Thanks for your posts @Abe It's great to see such clear and well articulated thoughts from someone with actual experience in having to make these sorts of ethical decisions.
It's sad to see how many are seemingly ok with the provision of medical care being based on the providers moral judgement regarding the worthiness or otherwise of the actions of patients.
I'm not sure anyone has said that. I know it's not what I'm suggesting. I would want overall triage protocols to change to take it out of the hands of individual providers and make it easier for them. The current system of triage would be modified to deprioritize people who haven't been vaccinated, among all the other factors that are included in triage decisions that are ethical quandaries, but that we've set up an a priori objective system vs. evaluating on a patient by patient basis by individual providers at the point of care. By not making this change, we are also making implicit ethical judgments that we should question our comfort with. Sins of omission are no better, at least in my mind, than those of commission.
I'll second this. I really appreciate Abe's post and I've learned a lot from them. They've helped me to see this situation in ways that I wouldn't have considered on my own.
At the same time I've been thinking that these decisions don't need to depend on any individuals morals, can't the decisions can be made at a system-wide level?
It could be, but in most cases the same system that would be making these decisions (state governments) are over-run by people who think wearing a cloth mask is too much suffering to impose on people.
And I don't think that would get around the essential ethical question - are we as a society OK with denying life-saving care to people based on their behavior? I don't think we, in general, are. This would be a hugely unprecedented step. I cannot emphasize this enough.
There are many more options before the "nuclear" option. Here is a short list that don't require any triage decisions (and are mentioned tangentially in The NY Times article NaN linked):
1. Better triage and transfer of non-critically-ill patients. The US system as a whole has not collapsed, and it seems that in general this will now be a regional crisis rolling through various states at a time. Though intra-state transfers are common, inter-state transfers (except in the Mountain West & Alaska) are unusual. Alaska, Montana and Idaho are special cases because they have limited ICU capabilities and many of the critically ill are transferred to Seattle even in normal times. There are some legal and insurance billing issues that would need to be sorted for this to work, but would resolve 99% of our triage problems outside of these very isolated areas.
2. For the special cases above, we do need to increased ICU capabilities. This is somewhat a failure on the states' part to prepare and coordinate with others on supply and personnel transfer agreements (the whole stick-your-head-in-the-sand attitude commonplace in these more conservative areas regarding COVID). This COVID pandemic isn't a surprise! We do not have a shortage of ventilators or dialysis machines in this country. We do have a shortage of sedatives and narcotics, but that's everywhere.
2. Delaying non-urgent operations in a given area until the crisis passes. On average the duration of elective shut-down is about 2-3 months. Again, in almost all cases urgent operations are continuing ahead in most areas. The places being most strongly affected by triage decisions are also the areas that are most anti-vaccine (hence the problem!). I don't think it is ethical for us outsiders to tell them how to run their healthcare systems since we have limited standing other than moral outrage. I also don't think there is a scenario where states would allow such an unpopular mandate to be enforced at a state level, especially if solution #1 hasn't been attempted.
3. Deploying National Guard, Army physicians and Army medics to provide coverage of ICU units. Though the Armed Forces cannot be deployed in a military capacity within the US, they can be deployed by request of the states for disaster relief. They are well qualified to provide basic life support in a civilian setting.
So there are several solutions to this problem beyond the obvious, punitory one. Extremely rural areas again are a special case, but we run into ethical considerations of autonomy and paternalism if we try to tell them how to triage.
While to us the answer may seem obvious, in reality it is not. There are downstream consequences to every action. I do agree with Sui generis that there is an error of omission, but lay that at the hands of the legislatures who repeatedly and intentionally ignore healthcare experts advising them on the above measures.
On another point worth considering in the examples from the article, here are some questions to mull over (modeled after similar questions from my medical ethics classes):
1a) What if the person who needed emergency surgery in that article was also not vaccinated and was anti-vaccine? It isn't mentioned in the article. Does the lack of knowledge on this subject affect our decision on triage? If not, why not? If so, why?
1b) How confident are we that the COVID-infected patient was not vaccinated? What if they had one dose? How much punishment should be assigned to being late to vaccination, even if one's intentions were good (they were planning to get a second dose eventually?).
1c) Are anti-vaccine people to be de-prioritized if they have a COVID-induced critical condition, for some critical conditions, or for all critical conditions?
2a) The patient in the ER had a better chance of surviving than the patient in the rural area. Thus a decision was made to save the one in the ER. How much should a patient with COVID who is not vaccinated be de-prioritized? If the surgical emergency patient had a 1% chance of surviving and the COVID patient a 40%, how should that be calculated?
2b) How confident are we that the person in the ER was not vaccinated? If they cannot answer for themselves, how much do we trust their proxy? What proof is required of vaccination?
2c) Why was the person not vaccinated? Discuss these situations:
1- they were not aware of the vaccines' efficacy and had no trusted healthcare resource to discuss with
2- did not think it would work because they were somewhat immunocompromised (a common misconception)
3- thought the vaccine had a Gates microchip in it that would turn them into a Biden slave
4- lived 350 miles from the nearest clinic and lacked resources to obtain the vaccine. Which of these are and are not acceptable to spare them from triage? How would we verify which one it is?
3a) Is it ethical to deny care to people who do not comply with a voluntary medical request in their jurisdiction? If so, which ones? How does the temporal relationship between lack of compliance and illness affect decision-making? Is a lifetime of non-compliance with medical advice leading to an exacerbation of a chronic condition acceptable? Why or why not?
- If an exception is made specifically for COVID, detail why it is different than all other stressors on the healthcare system.
3b) Is it ethical to punish members of society for the failings of their legislatures to prepare for an expected outcome?
I don't have a good answer to these (but many not-so-good ones), and am interested in others' comments. Feel free to add other hypothetical situations. This is an important part of ethics - to chance to discuss theoretical situations and understand how the nuances affect our thinking. That is why an absolute judgement, in my mind, is very difficult (regardless of who decides it).