Crowded hospital waiting room with patients sitting on chairs respecting social distencing and nurse explaining treatment to elderly woman wearing face mask against covid-19. Doctor consultating man

Bioethics Forum Essay

Vaccination Discrimination Goes Against Nursing Ethics

Should health care providers prioritize patients who are fully vaccinated against Covid-19 over those who are unvaccinated? There have been several incidents of vaccination discrimination in health care, such as two physicians refusing to treat unvaccinated patients in Florida and Alabama. We believe it is unethical to consider vaccination status when deciding which patients to treat and in what order.

 All human beings deserve appropriate timely medical attention. Providers have no right to decide who has a “valid excuse” for being unvaccinated against Covid-19. It is contrary to the nature of any healing profession for a health care professional to reject or deprioritize patients for care solely on the basis of vaccine status.

Patient prioritization schemes can be traced to the HIV/AIDS epidemic that emerged in the 1980s. HIV/AIDS patients, and members of the LGBTQ+ community in general, were met with significant discrimination, with some health care providers refusing to treat them. A world-renowned heart surgeon remarked that he would opt out of operating on HIV-positive patients, and many health care professionals followed suit by expressing an apparent revulsion towards HIV/AIDS work. Health status discrimination has resurfaced during the Covid-19 pandemic. Some people believe that in health care environments where resources are scarce, especially urgent care units, Covid-19-vaccinated patients should have their medical needs met before those who have refused vaccination. 

Some provisions in the Code of Ethics for Nurses  can be interpreted as arguing against prioritizing  vaccinated patients. Provision 1.3, for example, discusses how nurses must care for patients and respect their dignity by recognizing the unique nature of their health status. A patient’s vaccination status is one aspect of health status. Similarly, Provision 8.1 emphasizes that the highest quality standard of health care is a universal right that all patients are entitled to receive. Moreover, under Provision 3.5, nurses have an ethical obligation to protect and promote patient safety and health, which entails protecting their patients from practices that go against their best interests, such as of denying them timely medical care.

Some provisions in the Code of Ethics for Nurses could be interpreted as supporting  prioritization schemes benefiting vaccinated patients. Provision 4.3 discusses an obligation to design, execute, and assess mechanisms that protect the best interests of patients, colleagues, and the community– fundamental to maintaining the standards of professional practice. Provision 6.3 highlights the necessity of implementing practices that ensure a safe health care delivery environment for patients and health care staff.

Nurses and other health care professionals have a social commitment to promote domestic as well as global health welfare and safety by contributing to, and abiding by, public health policies that prevent suffering related to Covid-19. Such policies could include vaccine mandates, ineligibility for certain treatments such as transplants, and, for those who choose to remain unvaccinated, mitigation strategies such as mask and testing mandates. However, vaccination status alone is not enough to determine eligibility for basic medical care. The safety of staff and patients is important, but it does not justify unreasonable measures against individual patients, particularly when proper protection strategies can be used.

Provision 8.3 finds another tension with prioritizing the medical needs of vaccinated patients over unvaccinated patients. It is essential for nurses and other health care providers to collaborate to lessen health care disparities in our communities. We cannot overlook the role of racial injustice on mistrust in medicine and, in turn, on people’s decision not to be vaccinated. Deprioritizing unvaccinated patients could exacerbate health inequity and social injustice.

With the pandemic lingering and creating collective exhaustion, it is understandable that there is a growing animosity toward people who choose not to be vaccinated. But nurses and other health care providers, and particularly health leaders, need to combat compassion fatigue to ensure that the health care needs of all patients are satisfied. Nursing ethics principles serve as a stark reminder of everyone’s right to appropriate, nondiscriminatory health care; recognizing the equal value of all people is essential to a moral society in these pressing public health circumstances.

Epiphany Cruz-Maxwell is a MS in bioethics candidate at Columbia University and an intern with the American Nurses Association Center for Ethics and Human Rights. Ian D. Wolfe, PhD, RN, (@iandwolfe) is a clinical ethicist at Children’s Minnesota and member of the Ethics Advisory Board of the American Nurses Association Center for Ethics and Human Rights. Liz Stokes, JD, MA, RN, (@NurseLawEthics) is the Director of the American Nurses Association Center for Ethics and Human Rights.

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  1. With due respect for the fine authors they fail to take into account the PUBLIC health implications of failure to vaccinate. Most nurses work in institutions. Neither patients nor staff have the right voluntarily to put OTHER patients at risk. My wife has Alzheimer’s and is in a facility. She is helpless. It is UNETHICAL to put her at risk

  2. I believe this article barely scratches the surface of the complex issues that nurses are facing on the front lines of this pandemic. As a bedside nurse in a hospital setting taking care of laboring women and their newborns, considering vaccination status is routine, MMR, DTaP, Influenza, Varicella, Hep B…what makes the Covid 19 vaccine status any different? Not considering vaccine status of our patients would be negligent and therefore unethical. While we never refuse care to a non-vaccinated patient, it is often a more complex situation than these authors would have us believe. We also have to manage their support people, who may or may not be vaccinated. Many of the patients and their support people that refuse vaccinations also refuse testing upon admission…their unknown Covid status forces nurses to then take all the precautions that we would for a positive Covid patient…to protect ourselves, our families, our co-workers, and our other patients. It is no easy task to completely gown up, mask up with an N95 or respirator, plan and cluster care so that you are not going in and out of their room multiple times. When caring for these patients as well as other patients who have either been vaccinated or tested, prioritization must occur for the safety of everyone. In-patient nurses are never just treating and managing one patient, we have to consider the acuity of the entire floor and all the individuals in our care and prioritize care to benefit all. Breaking down the most impactful paragraph from this article:
    “With the pandemic lingering and creating collective exhaustion, it is understandable that there is a growing animosity toward people who choose not to be vaccinated”. Yes it is exhausting, and it is costing the healthcare system a great deal of both limited supply chain resources (we were told just yesterday to cut back on diagnostic lab tests by 50% because we are running out of blood collection containers!) as well as human resources. Next “But nurses and other health care providers, and particularly health leaders, need to combat compassion fatigue to ensure that the health care needs of all patients are satisfied. ” Health care leaders must do more to protect their most valuable resources…their nurses…or the fatigue will cause more nurses to leave the profession. The last sentence in this paragraph is most concerning to me…”Nursing ethics principles serve as a stark reminder of everyone’s right to appropriate, nondiscriminatory health care; recognizing the equal value of all people is essential to a moral society in these pressing public health circumstances.” Recognizing everyone’s rights and equal value of all people apparently does not include nurses? I would counter that healthcare professional have rights too…we have the right to go to work in a safe work environment and be supported to do our best work and provide the best patient care possible without the fear of becoming infected, assaulted (yes, nurses are being treated the same as flight attendants with regularity) or unintentionally passing the infection to others. There is nothing moral about treating nurses with less equity than the general public.

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