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As a doctor, I wonder: 'Can our waning empathy cause harm?'

People rally against vaccine mandates at Grand Park in Los Angeles, Calif. on April 10, 2022. (Wally Skalij/Los Angeles Times via Getty Images)
People rally against vaccine mandates at Grand Park in Los Angeles, Calif. on April 10, 2022. (Wally Skalij/Los Angeles Times via Getty Images)

I’m tired of hearing about anti-vaxxers. They’re loud, they’re wrong, and, after persisting through two years of the deadliest public health crisis in recent memory, I’m pretty sure they’re here to stay. But in watching the responses of my peers to patients who are anti-vaxxers, I’ve begun to worry for this group in a new way, beyond their risk for COVID. Now, I’m beginning to worry about how we, as doctors, might be treating them.

To put it lightly, anti-vaxxers are not well-liked by the doctors I know. In fact, I’ve heard them talked about with scorn, judgment and righteous anger.

“Why won’t they just get the vaccine?”

“These people are crazy.”

When we see bad outcomes in unvaccinated patients, the sentiment can persist: “Well, he could’ve avoided it,” and “she did this to herself.”

I’ve read so many essays by healthcare workers describing how they've lost  compassion for unvaccinated patients. Some have even suggested that anti-vaxxers shouldn’t be allowed to receive ventilators. And to an extent, I get it. The unvaccinated are not only causing harm, but, in many ways, they are the people most visibly standing between us and any real possibility of a return to normal. Our empathy for these people, much like our tolerance of the pandemic, is on its last leg. How might losing our empathy for this group affect the care we provide?

[In] watching the responses of my peers to patients who are anti-vaxxers, I’ve begun to worry for this group in a new way, beyond their risk for COVID.

I am very clear on the effectiveness of vaccines; they work. And so, it’s difficult for me — as a physician and researcher working in health equity — to see anti-vaxxers as possible victims. Nevertheless, I can’t help but apply what we’ve learned after decades of research on bias. It is now common knowledge that, when doctors judge or dislike patients, if affects the care we give. Sometimes, those patients get worse care. This can take the form of less face-to-face time with clinicians, fewer diagnostics or treatments, sometimes even active harm.

Right now, due to a combination of burnout and “moral fatigue,” anti-vaxxers have become a group that we’ve become quite comfortable judging openly and frequently, particularly in healthcare. Unfortunately, how this translates to patient care has yet to be uncovered or even looked into. More than two years into the pandemic, there has not been a single study investigating differences in care provided to vaccine-hesitant or anti-vax patients. But to understand how these sentiments might impact care, we can look to history.

Some the earliest reflections written by Western physicians’ have documented how doctors have struggled to deal with patients who disregard their suggestions. In the past, patients would be openly ridiculed and stigmatized for not following a doctor’s orders. In today’s practice, these are patients we label as “nonadherent” or “noncompliant”. In a real sense, anti-vaxxers are “defiant” patients.

Based on prior research, we know that being perceived as defiant impacts medical care. Patients are aware they can be seen as either “good” or “bad” based on their behavior. And healthcare practitioners have a history of using this information to “blame” patients for their conditions. Patients perceived to be actively or even “likely” to be defiant may receive worse care than patients perceived as “compliant”. This can lead to inadequate mental health careundertreatment and even expulsion from a doctor’s practice. As a medical resident, I have already seen all of these things take place in real-time.

To further complicate things, research suggests that minority patients, particularly Black patients, are more likely to be perceived as defiant when exhibiting the same health behaviors as white patients. My own research discovered that Black and poorer patients are disproportionately labeled as “nonadherent” in their medical records compared with wealthier, white patients.

[W]hat if we embraced defiance as an important invitation to address issues around trust, medical paternalism and historical trauma?

In short: doctors have a history of providing worse care to patients perceived as defiant. Additionally, there’s good reason to believe that this trend disproportionately affects communities of color. It makes me wonder: can our waning empathy cause harm?

We need to investigate whether our negative feelings about anti-vaxxers impact the care we provide. It’s research that could lead to a new line of investigation and self-reflection that could have relevance in many other areas of medicine. Why does our empathy fall short with patients who defy us?

The truth is that medicine has deeply paternalistic roots. This has given rise to a culture that assumes our recommendations are “good” and therefore those who defy them are “bad.” But what if patient defiance evoked something other than frustration? Instead, what if we embraced defiance as an important invitation to address issues around trust, medical paternalism and historical trauma? Perhaps then we could focus our frustrations not on the individuals exhibiting things like vaccine hesitancy, but instead on the conditions which systematically lead to “nonadherence”. Things like a for-profit healthcare system, systemic racism, or AI-powered misinformation.

Health advocates need to investigate the potential impacts of our lost empathy for anti-vaxxers. But, perhaps more importantly, we need to work on resolving our feelings about them — and other examples of defiant patients — so that we might shift medical culture away from blaming individuals and towards holding the systems that cause people to “choose” bad health behaviors to account.

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Sourik Beltrán Twitter Cognoscenti contributor
Sourik Beltrán is a resident physician and primary care doctor at Massachusetts General Hospital and Harvard Medical School.

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