Background
The consequences of the COVID-19 pandemic continue to reverberate. They may disproportionately impact the practice of otolaryngology given its close association with the upper aerodigestive tract. An AAO-HNS/F position statement early in the pandemic asserted the need to use mitigation strategies to prevent viral spread, stating: “COVID-19 is a dangerous disease that demands the participation of everyone to end this pandemic.”1 COVID-19 vaccines have proven safe and effective, and the U.S. Food and Drug Administration offers extensive guidance and resources regarding eligibility and rationale for COVID-19 vaccination.2
From a legal and public health standpoint, public-facing organizations and companies may use vaccination as a condition to provide (non-clinical) services.3 Fueled by the controversy over mandates for COVID-19 vaccination, there is debate regarding whether physicians have an obligation to treat patients who choose to remain unvaccinated.
Scope
This position statement is specifically tailored to otolaryngologists’ obligation to provide care for patients who are practically and physically able to be vaccinated against COVID-19, but voluntarily decline vaccination. This statement is informed by the current COVID-19 pandemic, but it may also apply to other vaccines. This document does not address details relating to other infection control and related COVID-19 mitigation strategies including masking, social distancing, travel or visitation policies. The Centers for Disease Control and Prevention offers detailed clinical guidance on these topics, which AAO-HNS/F espouses and supports.4
Some patients, due to age or medical contraindications, are not eligible for COVID-19 or other vaccinations, and the moral and professional obligation to provide care for these individuals remains unchanged. The AAO-HNS/F does not take a formal position regarding religious exemptions to vaccination. In addition, healthcare organizations including private otolaryngology offices may choose to mandate vaccination for their employees in accordance with local, state and federal ordinances.
Analysis
The AAO-HNS/F Statement of Principles and Code of Ethics affirms the primacy of the best interest of the patient and need to practice with respect, dignity and honesty. It also notes that “physicians in turn have a responsibility to their communities that goes beyond that of other commercial enterprises. Physicians must preserve their role as health advocates within the community [which] …may involve the physician adopting a protective role when the health and safety of a community is threatened.”5
This obligation of public health stewardship includes the need to promote and support evidence-based vaccination along with other infection control measures. When engaging patients who are wary about vaccination, it is first appropriate to explore and acknowledge their position. Resources including communication handbooks provide invaluable support in encouraging and supporting vaccination efforts that focus upon non-judgmental and non-adversarial approaches.6
The American Medical Association published specific guidance in September 2021: “In general… a physician should not refuse a patient simply because the individual is not vaccinated or declines to be vaccinated. The commitment to care for those who are sick or injured carries with it a duty to treat in other circumstances as well, including public health crises when a physician may face ‘greater than usual risks to [their] own safety, health or life’ (Opinion 8.3). Nor may a physician ethically turn a patient away based solely on the individual’s infectious disease status, or for any reason that would constitute discrimination against a class or category of patients (Opinion 1.1.2).”7 The AAO-HNS/F affirms this standing.
There is an absolute obligation to provide emergency services to patients regardless of vaccination status.8 There may be specific extenuating circumstances in which the elective, non-emergent treatment of unvaccinated patients may be appropriately delayed or modified. The extenuating circumstances may relate to situations in which risk to other vulnerable patients is deemed unacceptably high, such as clinical settings with a high proportion of immunocompromised individuals, or elective care involving high-risk aerosol-generating procedures. The extenuating circumstances may also apply to situations in which unvaccinated patients are also refusing to follow other established infection control measures such as mask adherence or pre-procedural testing. Such cases may also be mitigated by use of telemedicine when feasible.9
Conclusion
Otolaryngologists have a professional obligation to provide medically indicated care to all patients. They should not use vaccination status as a prerequisite to offer services except in exceptional circumstances. We all have a collective obligation to educate and encourage appropriate best public health practices and evidence-based infection control mitigation strategies including vaccination.
References
- https://www.entnet.org/resource/otolaryngologists-and-the-covid-19-pandemic/
- https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-vaccines
- Goston LO, Salmon DA, Larson HJ. Mandating COVID-19 Vaccines. JAMA. 2021;325(6):532-533.
- https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html
- https://www.entnet.org/about-us/leadership-governance/ethics/code-of-ethics/
- https://hackmd.io/@scibehC19vax/home
- https://www.ama-assn.org/delivering-care/ethics/can-physicians-decline-unvaccinated-patients
- https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA
- https://bulletin.entnet.org/home/article/21403362/teleotolaryngology-through-the-pandemic-and-beyond-interim-findings-of-the-study-of-telehealth-in-otolaryngology
