Orange County pediatrician Dr. Eric Ball still feels guilty about the Disneyland measles outbreak of 2014.

At the time, his office allowed children whose parents refused to vaccinate them to still remain as patients. Many took advantage of the policy, leaving the children in his practice well below the 95% threshold that experts say is needed to achieve herd immunity. In the end, a single measles case at the theme park spread to 145 people across the country; several were part of his practice.

“I was traumatized,” said Ball. “I felt that like we didn’t do enough as a practice, and I didn’t do enough as a pediatrician, to convince families to get vaccinated.” Not only were the children of his anti-vaccine parents left vulnerable to the measles, but they had also exposed other children in his waiting room who couldn’t receive the vaccine because they were too young or immunocompromised.

As a doctor, Ball felt torn: He had a moral obligation to care for all his patients, regardless of their parent’s vaccine choices. But he also had a duty to protect his other patients, as well as the rest of the community, from a deadly virus that was almost entirely preventable.

With another measles outbreak continuing to spread in Texas and New Mexico — bringing the first two U.S. measles deaths in a decade — and eight cases already in California this year, physicians are again facing a moral quandary: Should they refuse to see families who don’t want to vaccinate their children, or keep them in their practices in the hopes of changing their minds?

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After the Disneyland outbreak, the doctors at Ball’s practice decided to crack down. In 2015, they instituted a new policy: Southern Orange County Pediatric Associates would no longer accept patients who did not plan to immunize their children. Existing patients who didn’t want to vaccinate would need to find a new doctor.

A growing trend of dismissing unvaccinated patients

“Dismissal” policies were once discouraged by the medical establishment, both because pediatricians have a duty to care for all their young patients, and because some anti-vaccine parents can be convinced over time to change their minds.

But in 2016, the American Academy of Pediatrics came up with new guidance: Vaccines against preventable diseases like the measles were so important that if, after repeated attempts, a pediatrician couldn’t convince a parent to get their child immunized, a practice could righteously kick them out.

“I think that made a big difference to a lot of us. It gave us cover,” said Ball.

Since then, dismissal policies have grown much more popular.

In 2013, some 21% of pediatricians reported that they often or always dismissed families who refused vaccination, according to a survey published in the journal Pediatrics. By 2019, the share had grown to 37%; the 2019 survey, published in the Journal of the American Medical Assn., also found that just over half of pediatricians said their office had a dismissal policy in place.

For families that seek to spread out vaccines with an alternative schedule, dismissals are much less common: just 8% of individual pediatricians reported often or always dismissing these families, while 28% reported that their office has such a dismissal policy, according to the academy.

Dismissal policies are much more common among private practices. Academic medical institutions, including UCLA, large health systems like Kaiser Permanente, rural clinics and safety net systems for low-income patients generally accept all patients, regardless of whether the parents intend to vaccinate their children. Cedars-Sinai Medical Center is an exception and discourages pediatricians in their clinics from treating unvaccinated patients.

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The question of whether to dismiss has become increasingly pressing amid growing anti-vaccine sentiment and a decline in coverage. The proportion of kindergartners nationwide who completed their measles, mumps, and rubella vaccine series dropped from about 95% — the federal coverage target — before the pandemic to less than 93% last school year.

In California, 96.2% of kindergartners were fully vaccinated against the measles in the 2023-24 school year, a slight decline from the year before.

“No matter what your policy, you feel ethically justified,” said Dr. Sean O’Leary, a professor of pediatrics at the University of Colorado Anschutz Medical Campus, who co-wrote the American Academy of Pediatrics’ latest guidance on vaccines. In January, the New England Journal of Medicine presented arguments on both sides of the debate, with O’Leary writing a statement in favor of accepting unvaccinated patients. “I personally understand both sides.”

Why doctors dismiss vaccine-hesitant families

These days, many pediatric practices are upfront about their policies, and some announce it on their website, letting prospective patients know to stay away if they don’t want to vaccinate.

At Larchmont Pediatrics, for example, Dr. Neville Anderson requires all patients to be vaccinated. If parents refuse to vaccinate their infants after a final conversation at the 3-month visit, the practice sends them an official dismissal letter.

Dr. Neville Anderson is photographed in between vaccinating young patients at Larchmont Pediatrics in Los Angeles on Tuesday.

(Allen J. Schaben / Los Angeles Times)

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“If a parent is truly anti-vax and does not want to vaccinate their child, our values and our goals and our beliefs are so antithetical to each other that we’re not a good team,” said Anderson. “I’m not the right doctor for them, and they’re not the right patient for me.” Larchmont dismisses only one to four patients each year, she said, since most anti-vaccine families know their reputation and tend to go elsewhere.

But for some patients, the dismissal policy is a real draw. “We get a lot of people who will come to us because we have this policy and we enforce it,” said Anderson. “They’re afraid of bringing their 7-month-old into a waiting room where there’s an unvaccinated child.”

Doctors should make every effort to convince a family to vaccinate before dismissing them, said Dr. Jesse Hackell, a retired pediatrician in New York who also co-wrote the pediatric academy’s report on improving vaccine communication. The problem, he said, is that these conversations are time-consuming and unpaid for busy pediatricians who often only have 20 minutes with a patient. “It’s frustrating, and it’s one of the issues that leads to moral injury and burnout.”

Hackell, 74, remembers a time before vaccination, when many of his young patients ended up hospitalized with measles and other vaccine-preventable diseases. “I don’t want to ever go back to those days of worrying about the 2 a.m. phone call about a kid with 105-degree fever. That’s that’s not good for me as a physician. It’s not good for the kid or the family.” His practice had a dismissal policy long before the pediatrics academy said it was acceptable.

One ethical argument in favor of dismissing is based on parents having a moral obligation to vaccinate their children to reduce the risk of infecting others, said Dr. Doug Opel, a bioethicist and professor of pediatrics at the University of Washington School of Medicine.

Another point is that “vaccination is viewed as a social contract,” he said. “So it’s not fair to share in the collective benefits of vaccination without accepting the small burdens of vaccination by getting your child vaccinated themselves.”

The moral case for accepting vaccine-hesitant families

Opel said that, as a bioethicist, he comes down on the side of keeping families in a practice.

“In what other area of medicine even do we expect patients or parents to hold the same values and beliefs that we have?” he asked. “Instead, we approach differences with humility and respectfully explore those values as a way to find common ground and shared understanding.” Opel said about 30% of parents do end up changing their mind. “Vaccine hesitancy is a modifiable behavior.”

O’Leary said there is also little evidence that accepting unvaccinated children leads to the transmission of vaccine-preventable illnesses in an office setting. And it isn’t clear whether the threat of dismissal actually convinces parents to get vaccinated, or whether patients who get kicked out of a practice end up finding other sources of care.

ln San Diego County, Children’s Primary Care Medical Group — a large practice with 28 offices in the region — has a policy of accepting all patients, regardless of vaccination status.

“The basic philosophy is it’s not the kids who refuse, it’s the parents. And we don’t punish kids for the decisions of the parents,” said Dr. Adam Breslow, the group’s president and CEO.

About 90% of the group’s patients are vaccinated on schedule, Breslow said. Of the 2-3% who refuse all vaccinations, most come from wealthier areas where parents can afford to homeschool or send their children to private school. He said it’s rare that he’s able to convince them to vaccinate in a single office visit, but over the course of several years in his practice, some parents do eventually change their minds.

“By keeping them in the practice, there’s a chance they’re going to get vaccinated,” said O’Leary. “But if you kick them out, who knows what’s going to happen?”

Where do parents who don’t vaccinate kids go?

Widespread dismissal policies can make it difficult for vaccine-hesitant families to find regular sources of care. In local Facebook groups, parents often exchange tips about practices that are more tolerant of spreading out or refusing vaccines.

Some advise using concierge practices, which charge thousands of dollars in annual fees on top of insurance payments but may allow more flexibility with vaccination schedules. Some of these practices offer unproven alternatives to vaccination with little or no evidence to back them up.

Whitney Jacks, a mother in Escondido, recently posted in a moms group on Facebook for help finding a new pediatrician who would accept her preference to limit vaccines. With her older child, who is 7, she used to pay for a concierge doctor in Maryland whom she saw over Zoom. But her son doesn’t have a regular pediatrician and therefore skips his annual well visits, though he does see a specialist several times a year.

Now pregnant with her second child, she was hoping to find someone local who would accept her insurance and support her decision to wait until the baby turns 2 before starting vaccinating.

Other moms in the Facebook group were hesitant to share the names publicly for fear that the doctors could get into trouble, she said, preferring to direct message her instead. One mom sent her a list of names, which she used to set up meet-and-greet appointments with the four closest to her home.

But as she began to meet with them, one after another gave her the same response: “We won’t kick you out, but we don’t like this,” said Jacks, who is an acupuncturist. “So they’re already putting it at you that they disapprove of your point of view.” None made her feel welcome.

She picked the most convenient office. But Jacks worries that every visit will focus on vaccination instead of other issues like feeding and sleeping that are important in the first years.

“It doesn’t give me any confidence or faith in the provider.”

This article is part of The Times’ early childhood education initiative, focusing on the learning and development of California children from birth to age 5. For more information about the initiative and its philanthropic funders, go to latimes.com/earlyed.