Executive orders prohibiting vaccine mandates: Implications for transplant patients and physicians.

DISCLOSURE

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

There is ongoing discussion within the transplant community, lay press, and US government leaders about the appropriateness for vaccine mandates for transplant patients. In Texas, transplant centers are faced with the reality of having an executive order widely interpreted by hospitals’ administrations as prohibiting vaccine mandates in the provision of medical care.  This policy is based on the laudable goal of providing all citizens access to life‐saving medical care without discrimination based on their personal choices or personal responsibility for their medical problems. However, applying the executive order to ignore vaccination status to patients awaiting an organ transplant submits patients to a perfectly avoidable risk and puts transplant programs in a difficult predicament. The efficacy of the vaccine is inferior when it is given after the transplant and the severity of illness and mortality due to COVID‐19 infection are significantly higher in unvaccinated transplant recipients. ,  This translates into a higher risk of graft loss and patient death following transplantation, which leads to a negative impact on outcomes for transplant programs that cannot consider vaccination status as part of their evaluation for listing or transplantation.

There are strong clinical and ethical reasons to support at least a limited mandate for COVID‐19 vaccination prior to solid organ transplantation.  We believe that COVID‐19 vaccination should be seen as a modifiable risk factor similar to the many other modifiable risks we strive to control or eliminate to decrease the risk of death after transplantation. It is because of the clinical evidence of COVID‐19 vaccine benefits that the transplant community strongly encourages vaccination against SARS‐CoV‐2 among the steps in workup prior to an organ transplant.

The fundamental problem with the executive order to ignore vaccine status in the provision of medical care is that it takes the medical decision‐making out of the hands of transplant physicians. It is unacceptable to require transplant physicians to ignore a medically relevant modifiable risk in a patient being considered for listing or transplantation. For example, unvaccinated transplant recipients are at greater risk during peaks of infection when the risk of transmission within the hospital setting is high. Vaccination status is also an important consideration when deciding whether or not to offer a COVID‐19 positive donor organ to a patient on the waiting list. The fear of violating an executive order, an action that might have legal repercussions on transplant programs and their hospitals, forces transplant physicians into a situation where they provide knowingly suboptimal care with potentially severe consequences for the patients and the programs. The recently proposed nationwide mandate to ignore vaccination status in transplantation, is yet another example of undue interference in our right to provide care to our patients.  We, as transplant physicians, should be allowed to deliver the best care to our patients, make decisions based on medical evidence, and not bear the responsibility of transplanting high‐risk patients based on a government order.