Transplant patient rejected for exercising health choice in the absence of informed consent

Isn’t this a better title than the one CBS had about the transplant patient in Boston?

I did not intend to write about covid for my first actual article on Substack. After all I am a psychiatrist and I should stay in my lane, right?

CBS news recently ran a story today titled, “Hospital refusing heart transplant for man who won’t get vaccinated.”

But I feel called to comment on this CBS news article today. In the last two years of this pandemic, I have not felt as disappointed or as saddened, as I am today. Disappointed with the polarized discussion on social media about this issue. Sad because this article has made it clear that art of medicine is truly dead; nuance and personalized medicine is dead.

Let me explain here:

This article describes the situation of a 31 year old man who was top of the list to receive a heart transplant but just received news that the hospital (Brigham and Women’s hospital in Boston) has decided to not give it to him because he chose to not be vaccinated against covid 19. First of all, like all issues covid, this article (in my opinion) caricatures this patient on the basis of a single issue – pro vax or anti-vax. A complex, nuanced issue is reduced to a superficial, simplified, dichotomous problem. Either you get the vaccine or you don’t. Is it really as simple as it is portrayed to be? Let’s look at it, shall we?

Firstly, there is no mention of what kind of a person this patient is. What other health beliefs does he have and has he lived by them or not? Is he someone that has taken responsibility for his health in other ways before? The article has a statement from Brigham and Women’s which says, “Like many other transplant programs in the United States — the COVID-19 vaccine is one of several vaccines and lifestyle behaviors required for transplant candidates in the Mass General Brigham system in order to create both the best chance for a successful operation and also the patient’s survival after transplantation.”

Who is the patient slated next to get the heart transplant? Is that patient complying with all lifestyle behaviors. Let’s face it, it’s easier to get poked a few times than to sustain a lifelong lifestyle change for the better. How is the hospital deciding which behaviors they are going to overlook and which they will penalize? Is agreeing to be vaccinated a more important criterion for transplant or health creation for that matter; than say a commitment to healthy diet and exercise? Who gets to decide about this? Where is the scientific evidence to support one over the other?

Next, was this patient given proper informed consent with regard to the covid vaccines? True informed consent includes the following – 1. providing the patient a thorough and honest discussion about risks vs benefits of a proposed medical intervention; 2. Presenting the patient with available alternatives and 3. final decision making rests with the patient. There is no coercion within this model.

Let’s look at the risks of getting vaccinated for this patient. We now have more data about the myo-pericarditis risk following vaccination vs natural infection. Moreover this risk is age and sex stratified. It is clear that if you are male and younger than 40 (this patient is male and is 31 years old), you carry an increased risk of post-vaccine myo-pericarditis. (For a rational discussion about this issue, please read Dr Vinay Prasad’s article on substack).

Was this risk discussed with this patient? Even if he were to agree to the vaccine, when should he take it? Should he take it before the transplant when his heart is already not functioning well? Can his failing heart sustain the risk of myo-pericarditis? Also, per my perspective, anyone with a chronic disease is highly likely to also have chronic inflammation. Bear with me as I am making a huge assumption here that this patient is likely having chronic inflammation as well. If so, can his already burdened immune system mount an appropriate response to the vaccine? What level of protection is he likely to get? Or will his inflamed immune system have an exaggerated response in the form of serious adverse effects?

Or should he take it after the transplant when he is loaded with immune suppressants? If after transplant, does giving the vaccine make sense given he is on immune suppressants? What about the immune triggering effect of the vaccine then? Will it trigger transplant rejection?

People forget that vaccines do not miraculously bestow antibodies or immunity on us. Vaccine efficacy relies on the proper functioning of our immune system. In this sense, vaccines can be seen as inherently inert in the absence of an immune system. By which I mean a vaccine is only as effective as the health of the immune system it is working with. The varied response we see in people from robustness of antibody response to adverse effects is because of each individual person’s state of immune system. Vaccine response depends on whether your immune system is healthy or not. Is it in a balanced state or is it underperforming or is it in a state of inflammation?

We also have data that the vaccine effectiveness is diminishing with newer variants, including Omicron, the predominant variant currently. So, what is the benefit to this patient in getting the vaccine now?

To add more nuance here, has he had a prior infection with covid and hence natural immunity to it?

As you can see, I can go on in this vein. If I were to be evaluating this patient, these are the questions and concerns I would have. In systematically answering these questions for myself and laying it out to the patient in true informed consent manner, I would hope to help this patient make a decision that is in his best interest. After all, he is the one facing a life or death scenario. Should we still expect him to bear the burden of “saving grandma by getting vaccinated”?

So, I think the best title for this news article is my title here, “Transplant patient rejected for exercising health choice in the absence of informed consent.”

How different would the discussion be if the headlines were my title? Because with the CBS headline, as a reader you are given only two choices – for him or against him. I am hoping that my title will invite the reader to explore the nuance I have mentioned here.

I would like to clarify that I am not expressly arguing for this patient to receive the transplant or not. However, I would like to see that the transplant team and the hospital implemented a thoughtful analysis from all different angles, especially along the lines of inquiry I have raised here. Although, I would argue that if true informed consent principles were applied and followed, then there can never be a coercion of medical intervention on any patient capable of making their own health care decisions.

Finally, Brigham hospital’s stance is nothing short of medical tyranny exemplified by complete lack of nuance in approaching this patient’s situation. If they have indeed applied thoughtfulness and nuance, it is not evident in their statement. They have even ignored most recent data with regard to myo-pericarditis risk as well as vaccine effectiveness.

Albert Maysles said it best, “tyranny is the deliberate removal of nuance.”

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