Some clinicians wonder whether they are ethically obligated to treat unvaccinated patients. “This is a serious concern among many doctors. I suspect that sooner rather than later, some physicians will start avoiding unvaccinated patients in the outpatient setting,” says Jacob M. Appel, MD, JD, MPH, HEC-C, director of ethics education in psychiatry at Icahn School of Medicine at Mount Sinai.

A solid understanding of ethical obligations is essential in this tricky situation. “Ethicists should certainly have a seat at the table when hospitals and policymakers formulate rules in this area,” says Appel, an attending physician at Mount Sinai Health System in New York City.

The rules governing dismissal of patients who are unvaccinated against COVID-19 are basically the same as for other patients, according to Appel. In the hospital, physicians generally cannot refuse to treat patients.

“Specific religious or medical concerns may arise that merit consideration for exceptions,” Appel explains. For instance, physicians who cannot be vaccinated for medical reasons might ask not to be assigned to COVID-19-positive patients.

Did the patient willfully refuse vaccination? Or is the issue that the patient cannot be vaccinated for medical reasons? From an ethical point of view, it probably matters. “Many ethicists would be deeply troubled by a provider discontinuing care with a long-term patient who could not be vaccinated because of past anaphylaxis to vaccine ingredients,” Appel notes.

Physicians are ethically responsible for incurring some risk as part of their jobs. At the same time, hospitals are ethically obligated to minimize risk to clinicians. “That might mean shifting the care of certain patients away from immunocompromised providers, at their request, as long as patient care wasn’t significantly impaired,” Appel says.

Unlike in the inpatient setting, outpatient providers generally can “fire” patients for reasons such as frequent no-shows or nonadherence — or unvaccinated status. The caveat is the “fired” patient must be able to access another provider. Usually, that means giving patients enough time to find another doctor. “The only exceptions might be if religion or disability was the cause of the patient’s non-vaccinated status,” Appel says.

Physicians refusing to take on a new patient simply because they are unvaccinated is ethically questionable, according to Trevor M. Bibler, PhD. If the same provider refused to care for smokers or people with unhealthy diets, “it would be seen as a breach of good medicine, based either in stigma or an unacceptable amount of caution and self-preservation,” says Bibler, assistant professor of medicine at the Baylor College of Medicine Center for Medical Ethics and Health Policy.

Where vaccination is concerned, the provider would have been expected to care for the patient before the vaccine was available. The fact the vaccine is widely available now does not change that ethical obligation, says Bibler — even if the provider’s risk would be lower if the patient became vaccinated.

Bibler says requiring unvaccinated patients to engage physicians only through virtual visits also is ethically problematic, unless physicians are at higher risk for some reason.

“But even then, their reasoning should apply to all of those with communicable diseases, not just those who have refused the COVID-19 vaccine,” says Bibler, who argues vaccination status simply should not play a role in the distribution of resources. “One might view the decision unwise or selfish. But medicine deals with patients who refuse recommended interventions constantly.”

A patient might refuse to take their blood pressure medication and have a heart attack or a stroke as a result. “Part of the challenge of being a healthcare professional is working with people who make decisions we might view as ill-advised or deleterious to their own interests,” Bibler says.

The health risk to vaccinated medical staff treating unvaccinated patients in person today is “much smaller than it was during the earlier pandemic, when we lacked experience with treating COVID and lacked a vaccine,” says Olivia Schuman, PhD, a clinical ethics fellow at Baylor College of Medicine Center for Medical Ethics and Health Policy.

The ethical concern is refusal to treat unvaccinated patients seems rooted in a negative bias toward those patients. “We need to leave moral judgments out of medicine. Given their fiduciary responsibilities to their patients, clinicians shouldn’t refuse care on these grounds any more than on the grounds that they don’t like a patient’s political views, profession, or criminal record,” Schuman says.

Unvaccinated patients could pose a risk to others who are immunocompromised. “But we have to be cautious about treating COVID as morally exceptional,” Schuman says.

Regardless of vaccination status, patients and medical staff may be carriers of any number of infections that can harm others. “That’s just the reality of putting all the sick people into one building. What we need is evidence-based ways of maintaining the safety of these spaces, rather than excluding some patients from accessing care,” Schuman suggests.

Providers may offer many compelling reasons for wishing to avoid unvaccinated patients: protecting themselves, their families, staff, and other patients.

“Some may simply wish to make a moral statement that they object to the behavior of individuals who are endangering the public health by refusing to get vaccinated,” says Appel, who compares this to a psychiatrist who refuses to treat a patient who continues to drive intoxicated.

On the other hand, providers should factor in legitimate reasons for vaccine hesitancy, such as minorities’ historical reasons for distrusting medicine. “No one wants to deny care to individuals who have already been short-changed by the healthcare system,” Appel says.

Once a provider-patient relationship is built, state medical boards have established rules on patient abandonment. “These require that the patient receive adequate notice and, in some cases, be transferred to another provider to prevent gaps in treatment,” says Stacie Kershner, JD, associate director for the Center for Law, Health & Society at Georgia State University College of Law.

Generally, providers in outpatient settings can decline to treat people who choose to not be vaccinated if they are new patients. “However, that does not mean that this is ethically a good practice,” Kershner says.

For one thing, refusing to treat unvaccinated patients is unlikely to convince anyone to take the vaccine. “Rather, it reduces the opportunity for pro-vaccine providers to try to sway vaccine-hesitant patients to accept the vaccine through providing trustworthy information,” Kershner observes.

People with long-standing relationships with clinicians are more likely to take the flu shot.1 Refusing to treat unvaccinated patients might serve only to increase distrust of medical providers. It limits access to care if people cannot find other providers. “These patients may cluster with specific doctors who are willing to treat them, rather than being spread out across multiple providers, potentially increasing risk of disease spread at these offices,” Kershner says.

Telehealth might be a viable alternative for some patients, but health plans do not always cover it. “There may be concerns about access to care,” Kershner adds.

Do patients have a right to request vaccinated doctors and nurses? “I imagine educated patients will start making such requests,” Appel predicts. “This has implications beyond ethics, in areas related to hospital logistics, employee privacy, and even equity.”

It is possible if patients start making such requests, especially regarding elective procedures, hospitals will strive to meet the demand. “It is conceivable that hospitals and clinics will even advertise having all-vaccinated care teams,” Appel says. 

REFERENCE

  1. Heath S. Patient-provider relationships central in vaccine access efforts. PatientEngagementHIT. March 18, 2021.