Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on if it was ethical to force unvaccinated patients to use telehealth only.
Yes: 69%
No: 31%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
COVID-19 has raised many ethical challenges for healthcare providers, including the level of risk they must take when providing patient care. Early in the pandemic, the ability to mitigate these risks was relatively limited, especially when caring for hospitalized patients. Shortages of personal protective equipment rendered mitigation even more challenging.
As a result, it has been reported that 3,607 frontline healthcare workers died of COVID-19 in the U.S. from March 2020 through April 2021.
COVID-19 vaccines have been available to the entire U.S. adult population for free since April 19, 2021, and appear to be extremely safe. These vaccines are highly protective against hospitalization and death, but breakthrough cases have been reported. Children under 12 remain ineligible for the vaccine, certain individuals cannot be vaccinated for medical reasons, and some immunocompromised patients are still at significant risk even after vaccination.
The question raised in this scenario asks just how much risk the doctor and staff must take in the course of clinical care. The doctor's motivation here does matter.
One should compare this case to one in which all new patients are required to be vaccinated even if they agreed to virtual treatment. Under these circumstances, the primary purpose would be to pressure patients into vaccination, rather than to protect staff. While there may be a role for government or the private sector to mandate or coerce vaccination in this manner, such pressure is arguably not the best choice for doctors, whose preferable method is persuasion via therapeutic alliance.
The American Academy of Pediatrics, for instance, has taken the position that providers "should avoid discharging patients from their practices solely because a parent refuses to immunize his or her child." Yet, in the context of herd immunity, pediatric patients who are unvaccinated against measles or whooping cough pose an extremely low risk to providers and staff.
In contrast, COVID-19 remains a serious threat to healthcare workers, especially those who might bring the disease home to their children or immunocompromised loved ones. If the goal is protecting themselves and staff, as well as other patients, the doctor can take steps that discriminate against the unvaccinated as long as these steps do not lead to substandard care. Just because patients "enjoy" in-person visits does not mean that they are entitled to them.
On the other hand, if in-person visits are necessary to offer effective evaluation and treatment to movement disorder patients, the doctor should either treat these patients in person or refer them to other providers who are able to do so. Only in the rare situation in which patients require in-person care and no other providers are reasonably available might the doctor have an obligation to provide such care to current patients in order to avoid abandoning them. However, they would still be entitled to refuse new patients who posed a risk to others.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
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