Advertisement

Should Patients Who Refuse COVID Vaccination Be Denied Transplantation Eligibility?

Published:February 08, 2022DOI:https://doi.org/10.1016/j.cardfail.2022.02.001

      Graphical abstract

      Key Words

      Transplant centers have become a lightning rod in the COVID vaccine requirement debate. They are forced to choose between denying transplant listing to the unvaccinated—their best chance at life-extending treatment—or granting it knowing these individuals are at much higher risk of dying from COVID. When Brigham and Women's Hospital declined to list an unvaccinated person for heart transplantation, they were balancing his transplant need against the moral duty to generate the greatest number of life-years with the limited organ supply. To decrease the risk of unsuccessful transplants and ensure responsible stewardship of scarce organs, transplant candidacy depends on several factors, including sobriety, comorbidities, various vaccinations, and the capacity to adhere to treatment recommendations.
      Organ Procurement and Transplantation Network.
      Many hospitals have mandated the COVID-19 vaccine for transplant candidates to decrease the risk of post-transplant mortality.

      Aleccia J. More organ transplant centers require patients to get COVID-19 vaccine or get bumped down waitlist. October 8, 2021. Accessed January 30, 2022. Available: https://www.cnn.com/2021/10/08/health/organ-transplant-vaccine-khn-partner/index.html. Accessed January 30, 2022.

      These mandates are consistent with standard practices that draw on well-established ethical frameworks and are necessary to ensure transplant success, but they must be accompanied by strategic education and support to avoid exacerbating health care disparities.
      The risks of not imposing a mandate are high. Nonmedical exemptions for vaccines are associated with a heightened risk of severe illness and death for transplant recipients, and for both unvaccinated and vaccinated community members.
      • Phadke VK
      • Bednarczyk RA
      • Salmon DA
      • Omer SB.
      Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis.
      COVID-19 is especially fatal for immune suppressed transplant patients.
      • Russell B
      • Moss C
      • George G
      • et al.
      Associations between immune-suppressive and stimulating drugs and novel COVID-19-a systematic review of current evidence.
      Outbreaks could shut down centers, affecting services for all patients. Vaccination before transplantation leads to heightened immunity that lasts after transplantation,
      • Kates O
      • Stock P
      • Ison M
      • et al.
      Ethical review of COVID-19 vaccination requirements for transplant center staff and patients.
      which decreases adverse organ outcomes, sickness among staff, and infection spread.
      Candidates are already required to be vaccinated against influenza, hepatitis B, MMR, and other diseases. Patients must also demonstrate abstinence from drinking, smoking, or using illegal drugs before becoming transplant eligible.
      Organ Procurement and Transplantation Network.
      They must also demonstrate the ability to comply with a lifelong immunosuppression regimen. These requirements are not discriminatory; they exist to promote successful transplantation. The same justification applies for requiring COVID-19 vaccination. Patients who refuse to get vaccinated and then receive transplants put themselves at greater risk of illness and death from a COVID-19 infection, irresponsibly risking the loss of scarce organs that could benefit others.
      Patients might refuse vaccination owing to concerns about how vaccination will impact their health, or on religious or philosophical grounds. Rampant misinformation has clouded the fact that vaccine risks, like myocarditis rates, are approximately 12.6 cases per million doses, infinitely smaller than the risks of dying from COVID-19 when unvaccinated. The risks of receiving a life-saving transplant and taking immunosuppression are vastly more significant and substantiated than those posed by COVID-19 vaccination. Still, mandates prevent those committed to avoiding vaccination from receiving optimal treatment for their condition. How is this ethical practice?
      Transplant care is different from other medical care. There are not enough organs to give everyone optimal treatment, so allocation must proceed according to need and likely benefit. The vaccinated are more likely to live longer and, thus, benefit more than the unvaccinated. This kind of requirement is not unprecedented. Patients are not allowed to forgo prerequisites such as abstaining from alcohol consumption or receiving other required vaccines simply because these are against a patient's fundamental beliefs. Patients generally have the right as to whether to choose a treatment, but they do not get to choose the steps necessary to ensure treatment success.
      To be ethical, the vaccination requirement policy needs to be more than a gate. Patients with histories of alcohol use disorder are given the opportunity (and ideally support) to demonstrate abstinence and become transplant eligible. COVID-19 prevention measures, including vaccination, have been politicized in a way that other transplant requirements have not. Vaccine hesitancy is fueled by broadly disseminated misinformation about vaccine risks. Patients who initially refuse vaccines should be given resources and educated on vaccination, have space to voice concerns and ask questions, with ample opportunity to change their mind. If they still refuse, they should be given the best care possible. The individual at Brigham and Women's Hospital received a left ventricular assist device, which will extend his life, and is a fair treatment decision because the supply of left ventricular assist devices is not limited. Unvaccinated patients are also free to seek another center that will list them for transplantation.
      Health inequity has worsened during the pandemic. Racial disparities in COVID-19 infections and vaccine hesitancy are significant. Some critics argue that tying transplant eligibility to immunization care will exacerbate inequity. This practice could also fuel distrust among communities that experience discriminatory care.
      Creating a vaccine status eligibility policy without strategic education and support is unacceptable. Vaccine hesitancy must be acknowledged with respect for the experiences from which it derives. Clinicians responsible for the vaccination requirement conversation should receive training, and peer navigators can help to provide community outreach and patient support. Programs that decline to implement a strict vaccine requirement are considering the potential consequences of further entrenching the existing distrust of medicine among communities that demonstrate higher levels of vaccine hesitancy and potentially turning more people away from vaccination itself. Regardless of whether a strict requirement policy is implemented, all programs have a moral duty to ensure the highest levels of vaccination among patients, and especially transplant candidates, possible. Ultimately, justice is not served by the futile transplantation of scarce organs.

      References

      1. Organ Procurement and Transplantation Network.
        General considerations in assessment for transplant candidacy. 30, 2022; (January 2014. Available:) (Accessed January)
      2. Aleccia J. More organ transplant centers require patients to get COVID-19 vaccine or get bumped down waitlist. October 8, 2021. Accessed January 30, 2022. Available: https://www.cnn.com/2021/10/08/health/organ-transplant-vaccine-khn-partner/index.html. Accessed January 30, 2022.

        • Phadke VK
        • Bednarczyk RA
        • Salmon DA
        • Omer SB.
        Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis.
        JAMA. 2016; 315: 1149-1158
        • Russell B
        • Moss C
        • George G
        • et al.
        Associations between immune-suppressive and stimulating drugs and novel COVID-19-a systematic review of current evidence.
        Ecancermedicalscience. 2020; 14: 1022
        • Kates O
        • Stock P
        • Ison M
        • et al.
        Ethical review of COVID-19 vaccination requirements for transplant center staff and patients.
        Am J Transpl. 2021; 22: 371-380https://doi.org/10.1111/ajt.16878