Home Audiology Everyday Ethics: Do I Discontinue Services for Unvaccinated Clients?

Everyday Ethics: Do I Discontinue Services for Unvaccinated Clients?

by Donna Euben
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Question: I’m a private-practice, ASHA-certified speech-language pathologist who is three months pregnant. I have been treating a child in her home, but I want to discontinue services to the child because no one in the family has been vaccinated for the measles. Can I do so or would it be considered client abandonment?

More than 1,150 measles cases occurred in more than 30 states in the U.S. in 2019, and most of those cases involved unvaccinated people, according to the U.S. Centers for Disease Control and Prevention (CDC). Measles is highly contagious and there is no cure. Measles in pregnant women may have serious consequences, including low-birth weight and miscarriage, reports the American College of Obstetricians and Gynecologists (ACOG).

Your query triggers several ethical considerations specific to the circumstances of your situation.

As always, the welfare of your client is paramount. However, the ethical analysis in this situation doesn’t stop there.

Could it be considered client abandonment?

Discussion about vaccines can generate controversy given the strongly-held beliefs triggered by the topic. We are analyzing the specific facts and circumstances of your situation only: The below analysis should not be construed as general guidance, because different facts may lead to different analysis under the Code of Ethics.

First and foremost, as a CCC-SLP you must abide by the ASHA Code of Ethics. Accordingly, you have an ethical obligation not to abandon a client; but this obligation isn’t absolute. ASHA’s Issues in Ethics statement on client abandonment states, “no clinician is ever ethically required to work . . . in physical danger in order to offer client care.”

The risk of you being exposed to measles while pregnant and providing services to a nonvaccinated child in her home could be viewed as posing such a “physical danger,” and so your withdrawal from treating this client in the home probably would not be considered client abandonment by the Board of Ethics (Code of Ethics Principle I, Rule T). However, our ethical exploration continues about ways that may exist to maintain the relationship with your client.

If your state provides for telepractice, perhaps you could establish a remote treatment plan that would enable you to continue working with your client and her family. Alternatively, maybe you could provide the family with home exercises to undertake to bridge the gap of in-person treatment during your pregnancy.  If neither of those options is viable for some reason, then you should work with your employer and/or colleagues to find another SLP with the skills to provide similar services, but for whom potential exposure to measles poses less of a medical risk—during the hiatus of your pregnancy.

Is it considered religious discrimination?

It depends. Your ethical responsibility to clients involves not discriminating because of their religious beliefs. Your decision to stop treatment might potentially trigger a Board of Ethics complaint from the child’s family based on religious discrimination, if the family belongs to a religious group expressly prohibiting medical intervention, such as vaccines. Check whether your state public health law—including recently passed legislation—allows religious, philosophical, or “personal belief” exemptions to measles vaccinations. If you follow your employer’s health and safety policies and/or state health laws, there’s much less concern that your reason for ceasing treatment of the family might be perceived as religious discrimination (Code of Ethics Principle I, Rule C). In addition, some children are “medically fragile,” usually because of a weakened immune system, and so with a doctor’s note are often exempt from state vaccination laws.

Protect your health and safety

If you are working in a setting other than your own private practice, your employer and/or your collective-bargaining agreement might include a policy to protect staff health and safety, including infection control. If not, consider doing the following:

  • Work to develop health and safety policies to facilitate the provision of quality professional service in your workplace. (See ASHA guidance on quality indicators for professional service programs in audiology and speech-language pathology.)
  • Contact your state department of health—most provide guidance for private and public settings on children’s vaccinations against certain infectious diseases.
  • Check for applicable regulations under your state occupational licensing law for audiologists and SLPs, as well as the state’s occupational health and safety code.

Other professions face similar ethical dilemmas. Ethical guidance in 2019 from two other health-related professions—pediatricians and dentists—concluded that, while the decision should never be made lightly, declining to treat families who refuse vaccinations is not per se unethical, so long as necessary precautions are taken as may be dictated in your state, and patient abandonment does not occur.”

Donna R. Euben, Esq., is ASHA director of ethics. deuben@asha.org.

 

Legal Disclaimer: The information provided in this posting is for informational and educational purposes only. Nothing in this document should be construed as legal advice, and your use of the legal information provided is not a substitute for legal advice. ASHA has no knowledge of the specific or unique circumstances under which such information may be used by you. Your use of this posting specifically or ASHA’s website generally does not create an attorney–client relationship between you and ASHA, or between you and any of ASHA’s employees or representatives. Each state has its own laws and they can vary widely, so you should obtain advice from any attorney regarding answers about your state laws. 

 

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7 comments

Susan Johnson, MS CCC-SLP December 14, 2019 - 1:02 am

Abort services until you feel completely safe. Your pregnancy is a time of joy and optimism.

Reply
Sarah Van Winkle January 27, 2020 - 11:45 am

Why shouldn’t she feel safe if she’s already vaccinated? Is there a case of an unborn infant contracting measles from anyone while in utero. That’s suggesting that the client actually gets measles (which is just like any other virus). Maybe we should stay away from everyone with a cold too. Or anyone with Autism because they may react to a situation and accidentally touch the mother’s tummy.

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Megan January 17, 2020 - 3:12 pm

Can someone please explain how an unvaccinated child could possibly infect a woman with measles who is up to date on her MMR?
Wouldn’t the clinicians own vaccination history protect her from any potential infection?
How is this any different from saying “I’m not going to treat xyz client because they didn’t get their flu shot this year” (even when you yourself perhaps did).
Quick background: I am a 7 months along in my pregnancy, and am an SLP (not an immunologist) working in healthcare who personally chooses to forgo vaccines. I understand why many people would want to vaccinate themselves, and am wondering why, if this clinician is up to date on her vaccines, she believes she is somehow in physical danger working with this patient?

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ALISON January 25, 2020 - 1:38 pm

I agree 100%

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Sarah Van Winkle January 27, 2020 - 11:42 am

Thank you Megan, I was about to ask the same thing. This is complete discrimination. As in a doctor refusing treatment to their patient because they are choosing not to vaccinate on the Dr.’s schedule. What ever happened to the do no harm oath? Also, shall we not discuss the 4 billion+ dollars that have been awarded to vaccine injured cases? I would hope that would put every parent at pause before following the current schedule. However, to reiterate the OP, if vaccines are effective, why worry about being around someone who isn’t?

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Annie, MA, CCC-SLP January 24, 2020 - 4:49 pm

This is a very sensitive discussion of which I have dedicated my entire two-year plus sabbatical thoroughly researching (I’m a mother and an ASHA-certified educational and medical SLP with over a decade of experience in the EI, school-aged, adult, and geriatric populations). To start, I’d like to say that vaccination and immunology are far from black and white topics, as we have been lead to believe. This took me quite some time to learn, so I understand where the SLP who posed her question is coming from. Currently, she appears to be basing her viewpoints on the fear-mongering we have all been subject to, rather than the facts. In her defense, we mothers, especially, are susceptible to fear-mongering, as it is our primal instinct to protect our children. I also understand why she, like most of us (myself included, only a few years ago) is unaware of these facts. The facts take much digging to obtain, and as busy clinicians in the field, we’re hard-pressed to find time to research our own scope of practice, let alone that of the medical world. So I share this information with kindness and love, hoping it can help to open others’ minds, as it did mine.

First, I agree with Megan. An unvaccinated individual is no different from a vaccinated individual, in that they cannot spread an infection s/he does not have. So unless the client or someone in his/her family is actually infected with the measles, it cannot spread it to the clinician simply because they have not been vaccinated against it.

Second, is the clinician familiar with the client and his/her family’s medical histories? Unlikely so, as this information is usually privacy protected (as it should be). But did the clinician consider the possibility that this family may have previously been exposed to the wild-type measles virus, thus providing them with life-long immunity without requiring the vaccine? Or another thought: did the clinician consider the possibility that someone in this family may have a viral or bacterial infection for which there are no vaccines, such as HIV or tuberculosis? Let’s all consider the fact that by simply stepping outside our homes, we expose ourselves to thousands of viruses, bacteria, fungi, etc. that can all pose to us “physical danger.” As much as I wish it were so, being vaccinated provides no guarantees.

Third, I would like to point out the importance of familiarizing ourselves with primary and secondary vaccine failure (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6413513/). Unless this clinician is having each and every one of her clients’ titers regularly checked (as well as her own) to ensure everyone she comes in contact with has antibodies against the measles, she cannot discriminate against this particular family for their choice not to use a prophylactic drug (i.e., a vaccine). Unbeknownst to her, she herself may no longer be immune to the measles, and could potentially catch it and pose a “physical danger” to her own clients. It is important to remember, no vaccine is 100% effective (and no vaccine is without very real side effects, but that’s a post for another day), so in essence, everyone we come in contact with is potentially posing a “physical danger” to us. If we wish to avoid the “physical danger” of catching a communicable infection, we must stay away from ALL people, not just those who are unvaccinated.

Finally, Ms. Euben is correct in that the CDC reports that most of the measles cases occurred in unvaccinated individuals. While this is true, let’s ask ourselves – what does “most” actually mean? What does “most” look like in terms of numbers/facts? We SLPs must base our practice upon evidence. Let’s also base our opinions on evidence. Based on the CDC and NIH’s data, vaccinated individuals becoming infected with (and potentially spreading) the measles is a very real possibility (https://www.cdc.gov/mmwr/volumes/68/wr/mm6817e1.htm?s_cid=mm6817e1_w, https://www.ncbi.nlm.nih.gov/pubmed/29878209).

When there is a risk, there must be a choice. I’d like to conclude my thoughts repeating this: no vaccine is 100% effective, and no vaccine is without side effects. Until both of these facts cease to exist, vaccination is a choice that must be made between a patient/parent and a physician. And until vaccines are 100% effective and 100% without any side effects, I do not believe a speech-language pathologist has the right to base her services on whether or not an individual (or his/her family) is vaccinated.

Reply
Sarah Van Winkle January 27, 2020 - 11:49 am

If a child has a vaccine exemption form, you cannot refuse to see them simply because they are not vaccinated. I cannot even believe this is a discussion.

Reply

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