Bioethics Forum Essay
Should Clinicians Ask Hospitalized Covid Patients Why They Aren’t Vaccinated?
When patients are admitted to the hospital with a myocardial infarction caused by years of unhealthy lifestyle choices, clinicians first treat the myocardial infarction rather than discussing with the patient the dietary and other habits that increased their cardiovascular risk. When patients are brought to the emergency department with a cerebral hemorrhage from a motor vehicle accident in which they were driving while intoxicated, health professionals manage their bleeding rather than questioning them about their choice to drive when they were drunk. There is no justification for focusing on the morally laden decisions, often heavily influenced by other circumstances, that acutely ill patients made that contributed to their need for care. The role of doctors, nurses and other clinicians is to treat patients without passing judgment and to fulfill their fiduciary duty. However, the Covid-19 pandemic has muddled these obligations.
Clinicians routinely ask newly hospitalized Covid-19 patients if they are vaccinated. This is appropriate since vaccination status is associated with the need for hospitalization and severity of infection. However, clinicians are also asking unvaccinated, acutely ill Covid-19 patients why they are unvaccinated. This question is raised, for example, when patients are first admitted to the hospital, treatment is being initiated, and the clinical course is not yet clear. The question could elicit a response from patients that increases compassion or decreases bias on the part of the clinician if, for example, the patient wanted to get vaccinated but did not have access to a vaccine. But there is also a risk of harm to the patient. Clinicians must be mindful of this risk.
Many health care professionals are burned out, morally distressed, and experiencing compassion fatigue after caring for Covid-19 patients who, from their perspective, have chosen not to obtain an accessible, potentially lifesaving vaccine. This choice has led to tens of thousands of needless deaths, placed clinicians and their families at risk, and contributed to a mass exodus of doctors and nurses from health care. Nonetheless, patients and their families are often frustrated with clinicians and may even accuse them of faking Covid-19 infections in their loved ones – a transition from “health care heroes” to “health care villains” that has exacerbated the distress clinicians are feeling.
Clinicians’ frustrations also stem from having to make morally distressing resource allocation decisions. The influx of Covid-19 patients in hospitals has depleted resources such as space (e.g. critical care beds), equipment (e.g. ventilators, supplemental oxygen, extracorporeal membrane oxygenation machines), and staff (e.g. nurses, physicians, ancillary staff) that prevent other patients from obtaining needed care. This resource shortage has forced clinicians to decide which patients are more or less deserving of scarce medical interventions, aggravating moral distress. This recurring scenario has even led to discussions about whether unvaccinated patients should receive lower priority than vaccinated patients when receiving scarce resources. (Also see this recent Hastings Bioethics Forum essay.) Clinicians’ genuine consideration of allocating resources based on vaccination status demonstrates how a moral judgment is being passed on unvaccinated patients.
When patients inform clinicians that they are unvaccinated, this knowledge in and of itself may provoke anger and bias on the part of clinicians. But, again, this information is applicable to the patient’s care. However, asking why patients are unvaccinated while they are acutely ill goes one step further, seeking out knowledge that is not relevant to the immediate care of the hospitalized Covid-19 patient. Patients may have chosen not to get vaccinated for a variety of reasons, including categorical rejection of vaccines, distrust towards those promoting vaccines, or lack of access. Patients’ stated reasons might contribute to triggering feelings of anger, frustration, and distress in clinicians.
Today’s politically charged climate and the prevalence of “fake news” have led some people to strongly hold views based on incorrect information. In this context, when responding to physician’s inquiries about vaccination status, patients also may reference false information found online or touted by politicians. Clinicians may feel frustration, leading to bias, which then has the potential to alter the patient’s treatment and perpetuate systemic inequities in care.
At a time when people’s individual choices have massive public health ramifications, it is easy to despair about large-scale problems rather than focusing on the patient at the bedside. This is particularly the case when patients’ reasons for being unvaccinated may be perceived by physicians as selfish, uninformed, or belligerent. However, clinicians have an obligation to promote patients’ best interests and welfare. Fulfilling this duty to Covid-19 patients involves the same practice as for other patients–gathering a relevant history, performing a physical exam, and then determining, communicating, and implementing an appropriate plan of treatment while acting as the patient’s advocate. American Medical Association guidelines unequivocally state that clinicians have a duty to care for acutely ill patients regardless of vaccination status, and, one can infer, regardless of the reason for their vaccination status.
For clinicians to refocus their attention on their duty towards patients, they should be aware of the potential for introducing bias by asking patients why they are unvaccinated while acutely ill in the hospital. Clinicians should consider waiting until after a hospitalized patient’s acute illness has resolved to ask this question. In the appropriate setting and when asked with the proper intention, a patient’s response may provide a chance for the clinician to answer questions, clarify misunderstandings, and assess a patient’s values in a way that could strengthen the physician-patient relationship. When asking Covid-19 patients why they are unvaccinated, the intent should reflect a desire to foster compassion for the patient and a motivation to help the patient ultimately get vaccinated.
Holland M. Kaplan, MD, (@HollandKaplan) is a bioethics and health policy fellow at the Center for Medical Ethics and Health Policy at Baylor College of Medicine and a clinical instructor of general internal medicine at Ben Taub General Hospital. Faith E. Fletcher, PhD, MA, (@FaithEFletcher) is an assistant professor in the Center for Medical Ethics at Baylor College of Medicine and a Hastings Center fellow and senior advisor.
Under normal circumstances I agree with the authors’ argument. Where I would digress is when and if we hit crisis standards of care because the demand for care far outstrips our ability to provide it. The authors chose analogies such as cardiac arrest or an alcohol-related accident to make their case. Other analogies exist where a patient’s behavioral choices lead to services not being offered because the likelihood of successful outcomes are in jeopardy: liver transplants for active alcoholics or dialysis is one such example. If we look at asking “why” as an entrée into discerning life choices that limit effectiveness of treatment, then they could be important. I agree, though, that providers need to be aware of and careful about allowing prejudgment or subsequent bias to cloud their medical care.
I actually think the question can be medically relevant and potentially even necessary, as the answer to the “why” question could be another underlying medical condition that prevented the person from getting vaccinated. While hearing a typical “facebook said the vaccine is bad” answer may be inflammatory or frustrating when people do say that, doctors are likely searching for the few people who will say “my primary care physician said I shouldn’t get it because I have X disease that could react really badly with the Covid vaccine” as the disease could also complicate or impact the progression of their Covid-19 and the type of medical care they need to receive. You could say any other underlying medical conditions would come up during history taking, but I think this is a much easier way to prioritize and spot any immediate, possible related or relevant concerns that may affect the health care the person needs right now.
Another Reason why patients may have chosen not to be vaccinated is social capital. Under the current situation there is no information about adverse reactions to vaccines, only the most extreme outcomes get reported. However, according to the CDC over 4.5 million Americans have reported injury due to the covid vaccine. As a bioethicist, I am one of these people. After my first shot, I had an inflammatory reaction, not severe enough to be hospitalised, but the reaction lasted 10 days. I reported it. 6 months later I was still suffering from joint pain when I got up from sitting and was unable to walk uphill… fall hiking season ruined. I went to a rheumatologist, who said, “Oh we’ve seen a lot of that, but it gets better.”
If I worked as a cleaning lady, or a security guard who has to stand all day, and a friend told me that they had such a reaction to the vaccine, I would not take it if I was in good health. Enough people have had Covid now to know that for the vast majority it isn’t serious. The vaccines don’t stop transmission.
When there is a lack of transparency for adverse outcomes, poor recording standards to capture such outcomes, is it any wonder that rumours run wild? Such a lack of transparency fuels informal information sharing.
I suspect that my reaction was caused by the first shot entering the blood stream inadvertently. I didn’t have the same reaction from the second shot. After the first shot I felt dizzy almost immediately and was told by the physician that I must be experiencing anxiety. Again another dismissive physician .
If physicians’ are collecting data then it is appropriate for them to ask a patient’s vaccination status, and why or why not. Merely asking the question out of curiosity is a judgement of bias on behalf of the physician and likely to influence care whether conscious or not.
But more importantly, if bioethicists and sociologists are not asking the right questions transparency will never be achieved and trust will not improve.