The limits of refusal: An ethical review of solid organ transplantation and vaccine hesitancy

Abstract

Patients pursuing solid organ transplantation are encouraged to receive many vaccines on an accelerated timeline. Vaccination prior to transplantation offers the best chance of developing immunity and may expand the pool of donor organs that candidates can accept without needing posttransplant therapy. Furthermore, transplant recipients are at greater risk for acquiring vaccine‐preventable illnesses or succumbing to severe sequelae of such illnesses. However, a rising rate of vaccine refusal has challenged transplant centers to address the phenomenon of vaccine hesitancy. Transplant centers may need to consider adopting a policy of denial of solid organ transplantation on the basis of vaccine refusal for non‐medical reasons (i.e., philosophical or religious objections or personal beliefs that vaccines are unnecessary or unsafe). Arguments supporting such a policy are motivated by utility, stewardship, and beneficence. Arguments opposing such a policy emphasize justice and respect for persons, and seek to avoid worsening inequities or medical coercion. This paper examines these arguments and situates them within the special cases of pediatric transplantation, emergent transplantation, and living donation. Ultimately, a uniform national policy addressing vaccine refusal among transplant candidates is needed to resolve this ethical dilemma and establish a consistent, fair, and standard approach to vaccine refusal in transplantation.

Review of Early Immune Response to SARS-CoV-2 Vaccination Among Patients With CKD

“…Reduction of vaccine hesitancy seems pivotal, and some centres might adopt a policy of denial of kidney transplantation if patients refuse vaccination due to non-medical reasons [ 89 ]. Several arguments may reinforce such a strategy, but ethical considerations must be considered and withdrawal from the waitlist might be associated with legal issues.…”

Ethical review of COVID-19 vaccination requirements for transplant center staff and patients

“…Mandatory vaccination for transplant candidates may also be ethically justifiable. A recent manuscript summarized ethical arguments in favor of and against requiring routine vaccines prior to solid organ transplant listing citing net utility, stewardship, and beneficence in the justification of mandates versus justice and respect for persons in arguments against mandates 9 . At least one transplant center in the United States has been named in the media as denying liver transplantation to a candidate who refused pretransplant COVID‐19 vaccination 10…”

“…A recent manuscript summarized ethical arguments in favor of and against requiring routine vaccines prior to solid organ transplant listing citing net utility, stewardship, and beneficence in the justification of mandates versus justice and respect for persons in arguments against mandates. 9 At least one transplant center in the United States has been named in the media as denying liver transplantation to a candidate who refused pretransplant COVID-19 vaccination. 10 We believe that it is essential to specify the ethical analysis of vaccine mandates for staff and candidates to the novel context of COVID-19 vaccination.…”

Mandating COVID-19 vaccination prior to kidney transplantation in the United States: No solutions, only decisions

“…Another answer for center leaders inclined to a vaccine mandate policy, in the vein of “shared decision‐making,” relates hesitancy or outright refusal of the COVID‐19 vaccine to the question of whether such a patient fully understands the risks of long‐term immunosuppression, 16 apart from the risks of developing COVID‐19 infection. Connecting the dots in this fashion for a patient may result in a patient determining that the requirements for transplant immunosuppression also is not commensurate with their considered desires and values, or at least highlights a tension in the patient's stated values worth further consideration.…”

“…Another answer for center leaders inclined to a vaccine mandate policy, in the vein of "shared decision-making," relates hesitancy or outright refusal of the COVID-19 vaccine to the question of whether such a patient fully understands the risks of long-term immunosuppression, 16 apart from the risks of developing COVID-19 infection.…”