Vaccine Mandates: A Transplant Recipient's Perspective

Amy Silverstein


American Journal of Transplantation. 2022;22(2):335-336. 

In this issue of the American Journal of Transplantation, two articles highlight recent COVID-19 vaccine mandates for transplant recipients.[1,2]

As a heart transplant recipient of nearly 34 years, I am decidedly in favor of mandatory COVID-19 vaccination for all organ transplant candidates and health-care workers. My viewpoint is rooted in patient-centric truths that come from my hard-earned experience in the transplant trenches. Also central to my commentary is an insistence on seizing the present moment to speak frankly, as transplant time waits for no patient. With this in mind, here is some straight talk: Those who wish to live with a transplanted organ (or work in close proximity to one) should abide mandatory COVID-19 vaccination in the same way we accept the fundamentals of transplantation—that is, with awareness that the extraordinary benefit we receive is commingled with complexities, shortcomings, and even antipathies.

Organ transplantation is a privilege, not a right. The scarcity of donor organs and the imperative of stewardship are well documented and discussed. Evaluation of candidates for transplant is the clinical manifestation of an exacting effort to balance ethics, medicine, and management of a limited, lifesaving resource. Accordingly, transplant candidates are prescreened and put through a battery of tests, both medical and psychological, to ensure they will be suitable hosts to maximize the net utility of these precious gifts. Surmounting each of these hurdles to transplant candidacy is mandatory even if patients object vigorously to one or more of them. Why should a COVID-19 vaccination requirement be an exception?

As my transplant cardiologist told me on the first day I met him, "There is no free lunch in transplant." Instead, the hard truth is that transplantation—both pre and post—is a responsibility. It comes with doing medical things that you, the patient, never imagined you would have to do. Things that go against what you believe is right. Things that seem harmful, horrible, even unthinkable. Like suppressing the most health-giving system in your body (immune function) and living with the repercussions of this ongoing deficit. Or taking drugs that, if successful long term, are likely to give you cancer. And how about having pieces of your newly transplanted donor heart, liver, kidney, lung, or pancreas plucked out for biopsy again and again over time, leaving irremediable scarring in its wake? I have had something like 98 heart biopsies and found every one of them deeply objectionable, not to mention unnecessary (none of them showed actionable results) and mind-bendingly difficult to take on and tolerate.

Transplant is not for the faint of grit. Obligation to a donor organ is not met by referring first to one's own proclivities, beliefs, and standards. In this way, transplant is a humbling existence because the price of life means saying yes to medical undertakings that sometimes go against what you want, agree with, or believe to be good for you. Transplant can blow your mind that way.

I understand that some have argued against mandatory vaccination citing a lack of reliable data to quantify risk reduction (although most acknowledge at least a marginal benefit). To this, I say: "Welcome to transplant medicine!" where the operative rule is "We do our best, given what we know" and perfect precision always seems to be just out of reach. Yet, despite this uncertainty, transplant physicians give (and patients accept) treatments, medications, and invasive tests routinely, notwithstanding the physical and psychological costs. It seems to me that the "cost" of a mandated COVID-19 vaccine is remarkably small by comparison.

I am not suggesting that if a patient refuses a vaccine, they might not take their immunosuppressive medicines. My point is this: If you cannot fathom a COVID-19 vaccine for yourself, hold onto your hat once you receive your transplant. The transplant journey is a rodeo and patients mount the horse and start galloping the moment they become candidates on the waiting list. Hold tight and get vaccinated, buckaroo. It is going to be a bumpy ride.

Finally, regarding health-care workers in transplantation, it is hard to understand why we would allow these individuals to present a clear and present danger to those under their care. But beyond this, the imperative of vaccination for transplant health-care workers is central to patients being able to carry on in their complex medical lives. Consider for a moment what it is like for transplant recipients to seek much needed care from the many physicians outside their transplant centers. Most every medical appointment is an adventure in self-protection—like when a gastroenterologist tells you to take some Pepto-Bismol (Uh, I can't) or an ER doctor hands you a little cup with Advil in it for body aches (No, not allowed—ever). These encounters have left me feeling a little freakish and frustrated as I try to figure out what to do when a doctor says, "You're a transplant patient. I can't possibly know how or what…"

Only within the walls of our transplant centers, cared for by staff we have come to know from multiple visits, can we patients let our guards down. Surrounded by health-care workers who are immersed in transplantation, we can relax into a feeling that we cannot experience in any other medical environment: a sense of being normal. We can let our shoulders drop from our ears because no transplant health-care worker is ever going to hand us an Advil. Without mandatory vaccination, patients lose this valued sense of calm and trust. An increased risk of COVID-19 is only part of the picture, you see. Unvaccinated transplant health-care workers threaten the one source of medical refuge we patients can rely on: the perceived safety of our transplant centers.

And so, I must come out on the side of mandatory vaccination for all transplant candidates and health-care workers. The considerations are numerous, and I have only named a few as they stand out to me as a patient. But many aspects of transplantation have traditionally required difficult balancing for practitioners and unpalatable "mandates" for patients. COVID-19 vaccination does not add to these aspects. It simply illuminates them.