No COVID-19 vaccination, no care? Why that’s the wrong path

Timothy M. Smith , Contributing News Writer

While vaccine hesitancy is an age-old phenomenon, it has found a new—and profoundly frustrating—expression during the COVID-19 pandemic that has led some physicians to reportedly refuse care to patients who have forgone SARS-CoV-2 vaccination.

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But as infuriating as it can be to treat patients who refuse the safe and highly effective COVID-19 vaccines that are widely and freely available in the U.S., doctors should keep in mind their professional ethical obligations. It turns out there is extensive guidance for just such a situation.

“Ethics in our profession is about making hard choices in the face of conflicting values,” said AMA President Gerald E. Harmon, MD. “An important value for me—and this is inherent within our AMA Code of Medical Ethics—is a physician’s duty to provide care for the patient, even when that choice is difficult.”

Elliott Crigger, PhD, is the AMA’s director of ethics policy and secretary to the AMA Council on Ethical and Judicial Affairs. He expanded on Dr. Harmon’s forceful view.

“In general, no, a physician should not refuse a patient because the individual is not vaccinated or declines to be vaccinated,” Crigger said.

Physicians have a clear duty to provide care in emergencies, Crigger noted, citing principle VI in the AMA Code of Medical Ethics, which states that a physician shall, except in emergencies, “be free to choose whom to serve, with whom to associate and the environment in which to provide medical care.”

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But the physician’s 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, according to Opinion 8.3, “Physician Responsibility for Disaster Response and Preparedness,” doctors may face “greater than usual risks to [their] own safety, health or life.”

Moreover, Opinion 1.1.2, “Prospective Patients,” bars physicians from refusing care to patients based solely on their infectious disease status or for any reason that would constitute discrimination against a class or category of patients.

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Learn more with the AMA about how to answer the question, “Can physicians decline unvaccinated patients?

The strength of a physician’s obligation to treat may, however, vary based on the conditions, Crigger noted.

“Determining whether, in a particular instance, a physician may ethically decline a patient requires careful reflection,” he said.

For example, in the context of a highly transmissible disease that poses significant risk of severe illness for which a safe, effective vaccine is available, the decision to accept or decline a patient must balance three factors:

  • The urgency of the individual patient’s need.
  • The risk the patient may pose to other patients in the physician’s practice.
  • The need for the physician, and other staff, to be available to provide care in the future.

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These are among the questions to be considered.

What are the unvaccinated patient’s medical needs and how urgent are those needs? In emergency situations, physicians may not ethically refuse to provide care, regardless of the patient’s vaccination status. But it may be justifiable to decline to provide “routine care,” such as an annual physical examination, for an otherwise healthy patient.

What is the nature of the physician’s practice and patient population? “Physicians may decline a patient if meeting the individual’s medical needs would ‘seriously compromise’ the physician’s ability to provide care needed by other patients,” Crigger said, again citing Opinion 1.1.2.

“Likewise, if an unvaccinated patient would pose significant risk to other patients in the practice—for example, if the physician’s other patients are immune-compromised or cannot be vaccinated for medical reasons—it may be ethically justifiable to refuse an unvaccinated individual, the more so with the greater the risk of severe disease for other patients in the practice.”

Can accommodation be made to minimize the risk an unvaccinated patient may pose to other patients and staff? For example, can unvaccinated and possibly infectious patients be seen in a dedicated examination room or at dedicated times? Or can they be tested negative for COVID-19 before receiving care? Can care reasonably be provided via telemedicine? Opinion 1.2.12, “Ethical Practice in Telemedicine,” provides additional guidance.

Can the practice provide adequate personal protective equipment to minimize risk of exposure to physicians and other staff? “This has been a vexing question in the context of the COVID-19 pandemic, when initial supplies of PPE were extremely limited for some practices,” Crigger said. “As PPE has become more readily available, the responsibility has increased for physician practices and health care organizations to ensure adequate supplies of PPE to enable them to accept even unvaccinated patients.”

Can the patient be persuaded to accept vaccination? When an unvaccinated patient presents for care, physicians—or other appropriate staff—have an opportunity to explore with the patient why they are not vaccinated, respectfully acknowledge and address their concerns, and seek to persuade them to accept vaccination to protect themselves and others.

In sum, Crigger said, “A patient’s vaccination status alone is not sufficient reason, ethically, to turn that individual away.”

Visit the AMA COVID-19 resource center for clinical information, guides and resources, and updates on advocacy and medical ethics.