BUSI 506 Week 8 Discussion Board Forum 3 Replies Example

Discussion Board Forum 3 Replies: Dismissal Policies, Vaccine Refusal and Opioid Patients

BUSI 506 Legal and Ethical Issues for Health Professionals, Discussion Board Forum 3 Replies

Thread by [Student Name]

The classmates, their practices and the patients described are composites; the textbooks, Scripture and the peer-reviewed sources cited are real.

Both threads I chose this week defended a dismissal policy, and both made strong points about staff time and safety. My replies ask one question of each: once the policy is applied, where do the dismissed patients go, and who carries the cost of their care?

Reply to Kendra

Kendra, you made a fair case that a pediatric practice faces real costs when a family refuses vaccines, including long counseling visits and the risk to infants too young to be immunized who sit in the same waiting room. Pozgar (2016) would agree that a practice may end a relationship as long as it gives reasonable notice and time to find another clinician, so the policy you described is likely lawful. My concern is whether it achieves what it intends. O'Leary et al. (2020) surveyed pediatricians nationally and found dismissal policies were common, more so for families who refuse vaccines outright than for those who ask to spread them out. Nguyen et al. (2023) found the practice was even more common in Oklahoma, where 35% of responding pediatricians reported dismissing families for refusal, though pediatricians with more years in practice and those in rural areas dismissed far less often, perhaps because rural doctors know there is nowhere else for the family to go. That pattern deserves attention in your thread, because the practices most willing to dismiss are those in places where the family has other options, which shifts the hardest conversations onto colleagues rather than ending them.

The ethics are contested. Wiley et al. (2023) reviewed 121 publications on childhood vaccine refusal and found the literature divided over whether responses such as dismissal are justified, with arguments resting on the best interests of the child, the risk to others and physicians' professional duties. Silver et al. (2024) describe a county health department in Michigan that saw dismissal as a public health problem, since dismissed children cluster in the practices still willing to see them and some lose routine care entirely. Half of the 61 immunizing clinicians it surveyed said their practices dismissed refusing families at least sometimes, and after a brief educational session, agreement that dismissal is good for public health fell from 36% to 18%.

Rather than dismissal on the first refusal, I would suggest a structured path: a dedicated counseling visit, a signed refusal form, scheduling unvaccinated children at times when infants are not in the waiting room and dismissal reserved for families who become abusive. A policy that removes the children most at risk from the one clinic that keeps asking their parents to vaccinate may protect the waiting room while leaving the community less protected. When critics complained that Jesus ate with tax collectors and sinners, he answered that it is the sick, not the healthy, who need a doctor, and that he came to call sinners (English Standard Version Bible, 2001/2016, Mark 2:17). A child whose parents distrust vaccines may be exactly the patient who most needs a patient doctor. Would your practice consider tracking how many dismissed children ever complete their vaccines elsewhere, so the policy is judged by its results?

Reply to Joel

Joel, your thread argued that your primary care clinic should discharge any patient on long-term opioids after a single urine drug test showing an unprescribed substance, because a firm rule protects prescribers and is simple to apply. I understand the appeal of a bright line, and Pozgar (2016) makes clear that a prescriber may stop prescribing a medication judged unsafe. Ending the prescription and ending the relationship are different acts, however, and the evidence suggests the second carries serious risk. A positive test can reflect a false result, a medication taken from a relative during a bad week or an emerging use disorder, and each calls for a different response. A discharge letter treats all three the same way and hands the problem to whichever clinician the patient finds next, if any.

First, these patients struggle to find new care. Lagisetty et al. (2019) had researchers call 194 Michigan primary care clinics posing as relatives of a patient taking long-term opioids, and 40.7% said their clinicians would not prescribe opioids to the patient, while smaller practices were less likely to accept such patients at all. Second, abrupt changes are dangerous. Fenton et al. (2022) followed 19,377 patients through 21,515 tapering events and found that, a year or more after tapering began, rates of overdose or withdrawal and of mental health crisis were about 50% higher than before the taper. Third, the tools that drive these decisions can mislead. Hu (2026) examined Georgia's prescription monitoring program and its risk scoring and argues that the scores and documentation now shape whether a patient's pain is believed, a shift the 2022 federal opioid guideline itself linked to patient dismissal and abandonment.

There is a better model. Wiedemer et al. (2007) describe a primary care opioid renewal clinic run by a nurse practitioner and a clinical pharmacist at a veterans hospital. Of 171 referred patients with documented problem behaviors, 45% resolved them under a treatment agreement, 13% were referred to addiction treatment and only a small group were weaned because tests showed they were not taking the medication. I would suggest your clinic replace the one-strike rule with a repeat test, a conversation, a revised agreement and referral to treatment where use disorder is present, keeping the patient in primary care throughout. The cost is real, since such a clinic needs pharmacist and nurse practitioner time, but Wiedemer et al. (2007) also reported pharmacy savings, and the alternative cost of an overdose or a psychiatric admission falls on the same health system. A dismissal policy may look cheaper on the clinic's ledger while costing the organization more overall. King Lemuel's mother urged him to be a voice for people with no voice and to rule justly for the destitute (English Standard Version Bible, 2001/2016, Proverbs 31:8-9), and patients whom many clinics will not accept have little voice of their own. Would your clinic's prescribers support a pharmacist-run renewal clinic if administration funded it?

References

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Fenton, J. J., Magnan, E., Tseregounis, I. E., Xing, G., Agnoli, A. L., & Tancredi, D. J. (2022). Long-term risk of overdose or mental health crisis after opioid dose tapering. JAMA Network Open, 5(6), e2216726. https://doi.org/10.1001/jamanetworkopen.2022.16726

Hu, X. (2026). From listening to verification: PDMP risk governance and the transformation of pain credibility in healthcare. Social Science & Medicine, 408, 119850. https://doi.org/10.1016/j.socscimed.2026.119850

Lagisetty, P. A., Healy, N., Garpestad, C., Jannausch, M., Tipirneni, R., & Bohnert, A. S. B. (2019). Access to primary care clinics for patients with chronic pain receiving opioids. JAMA Network Open, 2(7), e196928. https://doi.org/10.1001/jamanetworkopen.2019.6928

Nguyen, C. G., Pogemiller, M. I., Cooper, M. T., Garbe, M. C., & Darden, P. M. (2023). Characteristics of Oklahoma pediatricians who dismiss families for refusing vaccines. Clinical Pediatrics, 62(1), 24-32. https://doi.org/10.1177/00099228221108801

O'Leary, S. T., Cataldi, J. R., Lindley, M. C., Beaty, B. L., Hurley, L. P., Crane, L. A., & Kempe, A. (2020). Policies among US pediatricians for dismissing patients for delaying or refusing vaccination. JAMA, 324(11), 1105-1107. https://doi.org/10.1001/jama.2020.10658

Pozgar, G. D. (2016). Legal aspects of health care administration (12th ed.). Jones & Bartlett Learning.

Silver, E. R., Fink, L., Baylis, K. R., Faust, R. A., Guzman, K., Hribar, C., Martin, L., & Navin, M. C. (2024). Challenging the "acceptable option": Public health's advocacy for continued care in the case of pediatric vaccine refusal. Vaccine, 42(21), 126144. https://doi.org/10.1016/j.vaccine.2024.07.045

Wiedemer, N. L., Harden, P. S., Arndt, I. O., & Gallagher, R. M. (2007). The opioid renewal clinic: A primary care, managed approach to opioid therapy in chronic pain patients at risk for substance abuse. Pain Medicine, 8(7), 573-584. https://doi.org/10.1111/j.1526-4637.2006.00254.x

Wiley, K., Christou-Ergos, M., Degeling, C., McDougall, R., Robinson, P., Attwell, K., Helps, C., Drislane, S., & Carter, S. M. (2023). Childhood vaccine refusal and what to do about it: A systematic review of the ethical literature. BMC Medical Ethics, 24(1), 96. https://doi.org/10.1186/s12910-023-00978-x