By Daniel Wikler / Special To The Washington Post
Two patients need urgent care. The first was vaccinated against the coronavirus at the earliest opportunity and has complied with advisories on masks and social distancing. The second has been skeptical about covid-19 from the start, has declined offers to be vaccinated and even now rejects masks as a violation of personal liberty. Unfortunately, there is room for only one at the hospital. Should vaccination status be considered in deciding who receives care?
The question is hypothetical, but it may not be for much longer. Hospitals in Kentucky, Washington state, Florida and several other states are reported to be at or near capacity. Scores of Texas hospitals have run out of ICU beds. This wouldn’t be happening if everyone eligible for vaccination had accepted the jab. Is it time to put those who are endangering public health by refusing vaccines on notice that if they need care they will go to the end of the line, behind the patients who acted responsibly?
Last week, the Dallas Morning News reported that the North Texas Mass Critical Care Guideline Task Force had quietly circulated a memo saying that doctors could take vaccination status into account if triage became necessary in assigning hospital beds, though hours later the group said the document had merely been a “homework assignment.”
It’s understandable that many would endorse a decision to prioritize the vaccinated patient, especially if the patients’ health problems are covid-related. Opponents of masking, social distancing and vaccine mandates often speak of personal responsibility. Doesn’t that work both ways? You make your bed, you lie in it?
It’s easy to feel anger — as I do — toward those who perversely promote unwarranted skepticism about the seriousness of covid infection, as well as the safety and effectiveness of vaccines that are now available in this country. Many of us are appalled by those who encourage people to reject public health mandates and requirements as violations of personal liberty, even though we have accepted such measures routinely in the past and continue to do so today. If we had pulled together to fight our common foe, we might be looking forward to a return to normality instead of facing the possibility that we’ll be under virtual siege for years to come.
As the wave of infections, hospitalizations and deaths driven by the virus’s delta variant engulfs regions where few accept vaccines and masks, all of us are wary of the spread. At some point, if conditions deteriorate enough, perhaps the compliant majority will decide that it’s not enough merely to resent the refusal of the noncompliant to face scientific reality and accept minor restrictions on personal choice. If lotteries and other incentives are insufficient, there would have to be penalties.
A threat of withholding health care — even if this consisted merely of assigning a lower priority in the event of triage — might send a powerful message. The Alabama doctor who announced that as of Oct. 1 he will no longer see unvaccinated patients is testing that theory.
But is it defensible to deny urgently needed health care to punish a patient for failing to make healthy choices?
This question isn’t new and the answer has long been no. Many of those who need a liver transplant ruined the liver they were born with through overconsumption of alcohol. Treatment for lung cancer would rarely be needed if people didn’t smoke. Injured practitioners of extreme sports had safer recreational choices.
When patients like these are evaluated for health care, their priority depends on how serious their condition is, how urgently they need help and how well they are likely to do if they’re treated. What does not matter is culpability, blame, sin, cluelessness, ignorance or other personal failing. Doctors and hospitals are not in the blame and punishment business. Nor should they be. That doctors treat sinners and responsible citizens alike is a noble tradition, an ethical feature and not a bug. And we shouldn’t abandon it now.
This ethical stance is amply justified. The doctor-patient relationship requires trust, which patients are less likely to extend if they think their healers are sitting in judgment of them. Clinicians are not trained to assess culpability, or decide how much weight to give to extenuating circumstances, such as a dearth of information apart from Fox News. With life itself hanging in the balance, these are not decisions that should be made at the ICU door, if ever.
But if “sin” alone should not be a consideration for rationed care, does that mean a covid patient’s lack of compliance cannot be considered on any grounds? Two possibilities come to mind: instances when an unvaccinated person poses a threat to the health of the hospital staff or other patients; and instances when the failure to vaccinate predicates a poorer health outcome.
Patients should expect to be told that being tested and wearing a mask are conditions of receiving care. For non-urgent care where sufficient advance notice is given, requiring vaccination as a condition of continued service might also be defensible, particularly if the patient has access to alternatives.
If an unvaccinated patient’s vulnerability to serious complications of covid infection predicts a poorer outcome than might be anticipated in a rival patient, this too might legitimately lower priority, as risk factors do in many triage contexts. But this would not in itself justify a default choice based on vaccine status. The vaccinated patient might have risk factors that predict the poorer outcome.
Few nations have managed to keep covid at bay, and given the possibility that new and still more dangerous and infectious variants are still to come, no one is entitled to claim certainty in charting a path forward in response to the pandemic. Still, it’s clear what we ought to be doing. Apart from those who are medically unsuited, everyone should be vaccinated. Where infections and hospitalizations continue to rise, all should accept expert guidance on non-pharmaceutical measures such as masking and social distancing, and avoid relaxing these safeguards prematurely.
The measures we successfully relied upon to meet threats from infectious diseases in the past are likely to work again with this virus and should be rigorously applied. Those who decline to be vaccinated or comply with non-pharmaceutical requirements should expect restrictions on school attendance, travel, employment and even access to indoor spaces, both public and private.
But the threat of denying care to patients in need to punish them for their imprudence hasn’t deserved a role in public health policy, nor does it now. Even where failure to follow public health advice is the reason hospitals and clinics must resort to triage, priorities should be based on the traditional canons of urgency, need and likely outcome. For some, schadenfreude may be unavoidable when covid skeptics find themselves battling the virus for survival. Keep that private. We owe everyone their best chance to come out of this pandemic alive.
Daniel Wikler is the Mary B. Saltonstall Professor of Ethics and Population Health at the Harvard T.H. Chan School of Public Health. He was the World Health Organization’s first staff ethicist.
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