‘Significant emotional distress’ as a criterion for medically confirmed exemption from vaccination
When is mandatory vaccination exemption justified?
The benefits of vaccines
Vaccines have tremendous benefits. A case can be made that vaccination is one of the greatest medical discoveries ever made and that it has saved more lives than most other medical interventions. It is important to recognise that the vaccines that have been developed for the current pandemic have a significant effect against SARS-CoV-2 and have saved millions of lives.
This is not an anti-vaccine site. For most people, the benefits of vaccination outweigh the risks.
The focus of this website is on a relatively small number of people who experience ‘significant emotional distress’ in relation to vaccination and examines such distress as a valid criterion for medically confirmed exemption from vaccination.
Ethics in healthcare
Medical ethics makes clear that the first duty of a doctor or healthcare worker is to act in the best interests of the patient, not simply as the healthcare worker sees the situation, but taking into account the ideas, concerns and expectations of the patient.
The World Medical Association’s Declaration of Geneva states that, “The health of my patient will be my first consideration.” Similarly, the International Code of Medical Ethics declares that, “A physician shall act in the patient’s best interest when providing medical care.” These international declarations arose as a result of treatment by doctors against patient’s wishes and have been agreed internationally as a safeguard for patients.
Healthcare practice in recent decades has emphasised the importance of ‘concordance’, as opposed to simple ‘adherence’ with respect to treatment regimens, recognising the autonomy of the patient in making choices about their own body, and respecting the individual’s freedom to make choices without coercion.
In the context of the recent coronavirus pandemic, many jurisdictions recognise ‘significant emotional distress’, or ‘severe distress’, as a valid criterion for exemption from wearing face coverings when attending public venues. This is relevant to the current discussion.
Significant emotional distress
‘Significant emotional distress’ may be defined as, “substantial, ongoing mental suffering that may, but does not necessarily, require professional treatment or counselling. It must rise significantly above the level of uneasiness, nervousness, unhappiness, or similar feeling, that is commonly experienced in day to day living.” (See link).
There is a clear case for the use of a similar criterion in relation to other contexts such as vaccination exemption.
The application of sustained pressure to those who are already emotionally distressed is generally counterproductive, and risks significant deterioration of mental health. There is a wider duty of care to such patients in line with the principle, ‘first do no harm’.
Mentally competent individuals who are experiencing significant emotional distress have a right to request medically confirmed exemption from one or more vaccinations.
To deny the validity of ‘significant emotional distress’ as a valid criterion for medical exemption would be in conflict with the duty of care that a doctor has to a patient.
Medical practitioners have strong grounds for providing patients who indicate that they have ‘significant emotional distress’ related to being vaccinated with confirmation of medical exemption from such vaccination.
Where statutory guidance (or employment criteria), require evidence from a doctor that there are grounds for exemption from vaccination, the doctor’s confirmation of ‘significant emotional distress’ as the basis for exemption is consistent with good medical practice.
It is presumed that:
• standard medical exemptions have been considered and do not apply
• relevant information on the vaccine has been supplied but has not addressed the ‘significant distress’
• anyone provided with such exemption recognises their duty to take all reasonable precautions to ensure that they do not put others at risk of infection
Would you be willing to sign our consensus statement below?
1. Ongoing ‘significant emotional distress’ at the prospect of vaccination constitutes a valid criterion for medically confirmed exemption from vaccination.
2. Consequently, medical practitioners have strong grounds for providing patients who indicate that ‘they have significant emotional distress at the prospect of vaccination’ with confirmation of medical exemption from such vaccination.
3. A doctor’s confirmation of ‘significant emotional distress’ as the basis for exemption is consistent with good medical practice.
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Discussion and further reading
The topic of exemption from vaccination is a complex and associated with a wide spectrum of perspectives. For those who are interested a number of references are provided below, which defend the position taken above.
There is a useful World Health Organisation paper (Voo et al, 2021) which states that, “Immunity certification should not be used to dictate which individuals or groups can access an area or activity”. In the USA, the historic position has been that ‘48 states allow religious exemptions, and 20 states allow exemptions for philosophical reasons’ (Kahambling, 20201; Malone & Hinman, 2003). A range of ethical and moral aspects of vaccine exemption are covered in a recent reflective piece (Prusi, 2021).
The interface between vaccination and informed consent is also explored in one paper (Singh, 20201). Potential lobbying by vaccine manufactures was considered in relation to one vaccine and recognises the importance of the individual in assessing the balance between benefits and potential disbenefits (Javitt et al, 20201). A systematic review dealing with children’s vaccines is helpful in exploring qualitatively the experience of parents and presenting the evidence on both sides of a complex debate (Smith et al., 2021).
Javitt, G., Berkowitz, D. and Gostin, L.O., 2008. Assessing mandatory HPV vaccination: who should call the shots?. Journal of Law, Medicine & Ethics, 36(2), pp.384-395.
Kahambing, J.G.S., 2021. Geophilosophical exemption to mandatory vaccination. Journal of Public Health. https://doi.org/10.1093/pubmed/fdab166
Malone, K.M. and Hinman, A.R., 2003. Vaccination mandates: the public health imperative and individual rights. Law in Public Health Practice, 338, pp.339-40.
Pruski, M., 2021. Conscience and Vaccines: Lessons from Babylon 5 and COVID-19. The New Bioethics, 27(3), pp.266-284.
Singh, J.A., Bandewar, S.S., Palmero, A. and Bhan, A., 2021. Acquiescence and submission to COVID-19 vaccination: ethics considerations. Wellcome Open Research, 6(91), p.91.
Smith, L.E., Hodson, A. and Rubin, G.J., 2021. Parental attitudes towards mandatory vaccination; a systematic review. Vaccine, 39(30), pp.4046-4053.
Voo, T.C., Reis, A.A., Thomé, B., Ho, C.W., Tam, C.C., Kelly-Cirino, C., Emanuel, E., Beca, J.P., Littler, K., Smith, M.J. and Parker, M., 2021. Immunity certification for COVID-19: ethical considerations. Bulletin of the World Health Organization, 99(2), p.155.