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.