Dr. Jason Valentine, a family medicine physician at the Diagnostic and Medical Clinic Infirmary Health in Mobile, Alabama, informed his patients this month that, effective Oct. 1, he would no longer treat those who hadn’t been vaccinated against Covid-19. Around the same time, a leaked memo indicated that the North Texas Mass Critical Care Guideline Task Force was considering whether to take Covid vaccination status into account in deciding who gets ICU beds when more of them are needed than are available.
Can either of these actions be considered ethical? In short, it depends.
It would be unethical if a doctor were to refuse treatment because of anger, resentment or frustration, including over a patient’s decision not to get vaccinated.
Determining when it’s ethical for doctors and hospitals to refuse to provide their services, including considering whether a patient has adhered to public health precautions, such as vaccination, rests on the intentions of those turning people away and whether their decisions are consistent with professional norms and established practices.
It would be unethical if a doctor were to refuse treatment because of anger, resentment or frustration, including over a patient’s decision not to get vaccinated. Doctors, and health care professionals more broadly, are bound by moral obligations to prevent illness and restore health for anyone without regard to certain objections they may have about them.
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These obligations stem from the foundations of medicine established since antiquity, current social structures supporting the health professions and cultural expectations that demand that everyone have equal access to health care without prejudice. Thus, anger and frustration with people whose actions, even if they’re potentially provocative, don’t themselves prevent a doctor from providing effective treatment in a safe environment don’t make refusing services ethical.
But when actions that cause anger and frustration do interfere with doctors’ ability to meet their obligations to provide safe and effective treatment, refusing services can be ethical. For example, taking vaccination status into account is ethical when it’s intended to protect health care staff members and patients and to select patients for scarce ICU beds who have the best chances for survival.
Valentine’s explanation for what he’s doing, while perhaps understandable, isn’t defensible from an ethical point of view. According to news reports about a Facebook post he made, he said he decided not to treat unvaccinated patients because “Covid is a miserable way to die and I can’t watch them die like that.” While his reasoning expresses compassion, it seems to have more to do with sparing himself emotional pain than with protecting patients and staff members from infection. (NBC News hasn’t verified the authenticity of the post. Neither Valentine nor representatives at the medical clinic where he works provided comment.)
The North Texas task force’s consideration, however, is on sounder ethical grounds. The memo says the expectation of better outcomes in vaccinated patients is a reason to consider vaccination status in allocating ICU beds. As a general principle of medical ethics, when there’s not enough of something for every patient in need, those who are most likely to survive and live the longest are generally given higher priority.
Furthermore, the task force explicitly implores its member hospitals not to consider anger and frustration in their decisions. One can argue about how important vaccination is to better outcomes for those who need ICU care, as we are still learning about how vaccines and Covid work. But to the extent that hospitals believe it can be helpful, prioritizing vaccinated people for UCU beds is ethically plausible. (After the memo was reported in The Dallas Morning News, its author reversed course and said vaccination status shouldn’t be a factor in assigning ICU beds.)
There is also a broader question about what physicians can do to encourage vaccinations in the first place and specifically how threats to refuse service come into play. Encouraging vaccination as a condition to keep unvaccinated patients might seem ethical on its face, but it is easily revealed as coercive. However, when such inducement is made to protect family members of the unvaccinated, other patients, schoolmates and office staff members from Covid infection, it can meet ethical requirements, because it’s being done to prevent illness for others.
Still, physician practices can’t ethically refuse to treat their unvaccinated patients to protect their patients and staff members if they can create safe environments and implement supporting procedures. When this isn’t possible, practices must give their patients adequate notice of any change in policy and help them make the transition to other practices. Valentine did precisely that.
Before physician practices give this notice, however, they must be sure they have made good-faith efforts to persuade the recalcitrant to get vaccinated, and they must ensure they can’t reasonably accommodate a small number of patients who can’t or shouldn’t be vaccinated for justifiable reasons, such as earlier severe vaccine reactions or ongoing cancer treatment.
Hospitals making ICU bed allocations don’t have as much room for mitigation. And if all else is equal between two patients who need one available ICU bed except for their Covid vaccination statuses and if vaccination is known to determine better outcomes, then vaccine status could be a reasonable factor in allocation decisions. But rarely is all else equal. In acute clinical situations that permit no time for investigations, a legitimate reason for a patient not to be vaccinated against Covid can be difficult to discern. That could be reason enough to disregard it as a factor in ICU bed allocation.
No laws prevent physicians like Valentine from excluding unvaccinated patients from their practices. In fact, medical professionals have long dismissed patients, and they have established policies and procedures. These set out expectations about how to dismiss patients so they aren’t abandoned and left in precarious situations. For example, the American Academy of Family Physicians procedures and communication templates to facilitate justifiable and safe dismissals.A 2016 survey of 794 primary care practices found that nearly half of them had dismissed patients for not following treatment plans.
Pediatricians, reacting to the acceleration of anti-vaccination campaigns during the last decade, have become particularly accustomed to dismissing families that refuse vaccinations, often over concerns about the preventable spread of infections in their facilities. A 2019 survey of 303 pediatric practices showed that about half of them adopted management policies permitting the dismissal of families that refuse routine childhood vaccinations. The survey also reported that 18 percent of parents who refuse vaccinations often or always changed their minds and agreed to be vaccinated. Half sometimes did.
ICU beds have been sufficiently scarce over the years that triage and allocation methods have long been in place. What’s new here is the science of Covid vaccinations themselves and whether vaccination status contributes enough to outcomes to allocate ICU beds based on it.
We know that ICUs or private practices that ethically turn people away must be motivated by the right intentions, applied with comprehensive and safe management protocols, implemented in good faith with an eye toward the best science and conveyed with compassion toward patients and families.