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One part of our argument relies on the distinction between requesting inappropriate care (which, per AMA guidance, would make nonacceptance of potential patients permissible) and refusing appropriate care (which would not, by itself, make nonacceptance of potential patients permissible). Vaccine refusers are doing the latter, not the former. Dr. Terk claims this distinction doesn’t make a moral difference. We disagree. First, to be clear, by ‘appropriate care’ we mean the standard of care, defined as minimally competent care; by ‘inappropriate care’ we mean something falling below the standard of care. The distinction we draw—between physicians not offering inappropriate care and physicians tolerating parental … E-mail: navin{at}oakland.edu

* Abbreviation: AAP — : American Academy of Pediatrics Vaccine refusal forces us to confront tensions between many values, including scientific expertise, parental rights, children’s best interests, social responsibility, public trust, and community health. Recent outbreaks of vaccine-preventable and emerging infectious diseases have amplified these issues. The prospect of a coronavirus disease 2019 vaccine signals even more friction on the horizon. In this contentious sociopolitical landscape, it is therefore more important than ever for clinicians to identify ethically justified responses to vaccine refusal. The American Academy of Pediatrics (AAP) says dismissing families who continue to refuse vaccines is an “acceptable option,”1 but some practices have gone further by not accepting vaccine refusers as patients at all.2,3 The phenomenon of nonacceptance has been underexplored; in both empirical studies and ethics analyses, researchers largely focus on dismissal.4–7 In this article, we first criticize arguments for nonacceptance that invoke a supposed right to choose one’s patients. We then argue that nonacceptance is problematic because (1) some of its motivations are intrinsically immoral, (2) it does not appear to accomplish some of its goals, and (3) even when nonacceptance does accomplish its goals, it fails to appropriately balance the various values it implicates. Throughout the article, we engage with the existing ethics literature about dismissal and conclude that even if dismissal is sometimes justifiable, nonacceptance is not. Some may argue that nonacceptance is ethically justified because they believe the clinical relationship is fundamentally a free association between clinicians and patients, as the American Medical Association Code of Medical … Address correspondence to Mark C. Navin, PhD, Department of Philosophy, Oakland University, 746 Mathematics and Science Center, 146 Library Dr, Rochester, MI 48309-4479. E-mail: navin{at}oakland.edu

* Abbreviation: AAP — : American Academy of Pediatrics More than 20 years ago, the pioneering pediatric ethicist William Bartholome1 wrote a fiery letter to the editor of this journal because he thought a recently published statement on pediatric assent, from the Committee on Bioethics of the American Academy of Pediatrics (AAP), showed insufficient respect for children.2 That AAP statement, like its 2016 update, asserts that pediatric assent should be solicited only when a child’s dissent will be honored.3,4 Bartholome1 objected that pediatricians should always solicit children’s assent and that they should acknowledge and apologize when they treat children over their objections even when they must do so to promote children’s best interests. We think Bartholome1 was right. In this brief commentary, we elaborate on his perspective about the moral value of pediatric assent, and we suggest improvements to the corresponding clinical guidance. The AAP grounds the moral value of pediatric assent by noting, “We are obliged to act out of fundamental respect for other persons by virtue of their personal autonomy.” But in drawing on the concept of autonomy, the AAP invokes too narrow a conception of respect. Indeed, the AAP acknowledges that many children “lack the agency required to be truly autonomous agents.”3 If respect is grounded … Address correspondence to Jason Adam Wasserman, PhD, William Beaumont School of Medicine, Oakland University, ODH 412, 586 Pioneer Dr, Rochester, MI 48371. E-mail: wasserman{at}oakland.edu