Only Physicians — Not Others — Should Grant Vaccine Exemptions, Says Ethicist

Arthur L. Caplan, PhD


March 09, 2022

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I run the Division of Medical Ethics at the New York University Grossman School of Medicine.

We have had quite a war in America and in many other countries, too, about vaccine mandates. Mandated vaccination is something that the Biden administration tried to push through for employers, but the Supreme Court tossed it out. However, there are many vaccine mandates littering the landscape of the United States and other countries.

Austria just put in a vaccine mandate for every citizen. You have to show proof of vaccination or you pay, on the spot, a $600 fine. NYU, where I work, has a vaccine mandate in place for all healthcare workers — anybody who has an ID that is part of the NYU health system. Many colleges and universities required or mandated COVID-19 vaccination to go back to school in person. There are plenty of businesses, despite what the Supreme Court said about the president's authority, that have imposed vaccine mandates.

The interesting thing about a mandate is that it can vary from very strong, like in Austria (show me a card on the spot), to moderate (you can't come to work, go to school, or enter a restaurant without showing proof of vaccination), to relatively weak (we're going to have an honor system that says you probably did vaccinate to come to this sports event, but we're not checking closely).

We've had mandates that range from fairly tough to fairly weak. In every instance that I know of vaccination, there's always been, with a mandate, a possibility of an exemption. Those exemptions fall into two main categories.

One is a medical exemption, where I can't be vaccinated because I have an allergy or a health problem that might be exacerbated if I were to get a COVID-19 vaccine. Another is if I have a religious objection and don't want to take the vaccine because it violates my religious ideas. Sometimes that's extended over to philosophical objection, meaning that it's something out of conscience I don't want to do or I just choose not to do it. It's not grounded in some claim of religious belief, that it violates some religious tenet. It's just a choice that ought to be respected.

Well, all of this sometimes winds up in the office of the doctor. The question becomes, "Who can grant those exemptions?" There are many people showing up at the doctor's office asking, "Could you give me a medical exemption?" I think the answer is that you cannot and should not unless they really do have a medical condition that exempts them.

For COVID-19 vaccination, there are very few things that would exempt you. For the flu vaccine, maybe you could claim an egg allergy. For some other vaccines, there might be other medical indications that would exempt you. Some people don't have an immune system, so there is no point in vaccinating them. They can't build up anything by way of antibody resistance. Maybe only in a few instances you should be thinking about an exemption.

What about the religious or philosophical exemption? I think you want to look for requests that are made in good faith and good conscience. Do you know this patient or are they just showing up out of the blue saying, "I want to get an exemption because I have a religious belief."

If they can explain what it is that they object to, rightly or wrongly, then probably, as a physician in good conscience, you might give them the exemption if you're persuaded that they're sincere and their belief is authentic, not something they're just making up out of fear of vaccines or misunderstanding of the dangers of vaccines.

The AMA recently suggested that it ought to be physicians or people supervised by physicians who have the ability to grant exemptions. I tend to agree. There are too many people out there doing homeopathy, natural healing, or who are licensed as chiropractors who are waiving vaccination mandates. I don't think they have the knowledge, and many of them are opponents of vaccination, which isn't the place I want society to turn to get exemptions.

You at least have to be well informed about the importance of vaccination and the safety of vaccination. It doesn't make sense for somebody to say, "Well, part of my healing practice is that I'm anti-vaccine, so come see me and you're going to get exemptions."

I don't think that protects the public health. I don't think that's an honest assessment of why someone might be vaccine hesitant, and I don't think that's a place to try to get educated about the reality of what's a danger from vaccines vs from COVID-19. Getting COVID-19 really is a heck of a lot more dangerous than getting vaccinated.

I know there's been political fighting about who can give an exemption. I know there are huge fights between mainstream medicine and alternative healers about their authority and their ability to license.

In this instance, it does seem to me that when we're in a plague or for a future plague, we ought to be tough in the name of public health and make sure that we don't invoke anti-vaccine opponents as the place to seek vaccine exemptions.

I'm Art Caplan at the New York University Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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