Reply to professionally responsible COVID-19 vaccination counseling.

We thank Dr Habiba for his interest in our article. Dr Habiba claims that our article failed to be “rooted in scientific rigor” because “vaccines have not been tested in pregnant women” in a randomized controlled clinical trial. In February 2021, Pfizer and BioNTech embarked on studying the effects of COVID-19 vaccination on pregnant women. Before the results of trial data, it was necessary to protect pregnant and lactating patients through emergency access and advocate for their participation in research. Recently, the US Centers for Disease Control and Prevention has endorsed recommending COVID-19 vaccination to pregnant women, relying on the best available evidence. When we submitted our article and to date, the best available evidence supports the judgment that, because of the significantly higher COVID-19 morbidity and mortality rates among pregnant women, vaccines will save lives.

Implicit in Dr Habiba’s criticism is the view that in professional ethics in obstetrics and gynecology (and in all other specialties), making definitive recommendations shows disrespect for patients, even when the best available evidence is clear. His concern is that making recommendations aims to “influence value judgments” and “sway women toward a particular choice.” For this criticism to become persuasive, Dr Habiba should have shown that making recommendations is incompatible with the ethical principle of respect for patient autonomy.

Making evidence-based recommendations is an accepted professional standard, such as smoking cessation, wearing seat belts, using baby car seats, and abstaining from alcohol in pregnancy. Such recommendations are standard components of the informed consent process. There is an ethical point to such standards: it would be negligent to not make a recommendation for fear that a patient’s value judgments about the health risks for herself and her fetus may be influenced or that she might be swayed toward a particular choice. If the patient disagrees with a recommendation, the professional standard of informed consent is clear: repeated, directive counseling aimed at respectfully providing knowledge for the patient to reconsider. These standards are beneficence based, reflecting the professional commitment to protecting the health of pregnant and fetal patients. Furthermore, Dr Habiba should have shown that respect for autonomy overrides such beneficence-based considerations.

There is a justice-based justification for directive counseling of patients who refuse COVID-19 vaccination, whether they are pregnant or not: their refusal to be vaccinated puts others at risk of morbidity and mortality without their consent. We proposed that such patients be asked if their refusal is fair, a strategy designed deliberately to avoid passing moral judgment on the patient. In addition, Dr Habiba should have shown why asking this ethically appropriate question entails passing such moral judgment.