Often, health care providers are responsible for educating parents on the benefits of vaccinating their children. While media attention focuses on parents' right to refuse vaccination, there is less emphasis on the impact of parental refusal on clinicians and nurses. In fact, as noted by Michael J. Deem in "Nurses' Voices Matter in Decisions About Dismissing Vaccine-Refusing Families" (Viewpoint, August 2018), more primary care physicians are dismissing vaccine-refusing families from their practices.

Deem emphasizes the lack of published data on the role of RNs in deciding whether vaccine-refusing families should be dismissed. Given the time nurses spend with families providing education and administering vaccines, they should have a greater role in making these decisions. Deem asserts that dismissal creates ethical dilemmas and moral distress for nurses who feel that alternatives can be proposed to families to move them from vaccine refusing to vaccine accepting. While the American Academy of Pediatrics views dismissal as an acceptable response to vaccine-refusing families, there is no position statement by a major professional nursing association on whether dismissal is appropriate.

As a nursing student and future nurse, I'm learning that nurses have a powerful voice when making decisions about patient care. Nurses not only educate and advocate for patients and their families, but they also have expertise that can influence practice policies. Nurses can and should voice their concerns when put in situations that create ethical dilemmas or moral distress. I want to thank Dr. Deem for emphasizing the need for more research on how nurses respond to vaccine-refusing families and for empowering nurses to speak up about controversial matters.

Leilani van Erp

California State University, East Bay

Hayward, CA