[As this goes to press the Biden administration is proposing a sweeping vaccine mandate that may affect an estimated 100 million Americans, making the following considerations all the more relevant]
Dear_________,
I received your message detailing your concerns about receiving a COVID vaccine and requesting a medical exemption. I understand that your employer is now mandating a vaccine unless you can obtain such an exemption (or perhaps a religious one). I find your concerns perfectly legitimate but, unfortunately, they do not justify a medical exemption.
As you’ve noted yourself, there is no evidence that a history of prior myocarditis or prior atrial fibrillation increases the risk of getting myocarditis from the Pfizer or Moderna vaccines. And even if there was such evidence, then the J&J vaccine would be the alternative immunization to address that particular concern.
I also understand that your worries go beyond the possibility of having another bout of myocarditis (however small the chance may be). You have serious misgivings about these vaccines because you’ve lost confidence in the medical profession, the pharmaceutical industry, or the public health authorities (or perhaps all three).
Who can blame you? Can anyone deny that self-interest is all too often a prime motivator in healthcare—even in public health—and all too often at the expense of patients or the public? Abuses of confidence by doctors and hospitals, greediness in the pharmaceutical industry, and ideological or political pressure in the public health sector are all plainly evident and warrant at least some degree of skepticism. Your distrust is not paranoid, it is actually rational.
My perspective on these vaccines
That said, from a purely biological perspective, my own view about these vaccines is generally favorable. I received the Pfizer vaccine early on. I was impressed with the efficacy that was demonstrated in the clinical trials. The rate of complications—at least in the short term—seemed quite low, and certainly low enough to make vaccination a very reasonable choice for many people, particularly the elderly and those most vulnerable to complications.
It sounds like you have been hearing it differently from physicians and scientists who view these vaccines with a great deal of suspicion. I must say that I personally disagree with the particular concerns being raised. For example, some people are suggesting that “spike proteins” produced by the mRNA vaccine can find their way into unintended parts of the body and cause widespread complications. I see no evidence for this. Others raise concerns about the high numbers of complications being reported in the vaccine adverse effects database (VAERS) but this is not, in my opinion, a reliable assessment of vaccine safety. There are other reasons to account for an abrupt rise in adverse effect reports during this pandemic.
Many of my patients have been vaccinated, and none of them have had serious complications. More generally, millions of people have been vaccinated, yet hospitals are not filling up with people suffering from vaccine side-effects. Also, I don’t see a spike in death rates that can be accounted for by the vaccination. It is theoretically possible that the vaccine could be more harmful than we currently observe, but for now I just do not see it.
To be sure, the vaccines are not completely benign. The condition that most concerns you—cardiac inflammation caused by the mRNA vaccines that affects primarily healthy young men—is a real one. For the time being, these cases of myocarditis seem relatively mild, at least in the short term. But we have to admit that we don’t really know if the inflammation will have residual effects in the long term.
The J&J vaccine also seems to cause blood clots, particularly in women, and these can potentially be very serious or even fatal. The incidence of such clots, however, appears to be extremely low. Additionally, there have been concerns raised about infertility. I think these are legitimate, given that the randomized controlled clinical trials were not designed to test that possibility. For now, however, I don’t find the evidence quite compelling that these vaccines cause infertility.
In summary, from a biological standpoint, I find that these vaccines offer an acceptable risk/benefit trade-off, provided they are administered to an appropriate recipient.
The crux of the problem
And here’s the crux of the problem: an appropriate recipient should at the very least be someone who freely accepts the risk/benefit trade-off. But now we have widespread vaccine mandates which essentially coerce people into accepting the trade-off. I find this completely objectionable.
The mandates are being defended precisely based on the fact that these vaccines are very effective (at least in the short term) and have low—and perhaps even very low—risks of serious complications. But this justification is misleading because the main reason for vaccine mandates is not to benefit you or whoever is targeted with the jab.
Vaccine mandates do not have your own benefit in mind. If they did, they would respect your personal autonomy. In medicine we never force a treatment on anyone against their will. We assume that people are capable of deciding for themselves if the benefits of a treatment are worth the risks, and we insist that they express their consent freely and without coercion. In day-to-day medical care, if a doctor or a hospital coerces a patient into receiving a treatment, they could be sued for violating a fundamental moral and professional principle.
The reason for vaccine mandates, then, is not to benefit the individual recipient of the vaccine but to benefit the population at large by increasing immunization rates in order to reach what is called “herd immunity,” at which point it is hoped that the spread of the virus would slow down and the pandemic would be under control.
I don’t want to dispute whether this is a realistic outcome (given what we know about the waning effectiveness of vaccines and the emergence of variants). Let’s assume that it is. Even so, this is a strategy that aims to use those who currently refuse vaccination as “human shields,” so-to-speak, for purely instrumental purposes. It disregards the harms (potential and real) inflicted on one group for the benefits of another group. I find that to be morally unacceptable.
Again, it is worth stressing that risk/benefit arguments cannot justify the mandates. Those who wish to impose widespread mandates argue that even in young, healthy people, the risk of severe complications from COVID is far greater than the risk of complications from the vaccine. That may be true in a technical sense, but the argument doesn’t hold.
First, when someone gets the vaccine they are directly confronted with the potential harm from it—however rare it may be. Whereas if they forgo the vaccine they are not confronted with the risk of COVID unless they get infected with the virus, which may or may not happen. Second, we only have short-term data on the effects of the vaccines, and one can legitimately be concerned about the long term effects of a new medical technology. Third, risk assessments should not exclude psychological harms. If I have a fear of heights, it wouldn’t matter if someone told me that the odds of falling from a building are minuscule. I would still be greatly harmed if I was dragged to the top of the Empire State Building against my will.
Furthermore, fear of the biological effects of vaccines is not the only reason why some people object to them. I know many individuals who are refusing to taking vaccines on moral grounds, because many vaccines (including the COVID vaccines available in the US) are tested or produced using cell lines derived from human embryos obtained from abortions.
Recent reports also suggest that the conditions under which these cell lines were derived may have been particularly violent. For many people, to receive such vaccines is abhorrent. I am not bringing this up to defend that view or convince anyone of it, but to explain that objections to vaccines often reflect certain beliefs that one should be able to legitimately hold without being coerced to do something that goes against those beliefs.
Yet here we are, with widespread vaccine mandates being imposed, and you’re risking losing your job unless you can obtain a medical exemption.
Medical exemptions are a false medical issue
But what I explained earlier should make clear that the concerns that you have are concerns that even a perfectly healthy person can also legitimately have. Therefore they are not “medical concerns” in the sense that it requires a medical doctor to legitimize them. If I issued a medical exemption for you, I would have to issue one for anyone who had similar and equally valid concerns. And believe me, I am getting many requests like yours: a city firefighter facing losing his job and his pension, a graduate student from a Catholic University who may be expelled from his program, a single mother also facing dismissal from work. These are very tough situations.
So you know, I am not primarily worried about inviting scrutiny on my practice if I issued medical exemptions (thank you for asking), although that would certainly happen if I did it consistently for every request I received. My principal concern with medical exemptions is to avoid perpetuating the false and dangerous notion that a “medical professional” must sanction a decision not to be vaccinated when, in fact, any person should have the right to make that decision for themselves.
I have spoken up publicly against vaccine mandates in the past, even before COVID emerged, and I will continue to do so as much as I can. But, at the end of the day, these are plainly immoral policies that will have to be fought in court or else rejected en masse rather than be negotiated surreptitiously in the doctor’s office.
Does that make sense?
Yours truly,
Dr. Accad
You make a lot of good points. I’m not sure I have a problem with any business or non-governmental agency putting out mandates, as long as the product or service in not of absolute necessity and is reasonably available elsewhere. But stretching the truth on medical justifications? I wouldn’t do it. How could anyone rely on your word?
Thank you, Anthony. Doctors stretch the truth on medical justifications all the time (especially to get paid). No wonder we’re in such a mess.
And what about those 75 and older who have pre-existing conditions….COPD, VASCULAR[STENTS]/HEAD & KIDNEY CANCER w/5000 rads?
“I also understand that your worries go beyond the possibility of having another bout of myocarditis (however small the chance may be).”
Dr. Accad states that he understands his patient’s worries but he himself does not accept them. The patient has already had myocarditis so he may be more prone to another bout. His body, his immune system has already demonstrated that the patient can have myocarditis. Therefore, the patient has a serious concern which will not allow his conscience to receive the vaccine. The medical system is such that he needs a doctor to assist in a medical exemption. The patient has medical reasons for a conscience exemption. The patient’s conscience causes him to question the vaccine. If his conscience does not allow him to get the vaccine, he ought not to get it.
No evidence of myocarditis recurrence with the vaccines is not evidence of no risk of additional myocarditis from them.
Dear Dr. Byrne,
You are absolutely correct that absence of evidence is not the same as evidence of absence of increased risk but, to a large degree, the physician must base his prognosis on what is known rather than on what is conjectured. The vaccine has undoubtedly been administered to many patients with a history of myocarditis, but I have not heard it reported that they have had an issue with relapse. This also makes some biological sense given the countless specific mechanisms by which inflammation can occur in the heart.
You also make a valid point that the patient’s conscience exemption could reasonably be based on medical considerations. A “medical exemption” is a loose term that may be understood in many different ways. I don’t think that it has any established legal definition, but the specific vaccine mandate rulings that I have read that pertain to COVID-19 vaccination are very explicit in limiting the scope of a medical exemption to the very narrow list of contra-indications and precautions listed on the vaccine manufacturer’s package insert. They do not seem to allow an exemption of conscience even if based on plausible medical reasons.
To be honest, though, an exemption of conscience is just that. Even if what jars the conscience is a plausible medical concern, it would seem “Jesuitical” (if I may use the expression) to construe it as a medical exemption which ordinarily would mean that the doctor’s medical knowledge and experience applied to the specific patient bears on the exemption. As I mentioned in the piece, I don’t think that’s the case here. A perfectly healthy young man without any prior medical history has equal grounds to have his conscience object to the vaccine based on the known increased risk of myocarditis in that population. No medical diagnosis is required.
Now, I hope I would not hesitate to issue a medical exemption if it were a matter of life and death for the patient. But it is not. He retains the choice of not receiving the vaccine, although that may come at an extremely high economic and social cost. The problem is therefore a social and political one. I would be strongly inclined to help my patient in friendship, but I also feel that I have an obligation to the medical profession which, as we know, is really on moral life support. To continue to let doctors become instruments of the system won’t help anyone in the long run.
Dr Byrne
I have had an antibody test. It came back positive. I have chronic pericarditis. My MD and NP both agree that risk of side effects from the vaccines is not necessary to endure because I have antibodies. My medical team still cannot offer me a letter of exemption because their governing body will not allow them to. Where do I turn in light of these upcoming mandates in my area?
Dr Accad
I am a patient with chronic pericarditis and have the same fears as your patient however, after consulting with my MD and NP it was determined I should take an antibody test before deciding on the vaccine. My test came back positive. So in that I have natural antibodies we collectively determined that the risk outweighed any possible benefits. This decision was made before vaccine mandates were announced to be coming into effect in my jurisdiction in Ontario Canada September 22, 2021.
So I went back to the same people who helped me navigate whether to get vaccinated or not and both now tell me that they would both like to issue me an exemption letter however the CPSO – College of Physicians and Surgeons of Ontario has issued a directive and if my pericarditis isn’t as a result of a previous vaccine they cannot. So their hands are tied.
I have the spike proteins that the vaccine is going to give me and I have unknown possible risk of pericarditis from the vaccine. I also have history of stroke so the vaccine that could cause blood clots is a risk too.
How is it fair I’m not afforded a medical exemption?
I feel I’m under undue stress because of this which is affecting my health on a whole other level.
Can you or anyone help in my situation?
I did not address the case of vaccinating previously infected and now recovered patients. It is even more absurd that patients like you should be required to be vaccinated since the immunity imparted by the prior infection is likely stronger than the one given by the vaccine. I think one could construct a legitimate case that in a previously infected person the risks outweigh the benefit and that a medical exemption could be issued. Unfortunately, I have no medical privileges in Canada and your only recourse is going to be with Canadian physicians. I am very sorry that you have to go through this.
I just came across this blog and notice it was written in 2021. Do you think differently now about some of the adverse reactions like myocarditis, etc? Sounds like there are more people, especially young people suffering from serious adverse reactions due to covid vaccine.
Thank you for your comment. As noted in the post, at the time the J&J vaccine was available as an alternative to the mRNA vaccines for those with concerns about myocarditis. I was and remain staunchly against vaccine mandates, regardless of whether they have adverse effects or not or whether they are efficacious or not.
Hello Dr Accad: Totally understand you are against mandates. Putting aside mandates. If you knew in 2021 the vaccine efficacy of mRNA vaccines, and what the possible short and long-term side effects were, as we have since learned, do you think you would have taken the vaccine? You sound like a very thoughtful and intelligent human being. Thanks.
Hello Sandy,
Thank you for your question and sorry for the delay in answering. Bearing in mind your question is addressed to me personally (and therefore assumes knowledge of my health and circumstances, risk tolerance, metaphysical worldview, etc.), the answer is that I would not have taken the vaccine. But it’s a personal question and therefore a personal answer.
Dr. Accad