Are We Actually More Paternalistic Or Patient-Centered These Days?

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To get us closer to an answer to that question, consider this example: The American Academy of Pediatrics’ recent strategy that makes it acceptable for doctors – as a last resort – to refuse to allow families who decline vaccination to be a part of their practice.

Though the current buzzword in healthcare is “patient-centered,” it appears our “thought leaders” instead tend to subscribe to more paternalistic endeavors to control – oops! I mean steward - behavior. Look no further than the debacle of how forced, mandatory electronic medical records were implemented and the havoc that continues to cause (see here) or the American Academy of Pediatrics’ (AAP) recent strategy to make it okay for doctors, as a last resort, to refuse allowing families who decline vaccination to be a part of their practice.

A just published opinion piece in JAMA Pediatrics argues the dismissal of vaccine-refusing families results in many issues for clinicians not the least of which is “redistribute burdens of care,” foisting your problem patients onto others. The authors urge the AAP to reconsider severing your relationship with the patient, dismissing them from your practice, as an acceptable option. They point out that this avenue could erode “professional solidarity.”

I have addressed my ethical concerns with normalizing such behavior previously. As I detailed then,

“Though the AAP is very clear this option is a last resort and must meet specific criteria, this action can have ramifications and a complexity of ethical issues for the physician in practice. It is a lost opportunity. The statement “However, there is anecdotal evidence that when pediatricians give parents the choice between immunizing their child or being dismissed, some parents accept vaccination even when other efforts at persuasion have failed” is in conflict with concepts of shared decision making and patient autonomy. It is a coercive slippery slope that can erode the doctor-patient relationship and bond formed.” 

What is their goal in normalizing the dismissal of a patient who refuses vaccination? Is disagreement with a physician’s considered judgment grounds for dismissal. A patient-centered practice means the bioethical principles of beneficence, non-maleficence and personal autonomy are honored throughout the totality of care. These concepts are the core of the doctor-patient relationship. Isolating vaccine hesitancy from all other disagreements we can seems to miss the point, allowing paternalism of the “physician knows best” to creep back into the conversation.

Compelling people to do things against their will has a tendency not to work out too well. Where do we draw the line? Should we apply the same standards to those patients who continue to smoke or decline surgical care? Are all other important aspects of a pediatric visit, ensuring proper development, child safety or managing active disease, worth being sacrificed to make a point about how we vehemently disagree?

It’s time to consider the end game in our health policies. Vaccination rates do not improve when care is reduced and one-on-one conversations with an informed provider are eliminated. Freeing up the nonsense that consumes a physician’s time during the busy office day to develop trusted relationships yields way more positive dividends in the compliance battle.

If the culture is going to emphasize patient-centered care, then isn’t it time our policies reflect that?