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Janet E. McElhaney is scientific director in the Health Sciences North Research Institute and professor at the Northern Ontario School of Medicine

Melissa K. Andrew is professor of Medicine at Dalhousie University

For those with high levels of decision-making abilities, access to COVID-19 vaccines in Canada is largely straightforward. From navigating a booking process – increasingly online – to travel to the site and access to the site upon arrival, we are observing high levels of vaccine uptake among this population.

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However, in order to respect the values of equality, equal opportunity, fair treatment, and an environment free of discrimination as enshrined in the Canadian Human Rights Act of 1977, we need to pay much more attention to situations in which there are challenges with respect to decision-making abilities and also with respect to access.

Consider, for instance, an elderly woman who is living with dementia and is supported in a long-term care residence. While the woman consents to receive a vaccine, her Power of Attorney declines the vaccine on her behalf. What is to be done?

Or consider a middle-aged man living with a disability who is reliant on home care to support his independence in the community. The man finds an online booking system challenging, and the experience becomes all the more complex due to questions of transportation to a site, parking, and accessibility of the facility including where someone is meant to wait.

Let’s consider these scenarios in turn.

For the elderly woman in long-term care, a key distinction is that decision-making ability ought to be determined in a manner that is task specific. In other words, a medical diagnosis of dementia does not preclude someone with that diagnosis from making a decision about vaccination. Instead, adhering to the following principles will lead to a more positive and equitable outcome:

- Understanding: she recognizes that the COVID-19 pandemic is a major public health concern, and that there is a safe and effective vaccine available;

- Appreciation: she recognizes her own high risk for serious COVID-19 illness;

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- Reasoning: she recognizes the pros (preventing severe outcomes from COVID) and cons (small risks associated with any vaccine, such as local or systemic reactions) of getting the vaccine. Here she may draw on their past experience with and views on vaccination to help them with their decision making. Vaccination is not a new concept for older people;

- Expressing a Choice: she communicates that she chooses to be vaccinated.

In our scenario, the autonomy of the elderly woman in long-term care is best respected using supported decision making. The staff at the facility would speak to the woman’s family about her decision, securing their support for the woman’s decision.

Where persons lack capacity to make their own decision, the Power of Attorney or Substitute Decision Maker should be consulted to make the decision on the person’s behalf.

For our middle-aged man receiving home care, it will be integral to enhance our capacity to deliver vaccines in homes. At the same time, we need to confront the level of vaccine hesitancy in community-based healthcare workers.

In becoming more sensitive to the distinct challenges being faced by so many Canadians, we can work toward ensuring a vaccine rollout that is consistent with human rights.

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