reported that the national childhood immunization rates of routinely recommended immunizations remained at or above record levels. In 2007, 77.4% of U.S. children between 19 and 35 months of age had received the recommended series of immunizations (CDC, 2008). According to the CDC guidelines (2008), the multiseries shot regimen consists of four doses of diphtheria, tetanus, and pertussis; three doses of polio immunization; one or more doses of measles, mumps, and rubella; three doses of Haemophilus influenzae type B; three doses of hepatitis B; and one or more doses of varicella vaccination. Although this regimen requires several visits to the primary care provider, statistics show that a majority of parents consider this an important part of their children's preventative health care, and as a result, fully immunize them.

However, as many as 22.6% of children had not received the recommended series of childhood immunizations in 2007 (CDC, 2008). Reasons for parental refusal are complex: confusion created by the massive quantity of information available that is of variable reliability, a general distrust of the medical profession, and skepticism as to whether scientists and government are being forthright about the issues (Omer et al., 2006). Currently, 48 states allow exemptions for school and daycare immunization requirements on the basis of religion (Johns Hopkins Bloomberg School of Public Health-Institute for Immunization Safety, 2008). In areas where a significant percentage of the population have strong religious beliefs that their children should not be immunized, children were 35 times more likely to contract the measles virus and 5.9 times more likely to contract pertussis than children who were immunized (Omer et al., 2006). More recently, Glanz et al. (2009) reported a 23-fold increased risk for pertussis in vaccine refusers when compared to children of vaccine acceptors. By not being immunized, these children are at a much higher risk of contracting diseases as well as spreading diseases within the community.

Reasons for refusal

There are a number of reasons parents may choose not to immunize their children. Parents reported being concerned that an infant's immune system is too immature to handle immunizations safely (Offit et al., 2002). However, biological aspects of the infant immune response allow infants to respond appropriately to these immunizations. Because of the passive immunity acquired from the mother, the development of B and T cells in utero, and the active immunity responses that the neonate is capable of generating, immunizations do not result in an increased risk of infection soon after immunization. The idea that multiple immunizations weaken the immune system has not been demonstrated by research. At this time, although children are receiving more immunizations, we are exposing them to a lower concentration of antigens than in the past (see Table 2). The short-lived immunosuppression caused by some immunizations does not result in an increased risk of infection (Offit et al., 2002).

Table 2.  The reduction of antigens in vaccines over time
YearVaccineTotal number of immunogenic proteins
  1. Note. Adapted from “Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant's Immune System?”, by Offit, et al. (2002), Pediatrics.

1900Smallpox200
1960Smallpox 3217
Diphtheria 
Tetanus 
1980Diphtheria 3041
Tetanus 
Whole-cell pertussis 
Polio 
Measles 
Mumps 
Rubella 
2000Diphtheria    123–126
Tetanus 
Acellular pertussis 
Polio 
Measles 
Mumps 
Rubella 
Hib 
Varicella 
Pneumococcus 
Hepatitis B 

Lack of funds to cover the costs of the immunizations may deter parents from vaccinating their children. In the United States, immunization coverage is funded by private health insurance, public safety net programs, and out-of-pocket spending. As many as one-half of children aged 0–5 years are covered by private insurance (Giffin, Stratton, & Chalk, 2004). Public programs such as vaccines for children (VFC) cover approximately 35% of children (Giffin et al., 2004). Strict criteria are in place to decide if a child under 18 years of age qualifies for the free vaccines. These include: being uninsured, eligible for Medicaid, Native Americans or Alaskan Natives, or those who receive medical care in federally qualified health centers. Public programs may not cover underinsured children in both private health plans and state-run programs even though their families may not be able to afford preventative care. In addition, although the cost of the vaccine itself may be covered, the cost of administration may not be reimbursed. The cost per injection including nursing time, billing services, nonroutine services, registry use, physician time, supplies, and medical waste disposal averages a total of $11.51. This excludes the cost of the actual vaccine, making vaccinations unaffordable for some children (Glazner, Beaty, & Berman, 2009). The remaining 13% of children are underinsured and have private insurance that does not cover immunizations. Some private insurance programs require deductibles and copayments for immunization administration. Although this amount is typically small, the cost to society increases when multiplied by a large number of children (Giffin et al., 2004). This small individual cost may be a significant barrier to immunization.

Another reason parents are hesitant about immunizing their children is a result of the biased presentation in the media or Internet of the evidence of immunization protection and the adverse side effects (Serpell & Green, 2006). We have most recently seen this phenomenon with the publicity regarding the safety of measles, mumps, and rubella immunization and its unproven relationship to autism. Because the numbers of adverse events are proportional to the rates of immunization, higher immunization rates will reduce the incidence of preventable diseases, while at the same time result in higher numbers of adverse events. As a result, the apparent frequency of adverse events related to immunization will increase and may result in sensationalist public reporting of these adverse events. Evidence shows that parents weigh the perceived risks of immunization-preventable diseases against the risks of adverse events caused by immunizations. If the seriousness of immunization-preventable diseases is underestimated, then this may reduce the rates of vaccine administration. Because the rates of many immunization-preventable diseases are so low, parents might consider these diseases trivial (Niederhauser & Markowitz, 2007). The extremely serious, yet rare, adverse events caused by immunizations might play a disproportionate role in the decision-making process leading to parental decisions to withhold immunization. There is also evidence that some parents consider the possible risks resulting from the immunization to be more serious than those from the actual disease. Consequently, some parents are opposed to immunizing their children and by doing so, they significantly underestimate the possible consequences of acquiring contagious diseases (Serpell & Green, 2006).

Additional reasons for parental refusal include the violation of religious principles and the low level of trust in the government. (Refer to Table 3 for a summary of studies on immunization refusal.)

Table 3.  Summary of studies on refusing immunization
ReferencesSampleDesignResult
Benin, Wisler-Scher, Colson, Shapiro, & Holmboe (2006)33 Mothers, 1–3 days postpartum, and again 3–6 months postpartum, ethnicity not specifiedQualitative, open-ended interviews•The theme of trust influenced the decision making of new mothers about vaccinations.
•Those who intended to vaccinate their children reported trusting their pediatrician and feeling satisfied by the discussion they had with the doctor. These mothers also wanted to adhere to the social contact and not diverge from the cultural norm.
•Mothers who did not intend to vaccinate reported feeling alienated by a pediatrician and strongly influenced by a person close to them who did not support immunizations. They also expressed concern about side effects that might create permanent damage, challenging the possible severity of vaccine-preventable diseases, and believing their child is not at risk.
Fredrickson et al. (2004)Part 1: 32 focus groups of parents and providers. Part 2: 544 physicians, pediatricians, and nurses who immunize children, no gender or ethnicity specifiedDiscussion groups, questionnaire•The most common reasons for parents’ refusal were:
 Fear of side effects, religious and philosophical
reasons, belief that the disease was not harmful, and antigovernment sentiment.
•More efficient communication between parents and providers is needed to address these concerns.
Glazner, Beaty, Pearson, & Berman (2004)12 practices (4 pediatric practices, 4 family practices, 4 public health agencies) in rural and urban Colorado, gender and ethnicity not specifiedSelf-report•The decline in reimbursement for the cost of immunizing in private practices suggests that practitioners will refer to public agencies, which may result in a decrease of high nationwide immunization rates.
Keane et al. (2005)4115 parents of children < 16 years, from across the United States with participant selection constructed to match the U.S. consensus on demographic and geographic variables, gender and ethnicity not specifiedClosed-set questionnaire•The majority of parents believe vaccinations are important and generally safe.
•Parents who were convinced of the benefit of vaccines were the most well educated and affluent.
•Cautious parents had the lowest mean income and education level.
•Relaxed parents were less likely to have their children vaccinated and tended to be higher than average socioeconomically.
•Unconvinced parents had little trust in information about vaccines provided by healthcare providers, government sources, school, insurers, and managed care organizations.
Salmon et al. (2005)277 parents of children with nonmedical vaccination exemptions, 976 parents of fully vaccinated children. Gender and ethnicity not specifiedCase-control study, survey questionnaire•Rates of nonmedical vaccination exemptions are increasing.
•The most common reason stated by parents requesting nonmedical vaccine exemptions was concern that the vaccine might cause harm, especially the varicella vaccine. These parents reported feeling vaccines were unsafe and ineffective, lack of trust and faith in the government, and a lack of belief that the diseases were relevant to their children.
•Efforts must be made to educate parents, especially those requesting exemption, of the value and safety of immunizations.
Zimmerman et al. (2005)78 vaccine critical sitesStructured web search, sites analyzed for design, content, and allegations•Vaccine critical websites were found to link vaccinations with multiple sclerosis, autism, and diabetes.
•Vaccine critical websites also reported: Vaccines contain contaminants resulting in adverse
events
 Vaccines provide only temporary protection
 Allegations of conspiracies to hide the truth about
vaccine safety
 Accusations that civil liberties are being violated by
mandatory vaccinations

Ethical principles

When analyzing the ethical dilemma of immunization refusal by parents, it is important to consider the responsibility of the NP in providing health care for a child and the family. Within the scope of their practice, all healthcare providers are bound by certain ethical principles, including autonomy, beneficence, and nonmaleficence. By referring to these principles (Beauchamp & Childress 1994), providers and parents should theoretically be able to work together to reach consensus.

It is the role of the pediatric provider to make appropriate treatment decisions consistent with ethical principles. Every person, including the parent, provider, and, if age appropriate, the child, has a unique ethical spectrum and value set that must be taken into account when dealing with the situation of parental refusal to immunize. Pediatric providers have the responsibility to protect children in our society from harmful diseases, and one way to do so is through immunizations. However, in the eyes of the parent, the immunization may be seen as potentially harmful to a perfectly healthy child. These vaccinations have proven to be extremely effective in controlling disease and mortality; however, they are not completely free of harmful side effects. Although adverse effects are very rare, they are serious and can be seen as very frightening to parents (Beauchamp & Childress, 1994).

In addressing the ethics that shape modern medicine, it may be challenging to apply these principles to children. Depending on their age, children may not be able to speak, understand these concepts, or even consider how their decisions may affect their future. As a result, the application of these principles becomes problematic and the decision of what is best for the child may fall into the hands of the parents, healthcare provider, or sometimes the court. Determining who should ultimately decide what is best for a child may result in conflict among those who each feel they have the child's best interest in mind. As the three principles are explored, they can be integrated and applied to address the problem of vaccine refusal.

Autonomy

The first concept, autonomy, which grants independence and freedom to choose the course of action, allows each person to decide what is best for him (Halperin, Melnychuk, Downie, & MacDonald, 2007). Many young children are not deemed competent and lack the understanding to make a choice with lifelong implications (Baines, 2008). It would be unreasonable to assume that an infant or child could make an autonomous decision to be immunized.

Who is morally designated to make such decisions for the child? As suggested by Baines (2008), parents may not have autonomy over the decision, but they do have parental authority, and because of this right, we must not exclude them from the decision-making process. As children become adults, they gain understanding but not the legal right to make autonomous decisions; therefore, for children, it is the parents’ responsibility and right to make medical decisions about immunizations. Although the risk of being unimmunized does not place a particular child at much risk, based on the concept of herd immunity, society does have a stake in protecting public health. This is not to say, however, that a parent's opinion automatically decides treatment. Each case must be examined individually to decide what is best for the child and the community.

Beneficence and nonmaleficence

The principle of beneficence implies the moral obligation of the primary care provider to benefit and help others, while that of nonmaleficence is the corresponding negative principle suggesting “first do no harm” (Swain, Burns, & Etkind, 2008). When applied to immunizations, there are two opposing views that must be examined: the benefit and harm of the immunization on the child as an individual versus the benefit and harm of the immunization on the community. The first considers the best interest of the child, in which the benefits of the intervention must outweigh the potential harms caused by the intervention, while the second evaluates the benefits to public health, where the general society will primarily benefit rather than the individual, who may in fact be harmed (Hodges, Svoboda, & Van Howe, 2002).

Immunizations may be seen as beneficial to both the individual and the community in several ways. The immunizations recommended for children are considered to be legitimate prophylactic procedures. First, the danger to the public, if these highly contagious diseases were to spread, is substantial and may result in severe mortality and morbidity. Second, if transmitted, the diseases have the potential to cause serious harm to each individual and immunizations are used to prevent this. Third, the effectiveness of these immunizations in protecting the public against diseases has been proven and is well established. Because neither the structure, appearance, nor the function of any body parts are altered by an immunization, the burden to the individual is minimal (Hodges et al., 2002).

Regarding the potential to harm, some may be concerned about the invasiveness of a needle in a child and the pain it might cause. However, immunizations are one of the least invasive means of preventing contagious diseases. In addition, the pain resulting from the injection is usually minimal and can be relieved by acetaminophen and other strategies including topical local anesthetics, sweet-tasting solutions, and breastfeeding (Shah, Taddio, Rieder, & HELPinKIDS Team, 2009). Some may also argue that by causing pain or potential harmful side effects to a perfectly healthy individual, we are violating the principle of nonmaleficence. In addition, by making immunizations mandatory, it can be argued that a person's individual rights are being violated.

Immunizations given to prevent those diseases resulting from potential future behaviors are also seen as problematic. For example, concerns may arise with immunizations given to children to prevent sexually transmitted infections, such as the hepatitis B immunization and the HPV immunization. These infections are normally contracted later in life as a result of lifestyle choices, and adult behaviors are highly unpredictable when evaluating an infant or a child. It is important not to attribute a causal effect between childhood immunization and behavioral choices in adulthood. Lastly, it can be argued that the benefit to society must be given greater weight than the individual's human rights burden (Hodges et al., 2002).

In summary, parents’ decisions whether or not to immunize are made in accordance with what they feel is in their child's best interests. However, the perception of what is in the best interest of a particular child is subjective. On the one hand, the parents may have an opinion that is diametrically opposed to that of the NP or other members of the professional community. The professional opinion must be based on scientific research and the best data available. By addressing these principles, it is the responsibility of all clinicians to provide prophylactic health interventions to better the lives of children and provide protection from infectious diseases that may cause future significant health problems.

Addressing and responding to parental concern or refusal

The main concerns associated with parental hesitation or unwillingness to vaccinate children include safety issues, the number of immunizations, and a lack of trust (Gust et al., 2009). There are a variety of approaches that may be used to respond to particular parental concerns as well as to correct any misconceptions.

One of the most important aspects to keep in mind throughout the entire parent/practitioner interaction is communication (Gust, Campbell, Kennedy, Shui, Barker, & Schwartz, 2006). The NP should be open minded and create a comfortable environment by listening first, because parents may have a variety of religious or philosophical beliefs and concerns that may need to be addressed (Cameron, 2006). In addition, the NP should respond to concerns by acknowledging them and by providing information using familiar words and avoiding jargon, while remaining friendly and efficient (Cameron, 2006). Sincere concern for the child's welfare should serve as a common ideal shared by the NP and parent. Expressing genuine concern will be an effective way to show that the NP and parent both have the child's best interest in mind (Fortune & Wilson, 2007). Other communication strategies that may help to foster a trusting relationship include informing parents of what to expect and using humor when appropriate (Gust et al., 2006).

Knowledge deficits are a major barrier influencing a parent's willingness to vaccinate. NPs should be current on the most recent information in order to help direct parents to informative websites that provide reliable information about efficacy and safety. It has been shown that practitioners who take the time to listen to parental concerns and respond thoughtfully are perceived as more trustworthy sources to parents. Even those parents who were previously distrustful of official sources may be more willing to accept information from a provider after a thorough conversation (Kimmel et al., 2007).

Some reputable websites to which parents can be referred for information pertaining to vaccines include:

In addition, some parents may in fact believe that vaccines are important to the health of their child, but may need the reassurance that everything possible is being done to ensure their child's safety (Wilson et al., 2006). An effective way to address this issue may be to explain the program used in the United States to continuously ensure the safety of vaccines through the Vaccine Adverse Event Reporting System, which is run by both the Centers for Disease Control and Prevention as well as the Food and Drug Administration (Vaccine Adverse Event Reporting System, 2009). The reporting system, which is easily accessible to the public through a website, provides an active surveillance system which collects information about adverse events resulting from vaccinations nationwide (Vaccine Adverse Event Reporting System, 2009). By monitoring adverse events, the government has the ability to ensure that the benefits of vaccines far outweigh the risks (Wilson et al., 2006; see Table 4 for additional responses).

Table 4.  Useful responses to parental concerns
Reason for refusalTips for addressing issue
  1. Note. Adapted from “Responding to Parental Refusals of Immunization of Children,” by D.S. Diekema and the Committee on Bioethics, 2005, Pediatrics.

•Belief that immunizations may be extremely harmful to their child•Explain the risk of the side effect is much less risky that remaining unimmunized
•Provide up-to-date information
•Explain any confusion and misconceptions they may have
•Be sure to provide the truth: immunization are not 100% effective or 100% safe
•Administering more than one immunization at a time will be painful and traumatic for the child•Suggest to space immunizations over time
•Take steps to reduce pain as suggested in the Red Book
 Z-track method of injection
 If multiple injections are required, have 2 health professionals administer them simultaneously to
lessen anticipation
 Apply pressure at the site for 10 s before injection
 Topical anesthetics
 Sucrose placed on the tongue or pacifier
 Have skin-to-skin contact between mothers and infants
 Breathing and distraction techniques for older children
•Concerns that one or two immunizations are particularly dangerous•Share honestly what is known about the risks and benefits of each vaccine.
•Discuss each immunization separately (because they may pose different concerns to parents)
•Cost•Work with parents to determine a cost-effective strategy
•Refer to a public health clinic where VFC may be administered

Another important consideration is the characteristics of vaccine refusers. A recent study by Wei et al. (2009) found that parents who refuse vaccines are more likely to come from well-educated and higher income groups than nonrefusers. In addition, unvaccinated children were more likely to be male, have married and college educated mothers, and to live with four or more children (Omer, Salmon, Orenstein, deHart, & Halsey, 2009). It is important to consider these findings and tailor the conversations to specific socioeconomic groups when targeting specific communities.

For those parents who refuse immunizations for their children over the course of several appointments, the NP should continue working on building a trusting relationship with the family (Gust, Darling, Kennedy, & Schwartz, 2008). At each appointment, the topic of immunizations should be revisited. As the relationship develops over time and the parents develop confidence in the provider, parents may change their minds and be willing to immunize their children (Diekema, 2005).

It is important to remember that the decision not to immunize is a reversible one. Because most immunizations are effective past early childhood, parents can always choose to immunize their children later in life after they feel they have had access to more information. Unless the child is at a high risk for acquiring a particular immunization-preventable illness such as during a flu epidemic, the parents’ opinion should be respected, but complete information needs to be provided.

Role of the NP

As healthcare providers, NPs have the responsibility to provide competent medical advice and nursing care. However, some NPs may feel that their authority and integrity are threatened when a parent opposes what is recommended after the risks and benefits have been discussed (Flanagan-Klygis, Sharp, & Frader, 2005). Each refusal to immunize puts a strain on the relationship between the parent and the NP. For an NP, parental refusal of a well-supported treatment is problematic. Because a major role for NPs in pediatric primary care consists of disease prevention and immunization, some argue that in order to do their job and treat the child to the best of their ability, parents must agree to the immunization schedule (Flanagan-Klygis et al., 2005). NPs may argue that it is also important to provide herd immunity, especially to protect those members of the community who are medically unable to get the immunizations (Flanagan-Klygis et al., 2005).

Furthermore, providers feel there is an ethical contract that is made between the parents and the provider. As primary care providers, if NPs are going to treat children to the best of their ability, it is their responsibility to give the immunization. Therefore, by not immunizing, NPs might believe they are at risk of harming the child as well as other members of the community. Because they believe they are not providing adequate preventative care, some feel it is necessary to dismiss families who are refusing to immunize their children from the practice. As rates of immunizations change, it will be important to take into account the parent/provider relationship and monitor the impact it has on immunization rates and availability of care (Flanagan-Klygis et al., 2005).

It may be viewed as unethical to dismiss a family because of a refusal to immunize. Kemper and Guth (2006) argued it is the providers’ responsibility to respect the Hippocratic oath and to care for the patient to the best of their ability, rather than dismiss them because of opposing views. Some may feel that if providers are allowed to dismiss patients on the grounds of conflicting views, families might be turned away in the future for other unethical reasons including having obese children, not consuming enough fruits and vegetables, or watching too much television (Kemper & Guth, 2006).

According to the American Academy of Pediatrics Policy Statements on Bioethics (Mercurio, Adam, Forman, Ladd, Ross, & Silber, 2008), universal immunization is strongly endorsed, with an understanding that parents may refuse some or all of the recommended immunizations. It is the responsibility of the provider to determine whether not having the immunization will put the child or the health of the community at a serious risk. However, each case must be considered individually. Because these refusals rarely endanger a particular child's health, it is advised that the opinions and actions of the parents be respected. Rather than dismissing the family from the practice, it is suggested that the provider work with the family to provide optimal medical care, including ongoing education and surveillance. Despite not receiving the recommended immunizations, well-child visits provide anticipatory guidance and opportunities to counsel on diet, growth, exercise, development, elimination, and sleep.

Conclusion

There are numerous reasons why parents may be opposed to immunizing their children, such as religious or philosophical beliefs, fear of the side effects, lack of trust in the government, a low perceived susceptibility to immunization-preventable diseases, and cost. By being respectful and carefully listening to parents’ concerns, NPs may in fact be able to ease parents’ anxieties regarding immunizations by providing the risk and benefit information as well as discussing misinterpretations that might exist. This may be an effective strategy in the immunization consent process.

Furthermore, information presented to parents should be credible, thorough, and honest. Parents must be given accurate information regarding possible adverse events. It is important they know that tragedies, such as the Hannah Poling's case, are extremely rare in comparison to the number of children receiving immunization. Also, it is important that sensational so-called facts presented in the media and on the Internet be reviewed and explained by the NP. With much media attention and focus directed to immunizations and their potential side effects, alternative sources should be recommended to educate the public about the risks and benefits of each immunization. Reliable sources such as the CDC, Immunization Action Coalition, and the American Academy of Pediatrics Immunization Initiatives can provide parents with the most up-to-date information.

By giving parents all the necessary information regarding risks and benefits, NPs can accomplish their job of minimizing harm to children. It can be difficult to determine what is in the best interest of the child; however, it is important to balance the parents’ opinion with scientific evidence. Although some parents may ultimately choose not to immunize their children, primary and preventative care should continue to be provided to these children in conjunction with ongoing parental education. As NPs serving the children in our communities, it is our responsibility to treat these children with the best preventative medicine possible. In so doing, NPs will gain the increasing trust of the parents who may subsequently make the decision to immunize.

Acknowledgments

A sincere thanks to Dr. Rita Marie John, DrNP, CPNP, for her guidance and support throughout the preparation of this manuscript.

Ancillary