Steven Novella on December 8, 2021
Should vaccination status be used to triage care for critically ill patients during a crisis?
There is a debate going on regarding how to allocate limited resources during a pandemic surge. During the COVID pandemic hospitals have been overwhelmed in terms of their availability of ventilators and intensive care unit (ICU) beds. When this happened early on in the pandemic there was no ethical dilemma – resources were allocated based on need. Now, however, the situation is different. In the US every adult who wants to be vaccinated can be vaccinated (unless they have a medial reason they cannot). We therefore have a population of citizens who are voluntarily unvaccinated, and in recent surges they make up the vast majority of those requiring hospitalization and ICU care. How should this affect decisions regarding triaging of care?
This is not a new issue for the medical profession. Organ transplants, for example, are a limited resource. People will die on the waiting list for an available organ, and so how do we decide who to prioritize? The core ethical principles involved are utility, justice, and respect for persons as individuals.
Utility is the easiest to understand – who is most likely to benefit medically from the limited resource, and who is most likely to suffer from the absence of that resource? For example, with organ transplantation, the person most close to death whose life is most likely to be saved by a transplant gets the highest priority. A less obvious factor is location. Being located closer to the donor organ and the hospital system able to do the transplant gives a higher probability 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 some individual at an unfair disadvantage in receiving care. This principle may at times conflict with the principle of utility, so basically they have to be balanced. At present the recommendation is to give each principle equal weight in making decisions about priority.
Respect for persons as individuals means that the life and welfare of each person is an end unto itself, not just a means to an end. Further, this requires respect for individual autonomy, including transparency, informed consent, and the right to refuse care.
Under the umbrella of justice, however, there are two other ethical principles that may come into play when triaging patients based upon their vaccination status – reciprocity and proportionality. In a recent editorial, William Parker, MD focuses on these principles, arguing that there should be a very limited role for considering vaccination status in treatment decisions. The principle of reciprocity as a general ethical rule simply means that in any social contract we get back what we give. We all play by the same rules, giving each other what we expect to receive from others.
Applied in a medical context, this could mean that medical care itself 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. What does or should reciprocity mean at the individual healthcare level, however? That depends on context.
In the normal healthcare context, everyone is treated as equally deserving, without any consideration for any personal details. We do not withhold 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 judgement, no politics, and no blame. That is part of the professionalism of medicine; we do not judge our patients, we treat them.
But as I said, this is in the context of normal medical care. There is also the context of crisis medical care, in which resources are limited. Now the decision is not whether to treat patient A, but rather whether to treat patient A or B if you can only treat one. This is a very real dilemma during this pandemic, and during local surges hospital systems are being overwhelmed. This means, for example deferring elective surgeries in favor of life-saving care for acutely ill COVID patients. By “elective surgeries” I am not just referring to cosmetic surgery or quality of life surgery. Patients needing mastectomy for breast cancer, or bypass surgery for coronary artery disease are also considered elective in that they can be temporarily delayed while a patient with COVID pneumonia may die without immediate life-saving care.
If we apply only the principle of utility, then it is clear that the people requiring immediate lifesaving 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 the risk of death if those with severe COVID are not treated. If mastectomy is delayed by 4 weeks, for example, the relative increase in mortality is 8% (or an absolute increase of about one in 100 patients). That is real and significant, but still much lower than if we do not treat the acutely ill.
This triage can happen subtly, by large hospital centers turning away transfers of COVID patients because they do not 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 now are the voluntarily unvaccinated, the question is – does the principle of reciprocity mean we can prioritize vaccinated patients with breast cancer over unvaccinated patients with COVID, essentially using reciprocity to trump utility? Some experts are flirting with this question. Dr. Parker answers this question by referring to the principle of proportionality – allowing someone to die because they chose not to be vaccinated is out of proportion (the punishment does not fit the crime). There are several reasons for this.
First, from a utility point of view, if you look at the numbers the decision to not get vaccinated likely does not place a burden on the overall society and healthcare system worth one full life. Parker estimates it is worth 0.001 of a life. He writes:
Proportional reciprocity (“payback”) for vaccination would be about 0.001 lives worth of medical care, orders of magnitude lower than what would be required to justify denying life-saving treatment to the unvaccinated so the vaccinated can get elective procedures.
Second, the decision whether or not to get vaccinated is not the sum total of a person’s worth nor their contract with society. An otherwise-upstanding citizen might have decided for various reasons to not get vaccinated, while a career criminal, spouse abuser, and drug user did get vaccinated. Should that latter really be the sole determinant of triaging care?
Further, the decision not to get vaccinated may be complicated. A member of a racial minority may not trust the vaccine because of historical medical injustice. Would we not be compounding that injustice to deny care based on their reaction to prior injustice? People may also have been influenced by their religious group, their family, or their social circle.
At SBM we are careful to distinguish the pseudoscience from the person. We are highly critical of false medical claims, poor regulations, and willing con-artists. But ordinary people who believe, use, and even spread false medical beliefs are victims. They do not deserve our condemnation, but our sympathy. I believe most people who decide to not get vaccinated are victims of misinformation, a society that does not sufficiently prioritize scientific literacy and critical thinking skills, and dysfunctional media and political systems. As frustrating as their choice to refuse a safe and effective vaccine at the expense of their own health and the health of others is, we still need to remember that this does not make them bad people. It makes them victims of pseudoscience (even if it results in them propagating that victimhood to others).
It’s also important for the medical profession to stay above the political fray. It’s easy to get sucked into blaming the unvaccinated for the pandemic’s continuing harm. The solution, however, is not to use triage of medical care as a solution or a punishment. That is not the role of the medical profession, which is primarily to care for all patients without judgement. Rather, the pandemic is all the more reason that we need to find other solutions to the problem of vaccine hesitancy. Education is the preferred method, but if that is not enough then applying a variety of carrots and sticks may be justified. But we can’t withhold medical care.