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Comment and Controversy Edited by Stephen P. Stone, MD| Volume 40, ISSUE 3, P297-298, May 2022

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Ethics of mandating all of your patients be vaccinated

      Abstract

      Herein we discuss the ethical implications of mandating all your patients be vaccinated and the consequenes of sending unvaccinated patients to another practice in your area.
      Recently, another community dermatologist referred a patient because he no longer will care for anyone who does not show proof of COVID-19 vaccination. Although previous publications have tackled the ethical issues around caring for unvaccinated patients,
      • Jayakumar KL
      • Lipff JB.
      Declining care to unvaccinated patients: ethical and legal considerations.
      ,
      • Hine AM
      • Grant-Kels JM
      • Feng H
      The ethics of considering COVID vaccination status in the provision of dermatologic care [e-pub ahead of print].
      this scenario involved a physician turning a patient away and referring the patient to another office because the patient was unvaccinated or refused to show proof of vaccination. Although many practices and organizations are mandating employees be vaccinated, is it ethical for a physician to refuse to see and care for an unvaccinated patient?

      Mandates and patients

      As physicians who follow the Hippocratic Oath, caring for patients with infectious diseases is part of our responsibility. In writings about medieval physicians, it was stated that “the doctor must treat all patients and visit infected places as it shall be found to be necessary”; modern physicians ethically need to care for the sick, even those with the “plague.”
      • Cipola CM.
      A plague doctor.
      ,
      • Fasih A.
      Enduring oaths.
      The dermatologist mandating all of his patients be vaccinated will potentially avoid harm to his other patients and staff protecting them from COVID-19, thereby conforming to an ethical social contract wherein no one should knowingly harm another's life or health; health care systems mandating that all health care workers get vaccinated reflects an extension of that social contract. Vaccines have unequivocally been shown to be efficacious

      Centers for Disease Control and Prevention. Possibility of COVID-19 illness after vaccination. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness/why-measure-effectiveness/breakthrough-cases.html. Accessed October 26, 2021.

      and are intended to enhance the common good and benefit everyone. In this case, however, referring this patient to another dermatologist's office will only transfer those risks to another office.

      Patients who are not vaccinated

      Those not getting vaccinated create the consequence that they are putting themselves and others at risk, especially the vulnerable. The ethical principles of beneficence, nonmaleficence, and justice are at play in this decision. When someone chooses not to be vaccinated, this creates a situation of injustice, because some unfairly share in the burden of trying to reduce COVID-19 spread, while others do not. Consequently, nonvaccinators are not promoting the greatest good, while vaccinators demonstrate responsibility to the well-being of society.
      Why do patients choose not to get vaccinated? They may be concerned about the personal discomfort of the vaccination and its sequelae, deny vaccine efficacy, distrust authority, have religious convictions that dictate against medical intervention, have an underlying disease that makes vaccinations dangerous, etc. Ethically their right to justice and autonomy grants them unlimited right to bodily freedoms. Additionally, mandating vaccinations is a clear example of paternalism; it reduces autonomy for theoretical justice or the good of the whole, rather than the individual, in an effort to be beneficent to many. Finally, moral relativism, wherein the relative weights of all views hold when applied in ethical situations, suggests that no one set of ethical theories and standards can be applied.

      Conclusions

      Legally, physicians can refuse to treat a patient for whatever grounds they wish except in emergencies. In the end, autonomy must be juggled with other principles including beneficence and justice; freedom of an individual to freely select their activities should be balanced by the respect for the life of those who may be affected by that decision. Encouraging patients to get vaccinated is appropriate but refusing to care for the unvaccinated goes against our oath as a physician to care for all.

      Conflict of Interest

      None.

      References

        • Jayakumar KL
        • Lipff JB.
        Declining care to unvaccinated patients: ethical and legal considerations.
        J Am Acad Dermatol. 2017; 77: 1188-1190
        • Hine AM
        • Grant-Kels JM
        • Feng H
        The ethics of considering COVID vaccination status in the provision of dermatologic care [e-pub ahead of print].
        J Am Acad Dermatol. 2022; 86: 258-259
        • Cipola CM.
        A plague doctor.
        in: Miskimin HA Herlihy D Udovitch AL The Medieval City. Yale University Press, New Haven, CT1977: 65-72
        • Fasih A.
        Enduring oaths.
        AMA J Ethics. 2019; 21: E300-E302
      1. Centers for Disease Control and Prevention. Possibility of COVID-19 illness after vaccination. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/effectiveness/why-measure-effectiveness/breakthrough-cases.html. Accessed October 26, 2021.