Even though COVID infection rates are decreasing, health care providers are still struggling with how to handle unvaccinated patients. Last month, a Colorado hospital system, UCHealth, stated it won’t provide transplants to patients who choose to remain unvaccinated. In August, a family doctor in Alabama posted a sign refusing to see patients who are unvaccinated against COVID.
It’s not just an issue of ethics — it’s one of emotion too. One ICU doctor let his anger spill onto the pages of the LA Times and another, an emergency medicine doctor put it this way: “Welcome to the new Pandemic of the Unvaccinated: the patients we love to hate.”
The thing is: none of this is new.
Behavioral choices of patients have bothered doctors for years. As justified as we may feel to be angry at unvaccinated patients, research has demonstrated that our attitudinal hang-ups compromise their health and only cause more harm.
Health professionals have a generally negative view of patients with substance use disorders, viewing them as manipulative, violent and poorly motivated to improve their health. These self-fulfilling negative views make patients feel disempowered and lead to worse treatment outcomes. So much so that in 2015, life expectancy in the U.S. decreased for the first time in over two decades. Fatal opioid overdoses were so common that they actually dragged down life expectancy.
Buprenorphine-naloxone seemed to be an answer to opioid dependency — a drug that could be prescribed in primary care offices to treat opioid addiction by stimulating a partial response from the same receptors for oxycodone, heroin, and fentanyl. Studies showed this drug not only decreased deaths due to drug overdose, but decreased deaths from any cause as well.
But doctors didn’t prescribe it. Only 3 percent of primary care physicians were certified to prescribe buprenorphine-naloxone. And of the physicians who were certified, many were prescribing far below their full capacity, at times treating as few as 3 patients even though they could have written prescriptions for 30 patients their first year of certification and 100 patients after that.
The training requirement for physicians to become certified to prescribe buprenorphine-naloxone has recently been relaxed. But widespread access to life-saving opioid addiction treatment remains scarce, especially for rural and non-white communities.
Surveys of certified and non-certified physicians found that physicians were unwilling to prescribe more because of a lack of belief in the treatment, because of a perceived lack of time, and a perceived insufficient amount of reimbursement to make it worth their while. The problem is that these are myths of prescribing buprenorphine, placeholders that excuse away the fact that providers allow their prejudice to prevent life-saving care.
It’s not just in substance use disorders. The health impacts of weight bias against obese patients are well documented. Lung cancer stigma arises when patients who smoke are blamed for their disease and leads to increased depression, poorer quality of life, delays to seek treatment and may be one reason for why lung cancer receives a fraction of funding despite being a leading cause of cancer death worldwide.
It’s difficult not to blame the unvaccinated. Their choices and actions spread the disease and make another mutation, perhaps a completely vaccine-resistant one, more likely. They also pose a more specific threat to health care personnel than drug addiction, smoking or obesity. Doctors have elderly parents, immunocompromised friends, and children who need to be back in school.
When I unexpectedly tested positive for COVID, I wracked my brain to figure out where I caught it from. Was it from the patients sick with COVID who I treated in rural South Dakota, both vaccinated and unvaccinated? Was it the group of people on my plane ride home who made it loudly known that they were unvaccinated and did not want to wear masks? Was it someone from work? I felt shame and disappointment in my test result. I wanted answers and someone I could blame for risking my health and the health of those around me. The personal choices of patients, which I often struggle to understand, have never affected my personal life as they do now.
But this is medicine, folks. This may not be the scenario he imagined, but these feelings are what William Osler, father of medical residency training, had in mind when he addressed new doctors in his 1889 essay, Aequanimitas. Osler advised physicians to maintain imperturbability, the “calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness.”
Maybe that clearness and calmness is guiding administrators in the case of transplants because they’re precious scarce resources — organs — that may be wasted if transplanted into a patient who eventually succumbs to COVID (more likely without the protection of a vaccine).
Medical school doesn’t teach what equanimity looks like when one must choose between patients’ lives. Or between patients’ lives and our own. Whatever the decision is, it must be guided by imperturbability.
The unvaccinated patient is the addicted person, the overweight patient, the smoker in the waiting room. Our antipathy toward them endangers their health, maybe their lives. The unvaccinated will not be convinced with stigma. They will be convinced with integrity, sincerity, and love.
Stigmatization has never been an effective health intervention. And that’s exactly what these reflexive responses to the unvaccinated are. It’s not righteousness, as if righteousness ever helped in an examining room. These days, maintaining grace and an open heart to the unvaccinated is the most ethical practice a physician can undertake.
Stephanie Sun is an internal medicine physician.
Image credit: Shutterstock.com
