The ongoing pandemic has raised complex, often troubling ethical issues for medical professionals. In addition to the enormous emotional and logistical burdens imposed by caring for those with COVID-19, there is now the stress and ambivalence in dealing with patients who have refused vaccination against SARS-CoV-2 infection.
In this dialogue, neurologist Dr Andrew N. Wilner and psychiatrist/medical ethicist Dr Ronald W. Pies discuss the unique conundrums physicians face when it comes to vaccinations and patients, beginning with this clinical vignette:
A 67-year-old man with a history of obesity and moderate hypertension seeks "holistic" treatment with an internist during the COVID-19 pandemic. The patient appears to be in no acute distress. The patient has noticed on the physician's website that he often incorporates "natural" healing methods into treatment regimens (which is true). The patient says he would like to explore "herbal remedies" and "meditation" as treatments for his hypertension, and does not want to take prescribed drugs. He has consistently refused vaccination against SARS-CoV-2 because he doesn't believe "in putting virus particles into my bloodstream that will rewrite my DNA code." The patient does not trust the opinions on vaccination promulgated by "the so-called experts." The patient is willing to consider only "natural" treatments that "boost the immune system, like those omega-3 fatty acids I've read about," but will definitely not accept vaccination, despite the internist's accurate explanation of mRNA-based vaccines.
Andrew N. Wilner, MD: Ron, I think this hypothetical vignette will ring true for many docs. To the physician, patients who refuse COVID vaccination are making an irrational decision that places themselves and others at risk of serious illness and death.
This situation raises a number of questions: Is this physician ethically obligated to accept this patient as a new treatment case? If so, under which theory of medical ethics? If not, why, and what is the ethical course of action for a physician who refuses to establish a relationship with an unvaccinated patient?
Ronald W. Pies, MD: Those are tough questions, Andrew. My off-the-cuff, oversimplified response is that this physician is probably not ethically obligated to accept this particular patient for treatment, for reasons I'll outline later. But I think it's helpful to back up and review some of the basic principles of medical ethics that should guide a physician's decision in such cases.
Wilner: Well, in that regard, I was looking recently at the preamble to the American Medical Association (AMA) Code of Ethics. It seems to me that there's a tension in the code, if not a contradiction, that's hard for me to resolve. Specifically, section VI reads, "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."
But then, section IX reads, "A physician shall support access to medical care for all people." [emphasis added]
Aren't these principles pulling us in different directions? As a physician, I have never refused to treat anyone, even if their disease is self-inflicted, or I don't agree with their life choices (ie, criminals, smokers). Accepting anyone and everyone seemed a basic tenet of the practice of medicine, but I'm not sure where I got that idea. It's not in the Hippocratic Oath, anyway.
Pies: There's definitely a tension between those two sections, though maybe not a contradiction. After all, supporting access to medical care "for all people" doesn't mean "under any circumstances, no matter how medically inappropriate a patient's demands."
And you're right that the Hippocratic Oath doesn't directly address the "Must physicians take all comers?" question. However, there is a line in the Oath that may reflect the attitude of Hippocratic physicians. It reads, "Into as many houses as I may enter, I will go for the benefit of the ill..." That's a pretty wide scope of practice!
And in his classic book The Hippocratic Oath and the Ethics of Medicine, physician Steven H. Miles notes that "...people from all walks of life sought out and paid Greek physicians for health care. Cobblers, vine tenders, shepherds...soldiers, potters, prostitutes...[and] slaves..." So, I suspect that Hippocrates would generally be of the view — perhaps with some exceptions — that it is our obligation to "take all comers."
Seeking Ethical Guidance From Physicians' Associations
Wilner: Okay, that's been my orientation, but what about section VI in the AMA's Code?
Pies: Section VI does give the physician some leeway in non-emergent situations. And that's a critical point in our vignette, where the patient is essentially "doctor shopping" and in no acute distress. But our hypothetical patient is placing a number of strict conditions on his care — for example, avoiding prescribed medications — that may be unacceptable to most physicians.
And COVID vaccine refusal may be a deal-breaker for some physicians, particularly during a pandemic that has killed more Americans than the 1918 flu pandemic and led to considerable "empathy fatigue" among medical personnel. I know I've found it hard to be empathic toward vaccine refusers.
Wilner: I confess, I'm all out of empathy for vaccine refusers for many reasons, not the least of which is that I have a son who is too young to be vaccinated. Many other parents face the same situation. The world is already a dangerous place for children, without adding the risk of suffering or even dying from a preventable disease!
So, Ron, if a physician believes that what a patient is requesting is medically unreasonable, scientifically invalid, or even "crazy," does the physician have a right, in non-emergent situations, to decline to treat the patient?
Pies: Well, that question takes us on a "deep dive" into the ethical guidelines developed by both the AMA and the American College of Physicians (ACP). Physicians of conscience are likely to differ on these matters, but we can at least say this much.
First of all, the AMA Code of Medical Ethics, in opinion 1.1.2, makes it clear that "...physicians have an ethical obligation to provide care in cases of medical emergency." That's pretty clear, although there may be some disagreement about the definition of "emergency." For example, one might argue that the pandemic itself is a "national emergency."
In any case, the opinion also states, "Nor may physicians decline a patient based solely on the individual's infectious disease status." I interpret this as saying that we can't refuse to care for someone solely because the patient has an infectious disease, whether HIV/AIDS or COVID-19. But, as I'll discuss shortly, it also implies that — with a few exceptions — we can't refuse to care for unvaccinated patients.
Wilner: Yes, I recall that during the HIV epidemic, there were physicians who were reluctant to treat those patients, especially at the beginning when the etiology and transmissibility of HIV was unknown. Despite these unquantifiable risks to themselves, most physicians bit the bullet and provided treatment. Of course, unvaccinated patients don't necessarily have an active disease — at least, not yet.
Pies: I remember those scary HIV years. In fact, the ACP ethics manual clearly states, "Physicians and health care organizations are obliged to provide competent and humane care to all patients, regardless of their illness" — period. And AMA opinion 1.1.2 states, "Physicians may not decline to accept a patient for reasons that would constitute discrimination against a class or category of patients."
Are 'Anti-Vaxxers' a Protected Class?
Wilner: Okay, but what does "class or category" really mean? Is the AMA Code referring specifically to race, gender, sexual orientation, and similar demographic features? Or would "the unvaccinated" constitute a "class or category"?
Pies: It's a bit ambiguous. "Class or category" certainly covers demographic and personal features, like race, gender, sexual orientation, etc. And it would clearly prohibit discrimination against people who have actual COVID-19–related illnesses. But just in mid-September, the AMA came out with a very strong statement regarding discrimination against unvaccinated patients. We don't have space to cover it all, but the key passage is this:
In general...a physician should not refuse a patient simply because the individual is not vaccinated or declines to be vaccinated. The commitment to care for those who are sick or injured carries with it a duty to treat in other circumstances as well, including public health crises when a physician may face "greater than usual risks to [their] own safety, health or life..." Nor may a physician ethically turn a patient away based solely on the individual's infectious disease status, or for any reason that would constitute discrimination against a class or category of patients (Opinion 1.1.2, Prospective patients).
So, that's the gist of it. However — and in medical ethics, there's always a "however" — the guidelines go on to note that "the strength of a physician's obligation to treat may vary under different circumstances..." For example, it may be ethical for a physician to refuse to treat an unvaccinated patient if accepting him or her "would pose significant risk to other patients in the practice..." such as immune-compromised patients. Similarly, physicians may decline to treat an unvaccinated patient "if meeting the individual's medical needs would 'seriously compromise' the physician's ability to provide care needed by their other patients."
This whole controversy flared recently when an Alabama family physician posted a sign on his office door saying that, as of October 1, he "will no longer see patients that are not vaccinated against COVID-19." According to reports in the press, the doctor then sent letters to his current patients saying, "I cannot and will not force anyone to take the vaccine, but I also cannot continue to watch my patients suffer and die from an eminently preventable disease...If you wish to choose another physician, we will be happy to transfer your records."
Several medical ethicists criticized this doctor for these actions. For example, psychiatrist and ethicist Dr Aaron Kheriaty commented, "The logic employed here would never be applied elsewhere in medicine," citing examples like discharging obese patients for failing to lose weight or refusing to treat people with addiction who haven't achieved sobriety. He added — implicitly invoking the "class or category" argument— "A blanket condemnation of all the unvaccinated is unwarranted, and unworthy of the profession of medicine."
Wilner: Well, also, the reason that doctor gave — that he can't stand watching his patients suffer — is that really a legitimate reason to refuse care? Self-induced illness isn't rare. I've treated many patients dying of alcoholic cirrhosis, for example. Isn't bearing with our patients' suffering part of being a physician?
Pies: Exactly right! Most medical ethicists would say that avoiding suffering is not a valid reason for refusing care. Now, we might reason differently if the Alabama doctor had cited, say, "the health and safety of his staff and his other patients" as a reason for declining care for a "particular patient or patients," as per the new AMA guidelines.
We know that the COVID-19 vaccines reduce the likelihood of viral contagion. In fact, Dr Linda Marraccini, a primary care doctor specializing in family medicine, sent a letter to her patients informing them that they could not be treated in person if they were not vaccinated by a specific date, explaining, "We will no longer subject our patients and staff to unnecessary risk..." Interestingly, she said she would still treat unvaccinated patients via telemedicine, which seems reasonable, given the rapid spread of the Delta variant.
When Refusal to Provide Care May Be Warranted
Wilner: Broadening out the issue a bit, does the AMA or the ACP Code specify other circumstances in which physicians can decline to provide care in non-emergent cases? What about when some request violates the physician's conscience, like, say, performing abortions?
Pies: Yes, the AMA Code says that, in non-emergent situations, a physician "may decline to establish a patient-physician relationship with a prospective patient, or provide specific care to an existing patient...[when] the patient requests care that is beyond the physician's competence or scope of practice; is known to be scientifically invalid, has no medical indication, or cannot reasonably be expected to achieve the intended clinical benefit; or is incompatible with the physician's deeply held personal, religious, or moral beliefs in keeping with ethics guidance on exercise of conscience." [emphasis added]
Now, going back to our vignette, the physician might very well argue that it is "scientifically invalid" to exclude all prescription drugs to treat hypertension, as the patient requests, and to rely only on "herbal remedies" and "meditation."
Similarly, the ACP Code states that the physician "is not required to violate fundamental personal values, standards of medical care or ethical practice, or the law. When the patient's beliefs — religious, cultural, or otherwise — run counter to medical recommendations, the physician is obliged to try to understand clearly the beliefs and viewpoints of the patient. If the physician cannot carry out the patient's wishes after seriously attempting to resolve differences, the physician should discuss with the patient his or her option to seek care from another physician."
And there are very specific things a physician must do to assure continuity of care when transferring care to another physician or terminating care, lest he or she risk the charge of abandonment.
Wilner: I think we can agree that the physician in our vignette is not obligated to treat that particular patient, given the non-emergent situation and all the inappropriate conditions the patient insisted on. But it seems the AMA is saying that had the patient been willing to follow all the physician's recommendations — except getting vaccinated — the physician would be wrong to reject the patient simply on the grounds of vaccination refusal. Is that right?
Pies: Yes, that's right, allowing for the exceptions mentioned earlier. A lot will depend on the physician's practice, the population he or she treats, the risk posed by an unvaccinated patient, etc.
Wilner: And what about the availability of other physicians? How does that figure into the equation?
Pies: Yes, the ACP Code states that, "Under rare circumstances, the physician may elect to discontinue the professional relationship, provided that adequate care is available elsewhere and the patient's health is not jeopardized in the process..." This means that if the physician decides to discontinue treatment with an unvaccinated patient for ethically justifiable reasons, it is still incumbent on the doctor to help that patient find adequate care elsewhere.
Clearly, this will be much harder for, say, a solo physician in a small, rural town vs a physician in a large city with many physicians.
Wilner: One final question: Do patients have ethical obligations, too, in working with us physicians?
Pies: Arguably, yes, they do. For example, section 1.1.4 of the AMA Code, under "Patient Responsibilities," states that the patient should, "refrain from behavior that unreasonably places the health of others at risk...," including knowingly spreading infectious diseases.
Of course, the AMA and ACP provide ethical guidelines, not binding legal regulations, and neither physicians nor patients are legally obligated to obey these codes.
That said, I think the bottom line, ethically speaking, is still this, from the ACP's guidelines: "Physicians and health care organizations are obliged to provide competent and humane care to all patients, regardless of their illness."
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Cite this: Is It Ethical to Turn Away New Patients Who Refuse COVID-19 Vaccinations? - Medscape - Oct 20, 2021.