By E. Wesley Ely / Special To The Washington Post
Covid-19 surges among the unvaccinated are forcing health care professionals into uncharted moral dilemmas just as they’re battling other stressors. With emerging strains of the SARS-CoV-2 virus now a predominant concern globally, we in the Southern United States are seeing a resurgence of newly infected patients flowing into our ICUs with failing lungs, clotted blood vessels and delirium.
As an ICU doctor in Tennessee, I am further faced with the gut-wrenching reality that in two-thirds of our state’s counties, only about 25 percent of the population is vaccinated against the virus. The state’s overall vaccination rate is under 40 percent. Yet rather than fighting this crisis, Tennessee lawmakers and the state’s Department of Health just fired our top vaccination leader and temporarily halted efforts to promote vaccination to children for all preventable diseases, including pertussis, tetanus and diphtheria, actions that would set us back 100 years in protecting vulnerable children.
This wave of the pandemic is occurring in the wake of one of the most impressive scientific achievements of all time: the development in under a year of a group of highly effective vaccines with the power to beat the virus into submission and bring the situation to an end. And yet, a Washington Post/Kaiser Family Foundation poll in March (when most health care professionals had long been eligible to get the vaccines) found that only 52 percent of health- care workers were vaccinated, and 18 percent said they didn’t plan to get the vaccine.
These facts prompt dizzying questions, starting for me with:
Should doctors and nurses be allowed to work on the front lines in 2021 without vaccination?
And if things continue to get worse in our area and two covid-19 patients appear to need the same scarce treatment or resource, should medical professionals give the treatment to a vaccinated patient before an unvaccinated patient?
Recently, I was standing next to yet another patient on a ventilator side-by-side with an excellent ICU nurse, whom I have known for more than a decade. I asked the patient if he had been vaccinated. “No, Dr. Ely,” the nurse replied, “but I know PPE works, so I feel safe.” To which I responded, “Well, it’s a personal choice.” But since then, I have been rethinking that answer.
We cannot forget that, as shown in a study reviewing over 400,000 people from 43 investigations who underwent PCR testing, one-third of those infected with SARS-CoV-2 remained completely asymptomatic. During periods of silent infection, we know that intense viral shedding occurs. Health care professionals, who are routinely around immunocompromised patients who can’t mount an adequate immune response even with the aid of a vaccine, clearly do become infected with SARS-CoV-2. Many experience severe outcomes, including death.
In fact, the unvaccinated nurse standing over my patient with me could have been shedding virus beneath his N95 without knowing it. What’s worse is that the delta variant, which is the predominant strain now, has figured out how to amplify itself more than 1,000-fold in terms of viral load.
It is never my place to judge my patients for their personal choices. But my vocation and that of my colleagues during this public health crisis warrants rapid expansion of a mandatory covid-19 vaccination policy for health care professionals. Nearly every one of the patients being admitted to hospitals today around the world for covid treatment are unvaccinated. Some who are unvaccinated live in underserved regions or have logistical problems because they are working two or three jobs and can’t take time off. Others have simply decided not to get it, even though it would be easy for them. Whatever the reason, though, patients without the shield provided by a vaccine pose an ongoing real and present threat to the overall safety of our society on multiple levels; especially in the Southern United States.
We can’t force these patients to do what we know is the right thing, nor can we change what they read or watch or the difficult conditions in which they might live. But we can control our own actions as people of science. We in health care must pass on the safety benefits of vaccination to the vulnerable patients we serve. Mounting data suggest that the vaccines are associated with decreased asymptomatic infections and an approximate 30 percent reduction in transmission. They work. We should take them.
What about complicated religious and personal exceptions posed by hospital workers? First, most religions wholly endorse vaccination. As the leader of the world’s 1.2 billion Catholics, Pope Francis considers it a moral obligation to take the vaccine. And health care systems can employ comprehensive programs to review the requests placed by the small minority of people who submit a desire for religious or personal exemption.
There is also a real and growing fear of scarcity in how we treat covid-19 as cases rise. In the United States, hospitals are much busier than a year ago because non-covid patients are more willing to seek medical and surgical care. Many ailments such as heart and lung diseases neglected during the pandemic are further advanced pathologically and more complicated than usual. This creates an excess need for interventions that are also required in covid-19 care, such as extracorporeal membrane oxygenation (ECMO) machines. ECMO is an advanced form of life support that is a very limited resource. It takes blood out of the body to provide oxygen that destroyed lungs cannot, then returns that life-giving blood to the patient’s vital organs.
A very realistic scenario that we and other colleagues may soon face is that the delta-variant-driven surge may create a situation in which only one ECMO circuit remains available in a given hospital. So who should get to use it? I recently asked about this on Twitter. The results of a Twitter poll are obviously not statistically valid, but the majority of over 20,000 votes cast indicated that a vaccinated person deserves to get precious medical resources over an unvaccinated person; no matter who those people are or how they got covid.
Any health-care professional who has to make such an impossible choice potentially incurs moral injury from being forced to make decisions that go against our deeply held beliefs to help all patients. We already know that our front-line essential workers are suffering from PTSD at alarming rates. The wave of distorted facts, either directly espoused or indirectly facilitated by government officials around the country, are having ripple effects that we have not even fully realized yet; effects that will last for decades, if you consider lost careers and those that are never realized by young people watching this unfold and being taught scientific fallacies.
The truth is that our best estimates to date show that the coronavirus vaccines have averted more than a quarter-million deaths and prevented more than 1 million hospitalizations in the United States alone. There is now very solid data that two doses of the mRNA vaccines in use in the United States provide effective protection against the delta variant. We already mandate vaccination for diseases such as influenza with great success among health-care workers. We know how to do this. We have a way out of this pandemic.
As a young boy in Louisiana, I heard my grandmother talk about the “righteous anger” she felt when my great-grandfather’s newspaper was burned down by the Ku Klux Klan because he spoke against injustice by printing articles supporting local Black families. Our current vaccine crisis is another social injustice we must quell. I am especially upset that this public health disaster disproportionately affects people who can least afford more heartache in their lives; people of color, low socioeconomic means and those with physical and mental disabilities. As a physician, I cannot abide the moral consequences unfolding now; especially since, collectively, we know better.
Dr. E. Wesley Ely is the co-director of the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center at Vanderbilt University and the Nashville Veteran’s Administration Hospital and author of “Every Deep-Drawn Breath,” to be published in September.