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Letter to the Editor

Recognizing Impaired Decisional Capacity in Vaccine Refusal: Reply to Kels and Kels

Joseph F. Goldberg, MD,a,* and  Jacob M. Appel, MD, JD, MPH, HEC-Ca

Published: February 1, 2022

J Clin Psychiatry 2022;83(2):21lr14357a

To cite: Goldberg JF, Appel JM. Recognizing impaired decisional capacity in vaccine refusal: reply to Kels and Kels. J Clin Psychiatry. 2022;83(2):21lr14357a.
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aDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
*Corresponding author: Joseph F. Goldberg, MD, 128 East Ave, Norwalk, CT 06851 (

© Copyright 2022 Physicians Postgraduate Press, Inc.



See letter by Kels and Kels and editorial by Goldberg

To the Editor: We thank Kels and Kels1 for the opportunity to expound upon the relevance of decisional capacity when considering reasons for vaccine refusal. As outlined in the original editorial,2 there are many reasons why someone might choose to refuse an FDA-approved nonexperimental lifesaving vaccine and, by doing so, put others at risk for harm. Some individuals who decline vaccination will meet Appelbaum and Grisso’s criteria for capacity.3 For instance, certain congregants of the Dutch Reformed Church acknowledge the efficacy of vaccination but question its morality, fearing that it interferes with God’s will.4 However, many vaccine objectors irrationally reject the safety or efficacy of vaccination. Such cases call into question an individual’s ability to appreciate the situation and its consequences or to recognize the danger that their unvaccinated status poses to themselves and others. It is the purview of psychiatry to recognize when mental processes that influence decision-making are impaired. A consistent inability to synthesize factual information or to recalibrate one’s choices in the face of correctable falsehoods (eg, “vaccine misinformation”) is fundamentally distinct from an “epistemic mistrust of authority.” Indeed, the DSM-5 defines delusions as “fixed beliefs that are not amenable to change in light of conflicting evidence.”5 Magical thinking in the face of dire stresses may be psychologically protective (eg, coping with grief or a grim diagnosis), but abject denial of reality can undermine decisional capacity—as when patients unreasonably and desperately embrace unproven COVID-19 “remedies” (such as ivermectin) despite a surfeit of negative scientific evidence.6

As the Kels note, the preservation of autonomy assures that people remain free to make terrible health care decisions without necessarily calling into question their decisional capacity, such as choosing to smoke cigarettes or ignore diabetic diets. Adverse health consequences from such bad decisions usually directly affect only the individual. Persons with capacity may also make choices that have deleterious health care consequences for others, such as refusing treatment for tuberculosis or driving while intoxicated; however, these individuals become subject to the police power of the state and often criminal sanction. At the extreme, an individual meeting criteria for sociopathy might indifferently or even intentionally seek to spread an infectious disease such as AIDS or COVID-19 while fully understanding the consequences of his actions7; while doing so is clearly unethical and likely illegal, it does not implicate questions of decisional capacity. In addition, the law often allows individuals who do not meet the formal standards of capacity to render their own medical decisions when doing so is consistent with a long-standing religious or cultural practice. For example, Christian Scientists generally do not have their medical decisions overridden, although they cling to beliefs highly inconsistent with the scientific underpinnings of allopathic medicine (eg, that antibiotics do not cure bacterial infections). That latitude is afforded to Christian Scientists, or similar groups, not because they possess decisional capacity but, rather, because our society has rendered a cost-benefit analysis that favors autonomy over intervention for certain groups, even in the absence of capacity, when the consequences fall entirely upon themselves.

What is distinctive about vaccine refusal vis-à-vis decisional capacity is that refusers both pose a danger to others and simultaneously fail to appreciate this danger due to fixed, false beliefs. These dangers may prove immediate, such as when a vaccine-refusing inpatient is discharged to a nursing home, where they run the risk of infecting other residents, or more long term, such as when vaccine refusal promotes further viral mutations and needlessly prolongs the pandemic and drives societal morbidity and mortality. If a single individual believed that vaccines caused human beings to become magnetic or contained microchips that tracked and controlled him, psychiatrists would have no difficulty in declaring that individual too psychiatrically impaired to render decisions related to vaccination. That other individuals share these paranoid, delusional beliefs do not render them any less pathological.

Published online: February 1, 2022.
Potential conflicts of interest: Dr Goldberg has served as an advisor or consultant to BioXcel Therapeutics, Lundbeck, Otsuka, Sage, Sunovion, and Jazz; served on the speaker’s bureau for Allergan, Intracellular Therapies, Otsuka, and Sunovion; and received royalties from American Psychiatric Publishing, Inc, and Cambridge University Press. Dr Appel reports no potential conflict of interest.
Funding/support: None.


Volume: 83

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