As physicians we pledge to take care of patients even if we don’t agree with their choices or lifestyle.
Terry Fletcher brought to my attention an article in Ethics Consult from MedPage Today. A poll was undertaken with the topic of “Is it ethical to force unvaccinated patients to use telehealth only?” Sixty nine percent of their respondents thought it was ethical versus 31 percent who did not agree. I interpret the question as, “Is it okay to refuse to see unvaccinated patients in person?” Provocative questions.
On the one hand, I think that COVID-19 has revealed that there are many conditions which are conducive to and perfectly acceptable to be treated via telemedicine. If a patient is sick from a condition which can be diagnosed virtually, why should we make them venture out while they’re ill to travel to the provider’s office, and why should we allow them to expose the other patients in the waiting room or the clinical personnel in the office? If telehealth can accomplish the goal, the patient should be encouraged to address their medical needs virtually.
But what if telemedicine is not appropriate? Is it ethical to insist a patient be seen via telemedicine even if that wouldn’t be the best approach for that condition or, to take that to the natural conclusion, to refuse to treat an unvaccinated patient? Private physicians always have the option to refer the patient to present to the emergency department. According to the Emergency Medical Treatment and Labor Act (EMTALA) that mandates stabilization and treatment regardless of ability to pay, emergency providers do not have a choice as to whom they see.
In March, Governor Asa Hutchinson of Arkansas signed a bill allowing medical providers to refuse treatment to LGBTQ patients and others based on religious, moral, or ethical objections, and in doing so, in my opinion, he opened a fetid bag of teeming worms. What grounds are acceptable to make that determination?
Is the ideal patient educated and intelligent, competent to engage in shared decision making, and independently wealthy so you don’t have to deal with insurance companies? Or does the provider prefer an ignorant patient who is receptive to paternalistic decision making, complying with all recommendations, and following instructions without question? If someone smokes or drinks or uses drugs, can you summarily dismiss them from your practice because they engage in behaviors with which you philosophically disagree? A physician might decide they morally don’t want to furnish medical care to patients with comorbidities like obesity, hypertension, or diabetes because if only those patients followed their diet and exercised, they wouldn’t be in that state. Is it acceptable for a devoutly Christian obstetrician to refuse to perform a maternally-life-saving abortion because it offends their personal faith? We healthcare providers are not supposed to be judgmental and just because I don’t agree with you, doesn’t mean you are wrong or unworthy of medical care.
Let’s return to the unvaccinated question. Is there a difference between caring for an unvaccinated 10-year-old child who is not eligible for a vaccine versus an adult who is making a conscious and intentional choice? And is there a difference between refusing medical care to an unvaccinated person versus a transgender one?
Regarding the latter question, I think the difference is the reason why everyone should be choosing to get vaccinated. It is a public health issue, and what we do impacts our community. Smoking used to have a public health implication; people exposed to secondary smoke had an increased risk of ill health. When I first started practicing medicine, people were still allowed to smoke at the nurses’ station. The government eventually stepped in and prohibited smoking in indoor public venues. Now, a provider may still think smoking is a bad choice, but no one in their office is being physically affected other than the patient (N.B.: I am not tackling the huge financial implications of tobacco here). The Cleveland Clinic has banned smoking from the hospital grounds, but they have not and would not deny medical care to smokers.
An unvaccinated patient can expose the provider, their staff, and other patients and their family members to a potentially deadly disease. In the office or waiting room, there may be people who are not eligible for vaccination or immunocompromised folks whose immune response was not adequate. We have a duty to protect them. It may not be a single exposure but multiple exposures over the course of the day and week, depending on where the practice is and who the patients are. Providers did not voluntarily sign up for this when they chose medical or nursing school. You don’t think about Ebola or SARS when you answer the calling to be a healthcare provider. That is fortunate; we might not have many healthcare workers otherwise. A provider who is staunchly anti-vaccine and is repeatedly exposed by a self-selecting anti-vaccine patient population is likely to contract and may suffer a bad outcome from COVID-19.
Complicating this issue is the problem that often the same people who decline vaccination do not wear a mask properly or willingly. It is a scary time for healthcare professionals right now, and they are exhausted from fighting this uphill battle.
To the original question. It is not explicit in the Hippocratic oath, but we physicians pledge to take care of patients even if we don’t agree with their choices or lifestyle. I don’t like the fact that there are gangs, but I never refused to call a Trauma Alert for a gunshot wound victim based on my personal feelings. I never refused to take care of someone involved in a motor vehicle collision even if they hadn’t been wearing a seatbelt. And I tried to be polite and respectful to patients even if they had tattoos or hats indicating membership in what I personally viewed as objectionable organizations.
However, I would posit that the healthcare provider has a duty to attempt to ensure safety for themselves, their colleagues, their staff, and their patients and their companions and should insist that an unvaccinated patient at least wear a mask correctly while in the office. If a provider wants to dismiss those patients from their practice, the provider is obligated to follow the standard procedure to avoid abandonment. I think choosing to not serve unvaccinated patients in your practice is fundamentally different than refusing to see Black or gay or Muslim patients, which I do not believe is acceptable.
In conclusion, my stance: Telehealth when appropriate and in-person, as safely as can be accomplished without vaccination, when necessary. Maybe that physician-patient interaction will be the one where their mind is changed, and they request their shot. If you just can’t accept the risk, proactively alert your patients that they will need to find an alternate provider.
It is really bad out there, and we are overwhelming the healthcare system. Readers and listeners, if you haven’t already, please get vaccinated!
Program Note: Listen to Erica Remer as she cohosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 Eastern.