LAUSR

Despite the important clinical and public health implications of a COVID-19 diagnosis, respect for autonomy allows patients to decline testing without explanation and with impunity. Whether physicians believe a test is indicated for clinical care of an individual patient, prevention of nosocomial transmission, or the greater public health, patients may refuse. Such refusals may be increasing due to quarantine requirements, concerns regarding contact tracing, and the persistent absence of a curative treatment.1,2 Mass screening of all healthcare workers (HCWs) is being considered to prevent hospital transmission,3 and universal screening in nursing homes has thwarted outbreaks while providing data to facilitate resource allocation.4 Given these circumstances, patients’ absolute right to refuse a noninvasive test with the potential for multifaceted downstream benefit is worthy of reconsideration, in favor of mandatory testing. Mandatory testing confers numerous benefits, including mitigating risk to other patients and HCWs, who play a central role in pandemic response. Because infected HCWs may transmit the virus to patients, they also should undergo mandatory testing,3 particularly in the presence of symptoms, since nasal secretions increase the diagnostic yield of testing.5 Although pretest probability (as an estimate of disease prevalence) typically determines the testing strategy for admitted patients, model-based analyses suggest that testing every 3 days for HCWs or continuously hospitalized patients would nearly eliminate infectivity.6 Tools for assisting frustrated HCWs navigating patients’ right to refuse testing have been developed that incorporate education, clear communication, and conflict resolution.7 Such approaches are, however, only moderately successful, making personal protective equipment (PPE) based on a default assumption of COVID-19 positivity common.8 The burden and disheartening waste created by low-yield PPE use among patients unwilling to be tested becomes particularly evident in the context of shortages. Such vexing, stressful shortages, as well as the dual responsibilities of hospitals as stewards of both individual patient and population health, serve as reminders that efficient allocation of resources must be valued alongside the autonomous rights of patients.9 Moreover, recent reports suggest that test avoidance is a growing problem.1,2 Refusal to accept testing may be rooted in anxiety, concerns about the consequences of a positive result (eg, inability to attend school or work), or a desire for self-determination.1,2 The hesitancy that leads to refusal may also arise from misinformation, poor public health messaging, distrust in the establishment, and unproductive considerations related to conscientious objection without foundation.2 Concepts of individual liberty that often underlie steadfast adherence to the principles of self-determination created opposition to masks that antagonized public health efforts to limit the spread of COVID-19. Although influencing inpatients’ behavior to benefit both the public and HCWs may be distinct from community settings, the attitudes that lead to test refusal and defiance of mask-related ordinances likely have substantial commonalities.