Should Doctors Refuse to Treat Unvaccinated People?

ETHICISTS DEBATE

Should Doctors Refuse to Treat Unvaccinated People?

A story appeared on August 17 in the Alabama News with the headline, “Alabama doctor says he won’t treat unvaccinated people: “COVID is a miserable way to die.”

Tarris Rosell, DMin, PhD, Rosemary Flanigan Chair, sent a link to the article to colleagues on staff at the Center for Practical Bioethics, asking three questions:

• Punishment or persuasion?

• Patient abandonment or physician’s right?

• Commendable or unethical?

Erika Blacksher, PhD, John B. Francis Chair, responded to Dr. Rosell, which led to the following lightly edited dialog, which we believe presents important ethical considerations. Please note that their thoughts are framed by an understanding of the facts of the case as presented by the reporter.

BLACKSHER:  Should doctors not treat obese patients on grounds that they will not control their weight? Should doctors not treat lung cancer in patients who have smoked all their lives on grounds they should have quit or never started? Should doctors not treat diabetic patients who do a lousy job of managing their diet? 

I’ve always argued against personal responsibility for health arguments on a variety of moral grounds, including these. That not treating these patients: 

(1) holds people responsible for conditions and situations not fully under their full control or whose health-consequential habits were set in early in life; 

(2) would violate a physician’s duty to treat those who are ill and vulnerable, regardless of causation; and furthermore, 

(3) that the origins of poor health and disease are manifold with behavior being only one among other causative factors. (The County Health Ranking Logic Model attributes 30% of preventable morbidity and premature death to behavior, 40% to social/economic environment, 10% to physical environment, and 20% to clinical care.) 

COVID cases are, however, different from these chronic disease cases in some ethically important ways, the most potent being:

(1) Causation is much more linear: no vaccine = vulnerability to sickness and potential death, and 

(2) This is a highly transmissible infectious disease that imposes serious other-regarding harms (health and economic) to individuals, communities, and society as a whole given the need for herd immunity. 

Still, some of the other concerns about personal responsibility remain relevant: 

(1) Social circumstances may make it difficult for some people to get the vaccine. For example, people may have to juggle multiple jobs, childcare and eldercare or may be hundreds of miles from the nearest pharmacy or vaccination site, or may worry about the cost, even though COVID-19 vaccines are free to all.

(2) People may not understand the science of infectious disease and vaccines and so may be vulnerable to misinformation or disinformation or overestimate the chances of side effects. 

But, Terry, I am very sympathetic to the fact that healthcare providers and anyone who is vaccinated are frustrated and angry and have good reasons to be.

ROSELL: Erika, I agree with you that, “COVID cases are, however, different from these chronic disease cases in some ethically important ways.”

Probably the Alabama primary care physician who is requiring COVID vaccination of patients who wish to remain his patients could agree with both of us about professional obligations versus personal (patient) responsibility in chronic care. 

However, I think he could have a ready rejoinder to your proposed arguments for why those considerations apply to COVID vaccination as well. Dr. Valentine might respond:

• If one of my patients say they have had insufficient time or access for immunization, we can offer them an appointment to be immunized at our clinic, and without cost to the patient.

• If a patient expresses misunderstanding of the vaccine and/or COVID, we can offer medical information and advice. That’s what doctors do.

If Dr. Valentine’s patient chooses NOT to take the appointment and also refuses medical counsel, that sounds like a choice to be seen elsewhere or nowhere. Not so?

BLACKSHER: I don’t disagree with you, Terry. That patient appears to be making a choice. Yet I am deeply ambivalent about triaging medical services on the basis of people’s choices rather than the patients’ needs even in the midst of this pandemic. The prospect of physicians refusing to care for patients whose ‘covid was their own dang fault’ is horrific to my mind. Where does such reasoning lead? What sorts of practice precedent does it set? 

Decades ago, a personal responsibility advocate argued that, when calculating the global burden of disease, the calculation should not include diseases caused by smoking —as if people’s choices can be cordoned off from the societies, communities and families in which they grow up and live, the peer networks and information to which they are exposed, and the stressors they deal with day in and out. Such a suggestion oversimplifies disease causation and makes no room for social responsibility. I think there are constructive ways to encourage personal responsibility for health, but any such effort must create environments that support healthy choices. I want to find other ways to persuade more people to get vaccinated.

ROSELL: Erika, I too want “to find other ways to persuade more people to get vaccinated.” And we have done so. Creating lotteries. Financial and other incentives. Recruiting ministers to preach vaccination from their pulpits. Public Service Announcements depicting sports and music stars, politicians and other celebrities rolling up their sleeves. We’re using empathy instead of shaming. Persuasion over coercion. And some of it’s working. But not nearly enough or quickly enough. We’re in a global pandemic of nearly two years duration. Delta variant surges have our hospital-based physician colleagues shaking in their boots, if they’re not too exhausted to move at all. 

This is a public health emergency. Emergencies warrant innovative means toward ends of human survival. It entails risk-taking. One family physician in Alabama took the risk of innovative action. At least he has gotten our attention. That is some sort of success in the midst of public chaos.

You also wrote: “The prospect of physicians refusing to care for patients whose ‘covid was their own dang fault’ is horrific to my mind.”

And to mine. Yes. 

But is that what Dr. Valentine is reportedly doing? What I read is that he aims to communicate with all of his patients that he recommends vaccination, and that if they choose otherwise, he can no longer be their doctor—for reasons given. Ought he send that letter? Does this constitute patient abandonment? Those are questions to discuss. 

I have not heard of anyone who is refusing or threatening to refuse care to actual current COVID patients on grounds that it was their own fault. Some (all?) providers surely feel frustrated by needing to care for COVID patients with a mostly preventable illness. So do I. Indeed, it seems obvious that we each do bear some responsibility for our own COVID illness if that is a result of having chosen to not get vaccinated. Even so, if that patient shows up at the ER or Urgent Care, they will be treated like everyone else, on grounds of EMTALA (Emergency Medical Treatment and Labor Act) if nothing else. 

Now, if a patient who used to see the Alabama doc for primary care still chooses not to get vaccinated after receiving the physician’s letter, then gets COVID and wants a non-urgent appointment, it appears they’ll need to look elsewhere. Probably Urgent Care or ER. At this point, I’m not convinced they are harmed by their former primary care provider thereby. Rather, this does seem to me to be a matter of the patient’s personal responsibility. We all make choices and live with the consequences—in this case, that of needing to find another primary care physician. 

Pediatricians have debated this issue for years. Some have sent those letters to parents who refuse to do childhood immunizations. “Vaccinate or find your child another pediatrician.” The rationale typically is that unvaccinated children pose a risk to other patients and especially to immuno-compromised persons in the clinic environment. This situation seems more ethically complex to me given that it involves pediatric patients without personal responsibility whatsoever. 

But adult patients refusing COVID vaccine? I am unable to make a cogent argument, thus far, that would fault Dr. Valentine for his stated stance. It might be that more primary care docs need to follow suit so as to incentivize vaccine-reluctant/refusing patients to do the right thing for themselves, their loved ones and the rest of us. Otherwise, a lot more people may suffer and die needless COVID deaths for years to come, including the wholly innocent, especially children. That is ethically weighty. 

I think this is an important discussion.