Should Anti-vaxxers be opted out of public health during a pandemic?
C.M Tan1, A.M Snodgrass 2, H.L. Tey 1,3,4
1 Yong Loo Lin School of Medicine, National University of Singapore
2 KK Women’s and Children’s Hospital, Singapore
3 National Skin Centre, Singapore
4 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
*Corresponding author: H.L. Tey, National Skin Centre, Singapore
Citation: H.L. Tey (2022) Should Anti-vaxxers be opted out of public health during a pandemic?1(1)
Copyright: ©2022 H.L. Tey, This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Received: 29 June 2022| Accepted :14 July 2022|Published: 18 July 2022
Keywords: COVID-19 pandemic, vaccination, Anti-vaxxers, non-maleficience
Introduction
It has been more than two years since the start of the COVID-19 pandemic and many countries are still grappling with the emergence of new variants, most recently Omicron subvariants BA.4 and BA.5, (1) as well as the increasing COVID-19 caseload worldwide.
While measures to end the COVID pandemic, such as vaccination, have been initiated in every country to inoculate and protect its citizens from COVID, hospital systems in many countries are still being pushed to the brink and many healthcare workers have been recruited to the frontlines to fight this pandemic.

Mass vaccination in the fight against COVID-19 is the key step to achieving herd immunity and a return to a life of normalcy. However, the anti vaccination movement has resulted in many people in the world remaining unvaccinated. This has negatively affected the control of COVID in many countries as the majority of the patients who are seriously ill due to COVID- 19 are largely the unvaccinated. According to the World Health Organization, one-third of the world’s problem has yet to receive a single dose of the COVID-19 vaccine (2).

If a sizeable proportion of the population remains unvaccinated, this can forma pool for the virus to spread, perpetuate and even mutate into new variants, heavily straining our healthcare system (3). In such situations, ethical issues arise and bring forth the question of whether anti-vaxxers who contract COVID-19 infection deserve to receive medical treatment.

Anti-vaxxers should not receive treatment

In a situation where there is overwhelming strain on healthcare resources and front-line workers need to struggle to prioritize who should receive treatment, this question comes up all too frequently(3). For example, if there were a person who was eligible for the vaccine but chose not to take it and now has respiratory failure due to COVID-19, as well as a vaccinated person with heart failure, how does a healthcare worker make the unthinkable decision of whom to prioritize for admission to the intensive care unit when hospital occupancy is
already strained to the limit?

While we should always keep in mind the 4 pillars of medical ethics when treating our patients (patient autonomy, beneficience, non-maleficience and social justice), how do we apply these key principles in such a desperate situation?

Should we consider whether the patient with heart failure responsibly complied with medications and medical recommendations issued by their attending physicians? What about whether we should allow anti-vaxxers to reap the consequences of their decision not to get vaccinated, which they do indeed have the right to make?
Should public health considerations, necessary for the good of all, impel us to protect those who are medically ineligible for vaccination to not only reduce transmission and strive for herd immunity, but to also reserve scarce medical resources for this vulnerable population?
In the midst of this pandemic, let us not forget the many other acute and chronic medical and surgical diseases which our patients continue to depend on us to treat. How long can elective surgeries be safely postponed? How much will the psychological and social consequences of this pandemic aggravate the condition of patients with mental health concerns, given that  both physiological and psychological stress has been shown to be detrimental to sufferers of cancer and autoimmune disease, as well as pregnant mothers and their unborn children?
Anti-vaxxers should receive treatment
Should our personal opinions regarding the choices a patient makes interfere with the moral obligation that all doctors have to their patients?

To respect autonomy is defined as respecting the decision-making capacities of autonomous persons with the mental capacity to make reasoned informed choices, whether we agree with those choices or not. The doctor’s duty of care towards the patient remains, regardless of the choices he/she makes. As a doctor, one should provide competent, compassionate and appropriate care to all their patients to the best of their abilities (4).
However, it is also imperative that doctors act in their patients’ best interests. Rigorous medical training and experience equips us with the necessary professional skills to make an evidence-based appraisal of a patient’s unique clinical situation in order to anticipate and manage the possible consequences of each patient’s decision regarding their own healthcare. Patients’ fears of receiving the relatively newly developed vaccines and lack of understanding of the true frequency and severity of potential side effects may impair their ability to appreciate the true consequences of severe COVID-19 infection in the unvaccinated, as well as the cumulative impact of their decision on the population at large. If the role of healthcare workers is solely limited to providing a repository of medical information rather than utilizing their clinical expertise to guide and protect their patients from adverse outcomes, is
this really in the best interests of the patient?

The COVID-19 pandemic has also taken a huge toll on front-line and healthcare workers. A recent study done on a group of intensivists working in one of the 2 COVID-19 hub hospitals in Central Italy showed that the high patient load faced by the doctors coupled with other factors such as fatigue, isolation, monotony and the recent need to interact with anti-vaxxers have resulted in them experiencing chronic stress from caring for COVID-19 patients during
the past 2 years(5).

As with many other disease epidemics, the healthcare worker’s courageous response to exigencies of service inevitably continues to cause conflict with their duty of care to their families and relatives. Less spoken of are doctors’ struggles to shoulder their personal fears of mortality and morbidity in the midst of their strenuous efforts to save others.

What about the mental health concerns that may arise in healthcare workers as a result of being stretched beyond their limits in the line of duty? Will this in turn have a detrimental
effect on patient care? After all, doctors are only human. The psychological agony inherent in being forced by finite healthcare resources to choose which person will live or die is a decision that no one should ever have to make (6).

Conclusion
While many countries have successfully carried out their vaccination programmes, anti- vaccination still poses an obstacle for many others. While it may be impossible to immediately eradicate such a phenomenon, addressing vaccine misinformation and ensuring good patient education are some small steps that can be taken to ensure pandemic preparedness in the future (7).

Furthermore, as the current COVID-19 variant wave surges and more and more patients require advanced medical care, hospitals worldwide are facing ever-increasing strain on their healthcare resources and healthcare workers are being pushed to their breaking points. In all likelihood, as medical students, doctors and healthcare professionals, we will continue to face
these dilemmas for some time to come.

Currently, there has been an emergence of a new virus known as Monkey Pox. While it has not yet been declared as a global emergency, it is evolving faster than expected with 48countries being affected thus far (8). While the risk to the general population is low, recent findings by the WHO have discovered that the virus could potentially affect higher risk groups including children, pregnant women, and the immunocompromised (9). The sudden emergence of a new variant or virus in the midst of the COVID-19 pandemic serves as a
reminder that such a scenario is unpredictable. Timely preparation, both strategic and psychological, in the making of situational decisions regarding prioritization of care in a setting of limited resources and competent evidence-based assessment of clinical prognosis, is crucial to ensure our healthcare system remains resilient and mentally-equipped in managing ongoing and possible future pandemics.
References
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4. Singapore Medical Council
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