Updated August 27, 2020

Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians

July 10, 2020; JAMA Network

Doron Dorfman, LLB, JSD1; Mical Raz, MD, PhD, MSHP2,3

Author Affiliations | Article Information

The Centers for Disease Control and Prevention (CDC) has recommended face covering in public to avoid the spread of COVID-19. This recommendation applies broadly to all people older than 2 years, unless they have difficulty breathing or are incapacitated.

Best current evidence shows that masking is effective at preventing viral spread, protecting primarily the public, although it likely offers protection to the mask wearer as well.1,2 Thus, a delicate balance arises between the public health interest and individual disability modifications. Inappropriate medical exemptions may inadvertently hasten viral spread and threaten public health.

Beyond the CDC’s recommended exemptions—children younger than 2 years, people with difficulty breathing, and anyone unable to place or remove the mask—there are certain categories of disability that warrant medical exemptions:

  • Some individuals, particularly children, with sensory processing disorders may be unable to tolerate masks.
  • Facial deformities that are incompatible with masking are an additional category of exemption.
  • Other situations, such as chronic pulmonary illnesses without an active exacerbation, are less clear. An individual with a chronic pulmonary illness is at higher risk for severe disease from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. Conversely, if that same individual were infected with SARS-CoV-2, he or she would likely also be at higher risk for spreading viral illness because many pulmonary illnesses are associated with a chronic cough. There is a risk-benefit ratio that must be carefully considered. Professional societies would provide a valuable service to clinicians if they could provide clear guidelines that include objective measures, such as a decrease in pulse oximetry results, to guide determinations. It is likely that chronic pulmonary disease in itself is a compelling reason for masking, rather than a category of exemption.

In evaluating an individual patient, clinicians should seek to balance appropriate accommodations with public health. It is crucial that individuals with disabilities be integrated in public spheres, a right that could be curtailed by withholding appropriate exemptions. But for many individuals seeking exemption, the risk of participating in public spheres during a pandemic may be high. For those with underlying pulmonary disease, if masking cannot be tolerated, sheltering in place is a reasonable and safe medical recommendation. Public health experts have cautioned that masking cannot replace social distancing, and avoidance of indoor spaces should remain our medical recommendation, particularly for individuals who cannot tolerate a mask or do not desire to wear one for any reason.

Clinicians have no obligation to provide a mask exemption to patients if it is not medically warranted. They do, however, have a clear obligation to address individual patients’ concerns, discuss appropriate alternatives, and offer clear recommendations for risk-reducing measures when patients are venturing into the public sphere.


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  4. Americans With Disabilities Act, 42 USC §12111(9) (1990).
  5. O’Fallon  E, Hillson  S.  Brief report: physician discomfort and variability with disability assessments.   J Gen Intern Med. 2005;20(9):852-854. doi:10.1111/j.1525-1497.2005.0177.xPubMedGoogle ScholarCrossref
  6. Dorfman  D.  Fear of the disability con: perceptions of fraud and special rights discourse.   Law Soc Rev. 2019;53(4):1051-1091. doi:10.1111/lasr.12437Google ScholarCrossref

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