No vaccine, No organs? The ethics of vaccine mandates for pediatric transplant candidates

Abstract: Some pediatric transplant surgeons have recently required patients to be vaccinated prior to being listed. These vaccine mandates aim to benefit patients by increasing vaccination rates among a population that is especially susceptible to vaccine-preventable diseases. They also aim to promote fair allocation of scarce organs by reducing post-transplant complications associated with vaccine-preventable diseases. But pediatric pre-transplant vaccine mandates are unjustified by either beneficence or fairness. First, conditioning life-saving treatment on vaccination status is an ethically objectionable form of coercion, even if it causes parents to vaccinate their child. Benefits should not be delivered to child-patients by threatening to let them die. Furthermore, vaccine mandates are surely not beneficent if parents continue to refuse vaccines in the face of threats to withhold transplant: it is better for children to be alive and unvaccinated than dead and unvaccinated. Second, fairness in the allocation of scarce medical resources does not require limiting transplantation of organs to vaccinated children. Unvaccinated post-transplant child-patients face somewhat higher risk of illness and death from vaccine-preventable diseases, but they nonetheless receive substantial benefits from transplantation, such that listing them meets equity and efficiency criteria for organ allocation. Finally, and counterfactually, if reducing the risk of vaccine-preventable diseases among pediatric transplant candidates did require not listing unvaccinated children, then other less coercive measures would also be required (for example, vaccine mandates for all staff at pediatric transplant clinics). Yet, even at the height of the COVID-19 pandemic, pediatric transplant centers did not insist on such measures.

Lainie Friedman Ross, MD, PhD, University of Rochester Aaron G. Wightman, MD, University of Washington