SINGAPORE – With no known next of kin, and suffering from cognitive impairment, 73-year-old Madam Tan (not her real name) poses a quandary for her carers.

She suffers from dementia and previously had a stroke, lacks the mental capacity to make her own decisions, Thye Hua Kwan Nursing Home @ Hougang told The Straits Times.

So, when the Covid-19 vaccine is made available to the nursing home, who decides whether she should receive it?

Mrs Jenny Bong, acting head of MWS Bethany Nursing Home, said the nursing home has been looking into this issue since it was announced that vaccination would be made available to the elderly.

Six nursing homes in Singapore started vaccinating their residents in late January.

In response to queries from ST, the Ministry of Health (MOH) said registered medical practitioners may make the assessment on whether to vaccinate individuals incapable of making decisions on their own, and have no known next-of-kin nor deputies. This is in accordance with the Singapore Medical Council’s Ethical Code and Ethical Guidelines, and practitioners should act in the best interests of the individual.

Mr Ardi S Hardjoe, chief executive of Thye Hua Kwan Nursing Home, said an advisory from the Agency for Integrated Care (AIC) in early January said the nursing home doctor can authorise vaccination according to his best judgement of the patient’s best interests for such vulnerable individuals.

“We would proceed according to our doctor’s assessment,” added Mr Ardi.

A person may lose his ability to decide on matters due to disability, mental illness or brain diseases such as Alzheimer’s.

Under the Mental Capacity Act, the person deciding for a mentally incapacitated patient such as Madam Tan should, among other things, consider the patient’s past and present wishes and feelings, and beliefs and values.

Mr Chandra Mohan Rethnam, a partner at Rajah and Tann, said: “You have to consider things such as the person’s age, the fact that he is living in a communal facility, and if he can protect himself by wearing a mask or wash hands regularly.

“If the individual can’t do these things to protect himself, then perhaps a vaccination is clearly in his best interest.”

Law Professor Kumaralingam Amirthalingam of the National University of Singapore added that in their assessments, doctors should balance the vulnerable person’s risk of contracting Covid-19 against vaccine side effects if the person is already health-compromised.

He said another aspect that should be considered is whether the patient has comorbidities, which refer to two or more medical conditions in a patient.

Certain comorbidities like obesity, hypertension, diabetes and heart disease put patients at risk of severe Covid-19 and even death.

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Prof Kumaralingam said: “If these individuals have comorbidities, and it is in their best interest to be vaccinated, they should be vaccinated.”

“For nursing homes and doctors, the safest thing to do is to seek a court declaration authorising their act (to decide for these vulnerable patients),” he said. But if they are unable to do so, they can proceed, acting in the patient’s best interest.

In a joint reply, Dr Sumytra Menon and Assistant Professor Voo Teck Chuan from the National University of Singapore’s Centre for Biomedical Ethics, said legal advice should be sought if healthcare professionals cannot agree on whether vaccination would be in a patient’s best interests.

Mr Chandra also stressed that healthcare professionals should take all practical steps to help the individual make the decision himself. If that is not possible, then the healthcare professional can decide.

Prof Voo added: “Even though a person lacks capacity because they are unable to weigh the risks and benefits – which may happen in the case of an intellectually disabled person or a person with a mental disorder – they may likely be able to understand what is happening.

“So it would be respectful for healthcare professionals to explain about the vaccination before carrying it out.”

In an ST Forum letter last Monday, Associate Professor Lim Poh Lian, who is a member of the expert committee on Covid-19 vaccination, said the vaccine is generally safe for those with medical conditions.

These conditions include kidney disease, chronic HIV, and cancer in remission.

But those with untreated cancer, or are undergoing treatment such as chemotherapy should defer vaccination, he added.

So, how can vulnerable individuals with no kin be protected if they are unsuitable to take the jab?

Infectious diseases expert Ooi Eng Eong from the Duke-NUS Medical School said these individuals can be protected if their caregivers such as doctors, nurses and allied health professionals, get vaccinated.

But Prof Kumaralingam noted that those who are vaccinated may still spread the disease.

It is still unclear if the vaccines can curb the spread of Sars-CoV-2, which is the virus that causes the Covid-19 disease.

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Prof Ooi added: “Even if the vaccine only prevents Covid-19 but does not fully prevent Sars-CoV-2 infection, the likelihood of transmission would be greatly reduced compared with someone with symptomatic illness.

“Vaccination of caregivers could thus reduce the risk of infection among those who are unable to provide informed consent.”

Prof Ooi said although Covid-19 vaccination is voluntary, if local outbreaks return, the Ministry of Health has the legal authority to make vaccination compulsory.

He said: “Such enforced vaccination, however, is unnecessary at this time and may never be needed if the rate of voluntary vaccination in Singapore reaches desired targets.”

As of last Wednesday, more than 113,000 people – largely healthcare workers and frontliners – have been vaccinated here since the drive started last month.

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