Childhood vaccination has made an important contribution to the health of children, preventing millions of deaths worldwide each year,1 yet thousands of U.S. parents choose to refuse or delay the administration of selected vaccines to their children. Some choose not to vaccinate their children at all. This can be frustrating for physicians, especially for those who have personally witnessed the positive impact of vaccines on child health during their lifetime. While most physicians continue to care for these families over time, using each visit as an opportunity to educate and encourage vaccination, an increasing number of physicians report dismissing these families from their practice unless they agree to vaccinate their children. This paper will examine this emerging trend along with the reasons given by those who advocate such an approach. I will argue that the strategy of refusing to allow families into a clinic unless they agree to vaccinate their children is misguided, and the arguments for adopting such a policy fail to stand up to close scrutiny.

The rise of managed care initiated a steady decline in solo and small group physician practices and the emergence of new delivery models built around large health care organizations (HCOs). Health care reform has only accelerated this trend as public and private payors shift to new payment methodologies that reward clinical and financial integration among providers. As a result, patients increasingly receive care from physicians and other health professionals organized into collaborative partnerships with one another and institutional providers, such as hospitals. As described below, this new organizational dynamic profoundly influences the clinical judgment of physicians. No longer can society simply depend on the professionalism of individual physicians to ensure ethical integrity in the health care setting. Rather, ethical integrity in the health care setting also requires a strong foundation of organizational ethics.