Home Moral guidelines Vaccine hesitancy complicates physicians’ obligation to respect patient autonomy during the COVID-19 pandemic

Vaccine hesitancy complicates physicians’ obligation to respect patient autonomy during the COVID-19 pandemic


Sitting barely 2 meters from me, my patient yelled angrily, his mask sliding over his upper lip: “No, I won’t get vaccinated. And nothing you do or say will change that fact. He offered no reason why he was so opposed to the COVID-19 vaccine.

As a primary care resident physician working in an underserved area of ​​Reading, Pennsylvania, I have seen patients of all age groups refuse to follow COVID-19 guidelines such as wearing a mask, social distancing or vaccination.

Exposure in health care settings has been the source of a large number of infections. At the start of the pandemic, healthcare workers and their household members accounted for 1 in 6 patients aged 18-65 admitted to hospital with COVID-19. Vaccines have significantly reduced this risk, and by August 2021, the risk of infection for healthcare workers had been reduced by two-thirds. According to the Centers for Disease Control and Prevention, less than 70% of the vaccine-eligible U.S. population is fully immunized, regardless of the booster, though those numbers change.

When a patient refuses to be vaccinated, a healthcare worker usually steps in to counsel that patient. This can take a considerable amount of time and, unfortunately, the results are not always favorable. Many in the medical community believe that it is the patient’s responsibility to get vaccinated, and if they don’t, they should be considered guilty of contracting COVID-19. One such example is the case being made for giving organ transplants a lower priority to people who are voluntarily unvaccinated.

As new variants of COVID-19 emerge and threaten everyone’s health, physicians grapple with their obligation to “do no harm” and their obligation to respect patient autonomy. Some wonder if the two might even come into conflict with each other.

‘Do no harm’

Doctors fear that unvaccinated people pose a risk to others.
Andriy Onufriyenko/Moment via Getty Images

People who refuse to be vaccinated endanger the lives of doctors and nurses. They also negatively affect the results of other patients. Whether done with malicious intent or not, this refusal is a disregard for human lives. As much as doctors are required to “do no harm” to the patient, they must also “do no harm” to everyone else.

Doctors respect the patient’s right to refuse treatment for their own illness, but may find it difficult to respect the patient’s right to refuse treatment for a contagious disease that can affect anyone.

Ethical theories can help to understand the duties of the doctor.

The German philosopher Immanuel Kant developed the concept of an absolute and universal reason to act out of duty. In this theory, it would seem that educating patients to get vaccinated is not just something doctors have the ability to do, but something they have a moral duty to do.

Although physicians cannot force the patient to be vaccinated out of respect for their ability to make informed decisions, physicians have a duty to educate their patients about COVID-19, the vaccine, and the importance of protecting other patients and the general public.

Patient autonomy

This also raises an important question of patient autonomy. Autonomy is one of the pillars of bioethics, and it is the notion that the patient has the ultimate decision-making power. It is undeniable that the decision-making responsibility of the patient is important. After all, patients want the best for themselves and respecting their decisions means respecting their well-being.

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However, some researchers also discuss the idea that the doctor knows best. This concept, known as “paternalism,” is the idea that physicians should be the ones who ultimately make the decision about what is ethically right for the patient, as physicians know best. An example would be using soft materials to restrain the hands of an intubated COVID-19 patient if they fidget and try to pull their breathing tube out.

Just last year, some doctors argued for mandatory COVID-19 vaccinations for healthcare workers. This argument of doctors is inevitably dismissed by those who are anti-mandate, and the discord further divides the patient from the doctor.

Rare resources

Then there is the question of who should receive the rare life-saving treatments: the one who has been vaccinated or the one who has refused the vaccine?

An example of this problem is the use of Paxlovid, a relatively new drug that can be prescribed on an outpatient basis for the treatment of COVID-19. Clinical trials initially treated those who were not vaccinated. Based on these studies, the pharmaceutical company Pfizer claims that Paxlovid is 89% effective in reducing the risk of hospitalization or death in study participants receiving treatment within three days of symptom onset. If there is one life-saving drug and two patients – one with breakthrough COVID-19 and the other refusing to be vaccinated – which should doctors prioritize?

There are other ethical implications from an insurance perspective, in terms of who should bear the cost and whether the unvaccinated should pay a higher premium.

In my personal practice, I have succeeded in changing people’s opinion of the vaccine through education and counselling. But what patient autonomy should look like as we learn to live with COVID-19 and how the doctor-patient relationship might change are questions that remain unanswered. The conversations about these bigger issues are just beginning.