During an ER shift at the beginning of 2021, I was caring for a very sick patient presenting with shortness of breath, fatigue, and loss of smell and taste. She tested positive for COVID-19, and when I started asking her about vaccination status, close contacts, travel, etc., she informed me that neither she nor anyone in her family had been vaccinated against COVID-19. 

She said she regretted this decision now and asked if I thought she was a horrible person. I simply stated, “Whether you are vaccinated or not does not make you a horrible person.” I considered asking her why she chose not to be vaccinated, but decided against it, as medically stabilizing her was my priority. Unfortunately, she had to be intubated and admitted to the ICU.

 

'Why haven’t you been vaccinated?!'

 

 

As physicians, we must provide treatment in an emergency, regardless of vaccination status. However, in non-emergency settings, the ethical lines can become blurry, according to the AMA.

Smith T. No COVID-19 vaccination, no care? Why that’s the wrong path. American Medical Association. September 21, 2021.

 

 

Patients can often sense our resentment and judgment behind “Why haven’t you been vaccinated?” They already think we are arrogant and look down on them, and they are not completely wrong, as we are often guilty of judging our patients, consciously or subconsciously. 

As much as I believe that everyone should receive vaccines to prevent diseases, especially when these vaccines are based on evidence-based medicine, I equally believe that we cannot force our patients to do things they do not want to do.

Is this frustrating? Of course. I have had many heated discussions with my friends and colleagues about the downsides of shaming and judging patients who refuse to be vaccinated, as this is only making our patients further distrust the healthcare system. 

 

Having an open-ended discussion about vaccines

 

I feel like we have to start taking a different approach to caring for our patients, especially regarding vaccines, as lately, vaccinations have been the headliner of controversy, misinformation, and distrust within the healthcare system. How can we do this?

As physicians, we need to remember that our recommendation carries weight.

Brown MT, Lora AM, Anderson MC, et al. Resolving patients' vaccination uncertainty: going from "No Thanks!" to "Of Course!"Family Practice Management. 2014;21(2):22–26.

 

 

Physician recommendation is the most important factor influencing a patient's decision to be immunized, and most patients won't get vaccinated without a physician recommendation.

The key is to take the right approach in opening up a discussion about vaccinations.

• Be friendly and empathetic when your patient raises concerns about vaccinations.

• Asking, "What specific concerns do you have about vaccines?" is always a great starting point. 

• Explain the basics of how our immune system works and how a vaccine can boost the immune system.

• Willingly admit that vaccines are not perfect, and although they will protect against most viral strains, there is always a chance of mutation, resulting in the individual’s getting the virus. 

• If the patient still refuses the vaccine, be polite. Don’t pass judgment, and leave the conversation open for any future questions. We do not want to dismiss the patient or make them feel shame. 

 

Can we refuse care to the unvaccinated?

 

With regard to delivering care to unvaccinated patients, the AMA’s Elliott Crigger, PhD, director of ethics policy and secretary to the AMA Council on Ethical and Judicial Affairs, put it succinctly: 

A patient’s vaccination status in and of itself is not sufficient reason, ethically, to turn that individual away.

As physicians, we technically have the legal right to refuse treatment to unvaccinated patients in our office (in non-emergency settings). If you strongly feel this is how you want to run your practice, it is important to inform your patient population of this rule, such as with a sign on the door and through email or a letter. 

Additionally, it is important to follow the AMA’s guidelines on circumstances that may affect refusal of care, or not: 

• In an emergency setting

Physicians should not ethically refuse to provide care regardless of the patient’s vaccination status. However, a physician may decline to provide care for an unvaccinated patient in a routine care setting, such as an annual exam for a healthy patient. 

• With an immunocompromised patient population

If the patient population includes pediatric or geriatric patients, or those in an oncology or infectious disease practice, and if there is a risk that an unvaccinated patient could potentially infect an immunocompromised patient in the practice, then it may be ethically sound to decline treatment to an unvaccinated patient. 

Questions to ask in making the decision include the following:

• Can practice-wide infection control efforts be made to accommodate unvaccinated patients? Things such as separate waiting rooms, separate examination rooms, and telemedicine, could help separate the unvaccinated patient population from the vaccinated patient population.

• Can the practice provide proper and widespread personal protective equipment to all healthcare workers who come in contact with unvaccinated patients? 

• Can the patient be educated, informed, and persuaded to accept vaccination? One of our main duties as physicians is to educate our patient population. 

 

And if we do refuse care …?

 

The main problem with refusing care to unvaccinated patients is that these patients will seek medical care elsewhere. We may be keeping unvaccinated individuals out of our waiting rooms, but they will come into contact with other individuals in the classroom, on the playground, at work, at school, or in other public places.

Neuhofel R. Should We Reject Unvaccinated Patients? American Academy of Family Physicians. 2023.

 

In sum, the AMA and the American Academy of Pediatrics stand behind this school of thought: 

Despite an American Academy of Pediatrics policy discouraging practices from discharging patients because of parental refusal to vaccinate,

Diekema DS, and the Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics. 2005;115(5):1428–1431.

 

a growing number of pediatric practices are doing just that.

Gavett G. Doctors to Parents: Get Your Child Vaccinated, Or Get Out. Frontline. February 16, 2012.

It is our duty to protect our patients from unnecessary harm, but how to promote the best public health in our communities is a complex issue. 

 

By barring the unvaccinated, we might be able to lower the risk of sick patients spreading infection in our waiting areas and exam rooms, but this practice fosters a false sense of security. Our patients are just as likely to come in contact with unvaccinated sick children elsewhere, as has occurred with measles.

Clemmons NS, Gastanaduy PA, Fiebelkorn AP, et al. Measles — United States, January 4–April 2, 2015. Morbidity and Mortality Weekly Report (MMWR). 2015; 64(14);373–376.

And if they seek care at walk-in retail clinics, urgent care centers, or ERs, those places cannot possibly proactively screen vaccine status or refuse care.

 

The AMA Code of Ethics says that, in general, no, a physician should not refuse a patient because the individual is not vaccinated or declines to be vaccinated.

Can physicians decline unvaccinated patients? American Medical Association. September 15, 2021.

However, the strength of a physician’s obligation to treat may vary under different circumstances, and determining whether, in a particular instance, a physician may ethically decline a patient requires careful reflection. 

 

In the context of a highly transmissible disease that poses a significant risk of severe illness for which a safe, effective vaccine is available, the decision to accept or decline a patient must balance the urgency of the individual patient’s need, the risk the patient may pose to other patients in the physician’s practice, and the need for the physician and staff to be available to provide care in the future.