There is a debate about how to allocate limited resources during a surge. Hospitals have been overwhelmed in terms of their availability of ventilators and intensive care unit beds. There was no ethical dilemma when resources were allocated based on need. The situation is different now. Every adult in the US can be vaccined if they want to be vaccined. In recent times, a large number of citizens are unvaccinated and therefore require hospitalization or intensive care. How should this affect decisions?
This is an issue for the medical profession. Organ transplants are a limited resource. People will die on the waiting list for an organ, so how do we decide who to prioritize? The core ethical principles are utility, justice, and respect for individuals.
The easiest way to understand utility is to know who is most likely to benefit from the limited resource and who is most likely to suffer from it. The person most likely to be saved by an organ transplant is the one who gets the highest priority. The location is a less obvious factor. Being close to the donor organ and the hospital system that can do the transplant gives you a higher chance of success.
The principle of justice means that the overall system operates fairly, so that there is no systematic bias in allocation that would put someone at an unfair disadvantage in receiving care. This principle may conflict with the principle of utility, so they have to be balanced. The recommendation is to give each principle equal weight.
The life and welfare of each person is an end unto itself, not just a means to an end, and that is what respect for persons as individuals means. The right to refuse care, as well as transparency, informed consent, and the right to refuse care, are required.
When triaging patients based on their vaccination status, there are two other ethical principles that may come into play. In a recent editorial, William Parker, MD argued that there should be a limited role for considering vaccination status in treatment decisions. The principle of reciprocity is a general ethical rule and means that we get back what we give. We all play by the same rules and expect the same from each other.
This could mean that medical care is part of a social contract, with society providing resources and privileges to the medical profession in exchange for their services, professionalism, and ethical behavior. Is it a good idea to have reciprocity at the individual healthcare level? That depends on the situation.
Everyone is treated equally in the healthcare context. We don't deny care because someone is a prisoner or because they are responsible for their own medical problems. If you get into an accident because you were speeding while drunk, you still get full health care to treat your injuries. There is no blame, no judgement, and no politics. We do not judge our patients, we treat them.
This is in the context of normal medical care. There is a limited amount of resources available for crisis medical care. The decision is not whether or not to treat patient A, but whether or not to treat patient B if you can only treat one. This means deferring surgeries in favor of life-saving care for COVID patients. I am referring toelective surgeries, not just quality of life surgery. Patients who need a breast cancer or heart surgery can be temporarily delayed. A patient may die without immediate life-saving care.
If we apply only the principle of utility, it is clear that the people requiring immediate life-saving care should have priority. The risk of death from cancer or heart attack will increase for those who delay surgery, but by a much smaller degree than if they are not treated. The relative increase in mortality is 8% if the mastectomy is delayed by 4 weeks. That is significant, but still lower than if we don't treat the acutely ill.
Large hospital centers can turn away transfers of COVID patients because they don't have any available beds, but some of those beds are occupied by patients who have had surgery that could have been deferred.
Since most of those COVID patients are unvaccinated, the question is, does the principle of reciprocity mean that we can prioritize breast cancer patients over unvaccinated patients? Some experts are interested in the question. The principle of proportionality says that allowing someone to die because they chose not to be vaccine free is out of proportion. There are many reasons for this.
If you look at the numbers, the decision to not get vaccine likely does not place a burden on the overall society and healthcare system. It is worth less than 1 of a life. He writes.
The order of magnitude lower than what would be required to justify denying life-saving treatment to the unvaccinated so the vaccine can get elective procedures is what proportional reciprocity would be.
The decision to get or not to get a vaccine is not the sum total of a person's worth or their contract with society. An upstanding citizen might have decided against getting vaccine for various reasons, while a career criminal, spouse, abuser, and drug user did. Is it really the sole determinant of triaging care?
It may be difficult to decide not to get vaccine. A member of a racial minority may not trust the vaccine because of historical injustice. Would we not deny care based on their reaction to injustice? People may have been influenced by their family or religious group.
We are careful to distinguish the pseudoscience from the person. False medical claims, poor regulations, and willing con-artists are critical to us. Ordinary people who spread false medical beliefs are victims. They don't deserve our condemnation, but they do deserve our sympathy. Most people who don't get vaccine are victims of misinformation, a society that doesn't prioritize scientific literacy and critical thinking skills, and a media system that doesn't focus enough on political systems. We need to remember that they are not bad people because they refuse a vaccine at the expense of the health of others. Even if it results in them propagating that victimhood to others, it makes them victims of pseudoscience.
It is important for the medical profession to stay out of politics. It is easy to blame the unvaccinated for the continuing harm. The solution is not to use medical care as a punishment. The role of the medical profession is to care for patients without judgement. We need to find other solutions to the problem of vaccine hesitancy. If education is not enough then a variety of carrots and sticks may be justified. We can't deny medical care.
Steven Novella is an academic clinical neurologist at the Yale University School of Medicine. He is the host and producer of the popular weekly science show, The Skeptics' Guide to the Universe, as well as the author of the daily neuroscience news and opinion website, the Neuro LogicaBlog. The Skeptics Guide to the Universe was published by Dr. Novella, as well as two courses with The Great Courses.
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