Neutrality Is Not an Option: Why ACOG’s Approach to COVID-19 Vaccine Refusal Falls Short

The American College of Obstetricians and Gynecologists (ACOG) has played an important role throughout the COVID-19 pandemic, issuing timely practice advisories on vaccination in pregnancy. Its most recent advisory continues to recommend vaccination for all individuals contemplating pregnancy, pregnant, recently pregnant, or breastfeeding. On this point, ACOG is clear and commendable: vaccination protects mothers, prevents preterm birth and stillbirth, and provides antibodies that protect infants too young to be vaccinated.

However, ACOG’s guidance falters when addressing vaccine refusal. The advisory states that if a pregnant or lactating patient declines vaccination, the clinician should document the refusal, re-offer the vaccine at subsequent visits, and reinforce general prevention measures. At first glance, this seems reasonable, even practical. But on closer inspection, it is a strikingly weak response to one of the most pressing public health threats in maternal–fetal medicine.

Why is this inadequate? Because such language treats refusal as a neutral option—an outcome that can be noted, filed, and revisited later without any judgment. It creates the impression that vaccination and non-vaccination are equally valid “choices,” and that the physician’s role is merely to present options and step aside.

This is a profound distortion of professional responsibility. The evidence is not ambiguous. COVID-19 vaccination is safe in pregnancy, reduces maternal intensive care admissions and deaths, prevents preterm birth, and protects infants. To present refusal as an option on par with vaccination is to mislead patients and to normalize hesitancy in a domain where neutrality is ethically indefensible.

The JAMA Viewpoint by Grünebaum and Chervenak (2025) offers a necessary corrective. Drawing on the professional responsibility model, it argues that physicians are obligated to make a clear, directive recommendation for vaccination and that neutrality in the face of overwhelming evidence constitutes a failure of duty. When patients refuse, the physician’s task is not merely to check a box and move on. It is to explore the reasons for refusal, address misinformation, and revisit the issue at future encounters. Refusal is not the end of the conversation—it is the beginning of an ongoing process of advocacy and education.

This distinction matters because the stakes are high. Pregnant women remain at increased risk for severe COVID-19, and vaccination rates in this population have lagged far behind those of the general public. ACOG’s procedural approach risks reinforcing this gap by signaling that refusal is acceptable and expected. The professional responsibility model, in contrast, acknowledges the asymmetry of the evidence and insists that physicians act accordingly. Just as obstetricians would never present smoking in pregnancy as a neutral lifestyle choice, we should not present vaccine refusal as an option that deserves equal respect with vaccination.

In an era when public trust in science is fragile, professional societies must choose their words with care. ACOG’s equivocal guidance may be well-intentioned, aimed at respecting autonomy and avoiding confrontation. Yet in practice it undermines both patient safety and public health. The role of the obstetrician is not to remain neutral when neutrality costs lives. It is to speak clearly, recommend forcefully, and persistently advocate for interventions that safeguard mothers and babies. On COVID-19 vaccination, the message must be unambiguous: neutrality is not an option.