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.

Eight Principles and Practices for Ethical Vaccine Distribution: A Proposal

The COVID-19, once-in-a-century, pandemic has now exceeded a year in duration. Nerves are frayed and relationships are strained. This is evident within families, communities, healthcare systems, and institutions of government. Hope, in the form of declining cases and hospitalizations and a vaccine, is on the horizon and yet we are literally at our wits end. Now more than ever, we need to think carefully and not just emote. We need more dialogue and less monologue, civil discourse instead of incivility posted to social media. We need to take the time to deliberate and exhibit virtue rather than vice, to replace narcissism with altruism. This is particularly true now in regard to vaccine allocation, hesitation, and resistance.

As a public health physician-leader and a bioethicist, we, like everyone else, are also citizens, impatient with pandemic restrictions and the scarcity of COVID vaccine. Having put aside our own frayed nerves and emotions so as to think and to dialogue, we have come to agreement on a set of principles and practices for ethical vaccine distribution that we hope might be helpful even beyond this pandemic. All of us bear responsibility; and we call upon our leaders especially—in state government, county or municipal health departments, and all healthcare institutions—to demonstrate fidelity to the following commitments:

1. Allocate and distribute vaccine in keeping with agreed upon protocols and without ethically unjustifiable deviation. Seek community member input to establish local protocols and factor the social determinants of health into risk stratification. If examples are needed, it is hard to imagine ethical justification for offering scarce vaccine to one’s institutional benefactors, boards of directors, or most others who fall outside of the agreed upon protocols.

2. If there seems justifiable reason to engage in practices of vaccination that fall outside of agreed upon protocols, first engage in dialogue with colleagues who have fully acknowledged their conflicts of interest so as to check one’s assumptions and build collegial trust rather than erode it.

3. Vaccinate the greatest number possible in the shortest time possible—and not without regard to other fundamental ethics commitments related to equity and justice.

4. Exercise transparency through frequent and voluntary release of all vaccination data for public analysis. Engage with local community representatives and stakeholders in a discussion of these data and in an effort to adjust protocols as necessary in response to this data and in an effort to further promote equity.

5. Reassess vaccine allotments to county/municipal health departments in comparison with those allotted to healthcare institutions, local pharmacies, and others. Build communication channels now so as to ensure equity of vaccine access to those most vulnerable to this coronavirus.

6. Seek new and improved means for getting vaccine to vulnerable persons who lack equitable access for appointment sign-ups, transportation to vaccination sites, or even news of availability. Talk to community members and test innovations until every possible individual, even those initially hesitant or resistant to vaccination has been repeatedly offered the vaccine at no cost and at a convenient time and location.

7. Assess practices pertaining to distribution of vaccine “leftovers”. Strategize means of avoiding waste while maximizing opportunity of access to those who most need the life-saving protection that vaccines promise.

8. Address vaccine hesitancy among individuals and groups with respect, acknowledging that some distrust of vaccine may be justified and is grounded in misinformation or disinformation, while much hearkens back understandably to historic racism and systemic injustice. Repeatedly dialogue with those who are hesitant over time, so that they have multiple opportunities to reconsider and until the pandemic is completely over and can no longer impact the most vulnerable, even in small numbers. Consider intense involvement of trusted health care professionals and primary care providers in this effort.

We acknowledge that the healthcare leaders, institutions and organizations of our country are well intended, perhaps more so than many of us who are simply impatient and too often self-absorbed. Healthcare facilities and professionals have been battered and pummeled over the last twelve months. Despite intense pandemic stress they have done their best in the hardest of times with insufficient resources; and now they face a massive shortfall of vaccine. Logistics are challenging, to say the least. Form the beginning, our healthcare system has done much with far too little, from PPE to staffing. And yet our society can and must do this better, with more collegiality, communication, empathy and professionalism. Each of us as citizens are responsible for promoting justice as well. We are making a commitment to vaccine equity, to personal altruism and community solidarity. We call upon our friends, neighbors, colleagues, and acquaintances in many places to do likewise.

By K. Allen Greiner, MD, and Tarris Rosell, PhD, DMin

About the Authors:

K. Allen Greiner, MD, MPH is Chief Medical Officer with the Unified Government Public Health Department, Kansas City, Kansas.

Tarris Rosell, PhD, DMin holds the Rosemary Flanigan Chair at the Center for Practical Bioethics, Kansas City, Missouri.

The Truth of COVID-19: An Ethicist Reflects on His Experience

I have been honored and privileged to serve the Kansas City region through my work at the Center for Practical Bioethics during this challenging year of COVID-19. My role has grown during this pandemic, as I share in the work of providing ethics services in several hospital systems in the region. This has involved front-end work, including structure and policy development, as well as groundwork such as conducting clinical ethics consults and supporting medical staff with ethics education and guidance. I am grateful to help our hospitals and health systems prepare for, manage and move forward in facing the ethical challenges of the pandemic. 

But this role comes with an additional emotional burden. While I share in these organizations’ successes as they build and grow ethics services, I also share in their hardships and challenges as we work to address highly unusual and sometimes unprecedented ethical issues. This access and knowledge have led me to a foundational truth about the COVID-19 pandemic: People are our greatest resource, and they are not an unlimited one. 

Every one of the healthcare workers I’ve encountered is exceptional, and exceptional people step up and grow during the most challenging times. That is exactly what I have seen this year. As a society, we place high expectations on healthcare workers. We take advantage of their skills and rely on their dedication. When patients arrive at the ER, we expect fast response and quality service. When patients receive a cancer diagnosis, we expect the marvels of medicine and intimacies of compassion. When a family member is in the ICU, we expect the best care possible. These expectations exist because that is what healthcare workers deliver, day after day after day. And when a global pandemic uproots our lives and threatens the health and safety of everyone, new expectations are placed upon healthcare workers. And again, they rise to the challenge. 

A Finite Resource

But this resource is not infinite. Why? 

• Hospitalizations Rising –  Not every hospital is at maximum capacity or needs to implement crisis standards of care. But after months of challenges and difficulties for our healthcare workers, we are entering a new time with more expectations. In the beginning of the pandemic, we faced the crisis related to shortages of PPE (personal protective equipment). Now we must face the possibility of a shortage of those who wear the PPE. As hospitals reach new levels of capacity and with new COVID-19 units being established, staffing is stretched to extremes. There are potentially not enough qualified clinical staff to care for the levels of patients in need of care. This is only expected to worsen as infections spread.

• Moral Distress – Distress from being required to do things that conflict with one’s conscience, professional duty and moral principles is particularly stressful now for front-line healthcare workers. These are individuals who are making the decision to go to work, day-in and day-out during this crisis, risking their health and safety and the health and safety of their families because they believe in the importance of their work. Selflessness does not begin to describe that level of commitment to their fellow companions. They see first-hand the burdens, the true pain and suffering, that the pandemic brings. 

The Empty Glass

I have worked intimately with many of these front-line healthcare workers and have heard their stories. Stories that bring the truth of COVID-19 to anyone willing to listen. 

• I have heard from the physician who stayed on for an additional shift to honor his promise to a dying patient whose family was unable to visit that he would not die alone. 

• I have heard from a nurse who was unable to see immediate family because of fear of bringing the virus back home.

• I have heard from a physician who watched four patients suffer and die from COVID-19, only to return to the clinic and be told by another patient that it was all political and that the virus would be gone after election day. 

Healthcare workers pour themselves into their work and their patients, like water from a glass. Without help, support and consideration, the glass eventually empties, and they have nothing more to give. This is what comes with the job and is a load shared by all. It is a why healthcare workers earn the respect we give them. 

United We Stand

Supporting our healthcare workers must be a united fight, or it is destined to fail. When faced with nearly impossible odds, Sir Winston Churchill said he had “nothing to offer but blood, toil, tears, and sweat.” His nation stepped forward to fight the threat to life and safety; from the solider to the factory worker to the caregivers at home and leaders at the top, they all gave everything together and overcame the grave threat. 

I have seen our great healthcare workers give all this and more to fight this fight against COVID-19, but I see some in leadership outside of the hospital step away, deny or ignore the threat and the fight. This is destructive to so much that we hold dear. This is a fight that will possibly worsen before it improves. We see the impact it has right now and fear what the future might hold.

I have had the privilege to work and share with those fighting and giving everything. 

We must not let them fight alone.

Ryan Pferdehirt, D. Bioethics, HEC-C

Clinical Ethicist

Director of Membership and Ethics Education

MEDICAL BANKRUPTCY, PERSONAL LUCK AND A NATIONAL SIN

By Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair at the Center for Practical Bioethics
Professor of Pastoral Theology—Ethics & Ministry Praxis, Central Baptist Theological Seminary
Clinical Professor, School of Medicine, University of Kansas Medical Center
Director, Hospital Ethics Consultation Service, The University of Kansas Health System

I was raised on a farm up in Minnesota by Fundamentalist Depression-era parents. Among the many rules taught by words and deeds was that you don’t buy what you can’t afford. And never accrue debt. Save enough to buy a car when it’s needed, and then only buy the car that costs the amount you have saved.

That policy worked well for my nuclear family because of white privilege and a whole lot of luck. Others in our family had not always been so lucky, however. My grandparents, on both sides, had bad luck during the 1930s. They had accrued debt that they couldn’t pay when times got hard. Family farms were lost. Everything gone to debt collectors, some of whom were luckier neighbors. So “Never buy what you can’t afford” became our mantra. Not cars or even farms. Never acrrue debt. 

What works for some and in regard to cars or farms doesn’t work as well when what one cannot afford is healthcare. I can live with a cheap set of wheels, or maybe none at all. But my Depression-era father could not live without expensive cancer and cardiology care when he needed it. And there were no cheaper options. In healthcare emergencies, there is no Ford instead of a Lexus. It’s all Lexus. Or Lamborghini. Thank God my Dad had Medicare. Thank God I have employer provided insurance. 

But not everyone is so lucky. That is the truth we all know and of which we’re reminded by a recent (September 1, 2020) West Health and Gallup report on bankruptcy due to medical costs. What researchers learned is summarized in the title: “50% in U.S. Fear Bankruptcy Due to Major Heath Event.” https://news.gallup.com/poll/317948/fear-bankruptcy-due-major-health-event.aspx  

While half of all adults reported that they are either “concerned” or “extremely concerned” that medical bills will bankrupt them, 64% of non-white adults are in that category, an increase from 52% reported in 2019.

 

There are no real surprises here. Why wouldn’t at least half of U.S. adults be concerned or extremely concerned about the specter of financial disaster if they get sick? On an inventory list of healthcare products and procedures for sale, there is virtually nothing the average person could afford to buy out of pocket. Yet when healthcare is really needed, we either buy or die. Or perhaps we don’t die but suffer instead, including the financial stress of accrued debt. For lack of good alternatives, many have bought what they couldn’t afford.

Of what am I reminded when reading this Gallup report? That Depression-era wisdom applicable to car-buying doesn’t work when it comes to healthcare—or only if one is very lucky. Surely in this nation we can and should depend on something other than luck. Shouldn’t we?

Actually, my people never used the word “luck”. We talked in terms of being “blessed”. We were blessed even if others were not when medical and then financial disasters struck. 

Really? I have come through my own faith journey to see things differently. Being blessed or not implies the intervention of a higher being, the actions of God. While remaining devout in my faith tradition, what I no longer believe is that God is the agent of inequity. When it comes to healthcare disparities and consequent financial disasters, I have stopped blaming God, even by implication. This mess is our fault. As a people, we have failed each other. It is a failing that many who believe as I do recognize as sin, both personally and socially. And individuals like my father and I who have thus far escaped the consequences of our national sin are indeed lucky while others are not. 

But even for those most fortunate and privileged, luck has a way of running out. If only as a matter of self-interest when it comes to healthcare costs, or possibly out of compassion as well, we all ought to be “concerned” or “extremely concerned.” Shouldn’t we?

[Portions of this essay were previously published Sept 14, 2020 in an article at GoodFaithMedia.org by Zach Dawes. https://goodfaithmedia.org/reaction-and-response-medical-bankruptcy-concerns-half-of-us/.]