Clinical Scenario
You are enjoying a quiet lunch in the physicians dining room of your hospital when you’re joined by a former physician acquaintance whom you have not seen in several years. Dr. Jones is known to be a bit of a loner and not normally very social. Rather than begin a conversation with general pleasantries, Dr. Jones jumps right into what’s concerning him in his practice.
Dr. Jones: “I can’t believe so many of my patients aren’t COVID vaccinated and refuse to get the shot no matter how hard I push them. They don’t seem to recognize the hard evidence behind the vaccines and want to spend 30 minutes, if I let them, telling me crazy theories about why they won’t get the vaccine. So, I’ve decided to not see anyone in my practice who isn’t vaccinated, and I won’t accept any new unvaccinated patients as well. You can see my point, can’t you?”
You: “I can tell you’re upset about this, Bob, so take a minute to relax and have some food, and we can discuss it.”
Dr. Jones: “Don’t they understand that they’re jeopardizing the health of my other patients, not to mention my staff and me, by not getting vaccinated? I just can’t get through to them about how important it is. It really bothers my conscience.”
You: “I agree that there seems to be more resistance to vaccination for COVID-19 than I’ve ever seen in the past for other infectious diseases. Have you tried finding out what your patients’ reasons are for not getting the vaccine?”
Dr. Jones: “Oh, it’s mostly crazy stuff like government-made microchips in the vaccine to control our minds, fear of changing their DNA to make them zombies, or too many risks of side effects. How can I reason with patients when they think like that?”
You: “Don’t these same patients have medical problems that brought them to you in the first place? Can’t you still treat them even if they aren’t vaccinated? There are ways to protect everyone in the clinic no matter the patient’s vaccination status.”
Dr. Jones: “I’m just tired of dealing with their resistance. I’ve just decided I won’t see them.”
How would you handle this situation? Would you do anything differently?
Discussion
As if the difficulties involved in caring for patients during the COVID-19 pandemic weren’t sufficiently challenging for physicians, we now find ourselves in the often uncomfortable position of advocating for the preventive health of our patients in the context of a politicized public health response—vaccination.
Previously, vaccination discussions with patients were relatively uncomplicated, involving explaining the science of a vaccination for influenza, major communicable childhood diseases, or painful disorders such as varicella zoster-induced shingles. Now, however, discussions regarding COVID-19 vaccination may elicit very strong, polarized viewpoints from patients, with a wide range of verbalized objections. Our responsibility to explain the science of vaccination occurs in a climate of misinformation, conflicting “expert” opinions, and changing scientific study outcomes. Some physicians’ frustrations have led them to ban patients from their practices, as noted in the clinical scenario above.
The questions for physicians then become, “How do I ethically deal with the reticence or refusal by my patients to be vaccinated, weighing their autonomy against the risks to other patients in my practice, as well as my staff? Is seeing unvaccinated patients a significant, realistic risk, or is it more of an over-reaction generated by my feelings about the devastation wrought by the pandemic? Is it unethical to refuse to see patients who are unvaccinated? What are my responsibilities to my patients with respect to vaccination, and how do I interact with them on these issues while still maintaining a positive patient–physician relationship?”
Vaccination discussions have traditionally been the purview of adult and pediatric primary care physicians. But the health implications of COVID-19 infections have placed the importance of vaccination discussions directly onto all physicians, regardless of specialty. Aerosol-generating procedures continue to carry risks and still must be performed with the necessary precautions by otolaryngologists. Patients request medical waivers for COVID-19 vaccination requirements from any physician available to them, as did many patients for mask-wearing health waivers.
Current governmental vaccination mandates have added gravity to the situation and could mean the loss of a job and income for families still reeling from financial difficulties during the worst of the pandemic. Additionally, unvaccinated patients cite the reluctance of some healthcare workers to be vaccinated as affecting their own decisions to decline vaccination.
Decisions by patients to be unvaccinated aren’t based on a uniform concern—we speak with patients who self-designate as “vaccine-hesitant,” “vaccine-refusing,” or “anti-vaccination.” Some will accept other vaccinations (influenza, shingles), while some won’t accept any vaccinations. Some patients are activists about the COVID-19 vaccines, while others are simply confused about the science. Misinformation abounds, especially on social media. If we collectively agree that we have a duty to inform patients, how do we go about it, and what do we hope to achieve?
We used safe protocols to care for patients during the height of the prevaccination pandemic that are still valid for caring for unvaccinated patients—without refusing them care.
The Physician’s Role
Autonomy, or self-determination, has ostensibly been the primary ethical principle in U.S. society, perhaps because our country was founded on individual rights and personal choice. This ethical concept, perhaps more than any other, has driven the disagreements on COVID-19 vaccination. The role social justice has played in healthcare’s systematic response to the pandemic is now being examined as a necessary component of public health moving forward. With respect to vaccinations, we must reaffirm the public health imperatives for control of the pandemic and general preventive medicine while still understanding the role of autonomy in patient decision making.
When we counsel patients regarding their illness and make therapeutic recommendations, we focus on informed consent, where we present risks, benefits, and alternatives to our recommendations. Informed consent is itself an ethical tool for weighing autonomy and beneficence against potential harm. As with any conversations with patients, we must listen as much as we speak. Patients need to express their values and wishes to us, ask questions, and seek reassurance and honesty.
Likewise, discussions with patients regarding vaccination, particularly COVID-19 vaccination, must take place in an environment of nonjudgment and understanding. We shouldn’t make inappropriate assumptions about patients who are hesitant, reluctant, or resistant to vaccination. Refusing vaccination doesn’t make patients “bad people.” They may be confused in the current environment of misinformation and information overload. Their concerns may indeed be valid and realistic—whether to choose to have their 6-year-old child vaccinated, for example, which carries a great deal of responsibility.
The physician’s role, as it has always been, is to provide information, to listen, and to be understanding. We have a wonderful patient–physician relationship to maintain, the most important foundation of our profession. We aren’t commissioned to be “vaccination police,” and our professional obligation is to all our patients, regardless of their vaccination status.
To directly address the clinical scenario, we must first acknowledge the frustrations that both patients and physicians have experienced during the course of the pandemic. Moral stress and injury have been common companions for healthcare providers, with burnout a not-uncommon side effect. It may be difficult for physicians to understand why some patients do not select vaccination, but that alone doesn’t constitute a compelling reason to refuse to care for patients with whom a physician has an established relationship. We routinely continue to care for patients who may disregard our advice by using honest and educational conversations. Some patients, particularly the underserved and those for whom the healthcare system hasn’t been supportive, may well have valid reasons to be suspicious—and those reasons may be identified through tactful and supportive listening.
Many, if not most, medical offices and hospitals still require masking for entry and care. Proper preventive examination and procedural protocols developed over the course of the pandemic will likely be sufficient assurance in caring for nonvaccinated patients in the clinical setting. Patients in exposure isolation or convalescing from a positive COVID-19 infection can be cared for by telehealth; it can also be an alternative for patients who are unvaccinated and concerned about exposure in a clinic setting. We used safe protocols to care for patients during the height of the prevaccination pandemic that are still valid for caring for unvaccinated patients—without refusing them care.
Lest this go unmentioned, it’s also appropriate for patients to understand their own responsibilities. The AMA Code of Medical Ethics Opinion 1.1.4 notes that patients should “be aware of and refrain from behavior that unreasonably places the health of others at risk. They should ask about what they can do to prevent transmission of infectious disease.” This would include following COVID-19 public health protocols in the clinic and hospital as posted and enforced. There are only very rare exceptions where patients could ethically be declined to be seen, and there would remain a responsibility for the declining physician to assist the patient to find appropriate care elsewhere.
For physicians who contend that they decline to treat unvaccinated patients as an exercise of conscience, the AMA Code of Medical Ethics Opinion 1.1.7 has a caveat to consider: “In following conscience, physicians should thoughtfully consider whether and how significantly an action (or declining to act) will undermine the physician’s personal integrity, create emotional or moral distress for the physician (or patient), or compromise the physician’s ability to provide care for the individual and other patients” and to “take care that their actions do not discriminate against or unduly burden individual patients or populations of patients and do not adversely affect patient or public trust.”
This is the key: We must always remember that we are part of the “healing” profession.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.