The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!
Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director
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Vaccine – noun – vak-ˈsēn- definition: a product to stimulate a person to produce immunity.
As surgeons exposed to patients with COVID-19 not infrequently, we were among the first afforded the opportunity to be vaccinated against the disease destroying life as we know it. When vaccine ideas and dreams transitioned to trials and approvals, the anticipation of protection soothed the abrasiveness of life on the front lines. The daily death toll, the social injustices occurring around the country, and the stark isolation from human contact on top of going to work shrouded in PPE was suffocating. Hope of a vaccine, even proceeding actual inoculation, provided its own immunity as protection from the struggle to believe that watching patients die alone and saying farewell by iPad was meeting our career expectations of healing. Excitement replaced despair when vaccine production was underway and approval for emergency use was imminent. Physician-scientists swelled with pride as colleagues in medical centers around the world became the heroes of the world, replacing the athletes, politicians, and billionaires that graced the front pages of newspapers just months before. Even before release, the vaccine gave immunity to the physical and emotional drain of the disease. When asked by family and friends if we would get the vaccine when it became available, the answer was a resounding yes, based on true belief that the vaccination was the crucial step in bringing about the end of this pandemic.
As second doses were administered to trial participants, the unsettling news of unanticipated side effects, including commentary on the frequency and severity of the response to the booster, came to light. Enthusiasm was disrupted by bouts of hesitancy as the excerpts from the Pfizer presentation showed the many areas in which data and risk were simply unknown. There was a lack of diversity among the trial participants with no children or pregnant women, and only a couple months of data, leaving long-term side-effects in the realm of horrifying possibilities. The definition of “success” for the vaccine was elusive at times. Assurances that the vaccine prevented severe illness had to be considered in light of the study participants still practicing mask-wearing, social distancing, and infectious precautions. Different vaccines around the world were introduced using different methodologies, including some never used before on the diverse biome of the global population. Even under full approval as opposed to emergency approval circumstances, vaccines in the past have been withdrawn from the market for unintended harms found after release, including Guilliane-Barre Syndrome after the Swine Flu Vaccine and intussusception after the Rotavirus Vaccine.
In modern surgical consent, we are asked to provide the risks, benefits, and alternatives in a truly patient-centered manner, respecting that each person has different values guiding decision-making. Medical professionals had to make an informed decision on being the first population in the country to receive the vaccine based on incomplete knowledge. Many jumped at the opportunity to be first based on the belief that the risk of the virus was outweighed by the very real deaths seen in our patients. But when the patients you were treating differed so much from you in age, race, health status, co-morbid condition, and more, it can be harder to take on the risk of a novel inoculation. For some of us, the concern over the lack of a safety profile in discrete populations combined with concern for impact on fertility in women of child-bearing age or unborn children made consideration of vaccination a Faustian bargain. Although not legally mandated, choosing to receive the vaccine felt forced. Every day we were inundated with questions of whether we had gotten our vaccine from our peers and coworkers, many of whom recounted tales of how long they were in line and how many obstacles they overcame to obtain their shot. Social media was flooded with vaccine selfies, with absence of such an image proving conspicuous to others. Surrendering to the vaccine began to feel more like an obligation than a choice. Admission of not yet receiving the vaccine was to be avoided and when confessed came with a dose of overwhelming guilt for not conforming to expectations. Patient-centered decision-making on the weight of risks and benefits seemed to only apply to non-medical personnel. Even the consent-based review of the alternatives was withdrawn as most centers had only access to a single vaccine. A paternalistic expectation that we should take what is given to us without question or complaint replaced the supportive, respect for autonomy usually found in healthcare.
Immune – adjectivem- i-ˈmyün – definition: not affected by a given influence.
With time and tens of thousands more vaccinations administered, we chose to receive the COVID vaccine for our physical and emotional wellbeing of our own volition. We continue to be exposed to this novel virus on a near-daily basis, though our armamentarium for treatment and the evidence to support management grow rapidly. As we bypass the anniversary of the first known cases of COVID-19 in the United States without any reprieve, we are reminded that there is hope in the vaccine. Using the familiar model of the surgical consent combined with our personal journey of developing immunity, we now reach out to others for open and honest discussion of the risks, benefits, and alternatives of each vaccine to those who are still deciding. We manage expectations of side effects and describe how it can provide significant protection against COVID-19. We discuss the risks, both known and unknown, the shortcomings, and the areas where data and efficacy are still lacking. And then, we listen, providing support to the patient deciding what to do, without judgment, without coercion, and without dismissal of concerns. We choose this vaccine for ourselves despite the pressure of those around us, and while now immune and healthy, we still recall the discomfort of not getting the vaccine exceeding the discomfort of the jab. As surgeons, we have a responsibility to our community, inclusive of both patients AND healthcare professionals, to be exemplary role models in both provision of care and educating on healthcare decisions. Only through the lens of patient-centered autonomy can true immunity occur.