What are the ethics around treating vaccinated patients vs. unvaccinated ones?
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Perhaps one of the most contentious issues surrounding medical ethics lately is whether or not the unvaccinated, or the unmasked, should be denied medical care . Not just any kind of medical care. Some even talk about denying lifesaving medical care to these people. In a 2020 blog post from dw.com, Dr. Wolfram Henn, a human geneticist, stated that if they wish to leave the prevention of disease to others, then they should also leave beds and ventilators to others.
On the other side, an article was published in The Atlantic on January 20, 2022, titled “It's a terrible idea to deny medical care to unvaccinated people'' by Ed Yong. I would generally agree with this mentality for a number of reasons I`m going to lay out in this blog post. Some are clear and talked about widely, others I don't see talked about so much. But, they`re still important to address.
And the thing is, I understand the logic. If they don't vaccinate, they don't get treatment. It's just a case of actions having consequences. Simple, right?
Well, no, not really….
I'm going to echo something I wrote in an earlier blog post. Would you apply this same reasoning in other scenarios?
Would you deny medical care to an obese patient with coronary heart disease or diabetes?
What about a smoker with lung cancer?
An alcohol or drug addict with health complications from the issue?
I think anyone with any degree of empathy would have to say “no”.
“Those other cases; they`re different” some might say
In my opinion, no they aren't
What's the common denominator among all these cases?.
Admittedly, they all didn't make the best choices for their health. However yes, that`s had consequences for them. That said, in each case it`s impacted other people.
Others can develop health complications from second-hand smoke.
Obesity takes beds, staff, and other health resources from those who may be critically ill for reasons out of their control.
Alcohol and/or drug addiction causes a host of health and psychological issues for the addict, their family, friends and other loved ones.
The same principle applies to those with self-harming tendencies, or eating disorders. A
Many people, if they have one of these issues, have a high chance of developing another one. So for instance, someone with psychological issues causing self-harming or disordered eating patterns, are also vulnerable to developing addiction to food, drugs, or alcohol. So they feed into each other, making care quite complex.
However, for each of those cases, I`m very doubtful that they would be denied treatment. Or that denying them treatment would even be suggested. In fact, anyone who said that would probably be shunned. People would be horrified! Their narrative would be something like “There remains a duty of medical care, despite the specific reasons why a patient becomes ill. Maybe genetics, the environment they grew up in, or both, led them to become dependent on alcohol or other substances. ”
And they`d be right.
I mean, we don't have control over the environment we were born in, right?
We don't have control over our parents' socioeconomic status, where we live as children, access to education, or our genetics. All of which influence the likelihood of addiction, obesity, eating disorders etc. Yes, choice plays a role. Yes, it's possible that there is awareness in some people. But I don't think it would be ethical to ignore the other contributing factors that are out of their control.
But people don't often think about how this relates to being unvaccinated or unmasked. Take a person growing up in a “natural living” community. Something like Fremantle that I described in my last blog post. Eco-friendly. Cloth nappies. Home Birthing. Growing vegetables. Homoeopathy, and other alternative medicine. That sort of thing. However, unsurprisingly, low vaccination rates. So, a child grows up in this community. These tend to be very isolated pockets of people, and don't all have exposure to anyone else. Their education, and culture is generally focused on this eco-ethical lifestyle. So people grow up exposed to only this culture. Maybe they marry someone from this community. Raise their children with certain values. It's difficult to turn back once you`ve integrated yourself into a community this much.
So, was there really a huge choice for them in this? Could they really have chosen not to have been born into and raised into a specific lifestyle? Which would ultimately influence who, and what, they associate with and feel comfortable with for the rest of their lives? Which would also influence who and what they value?
Now, I do believe we are responsible for our own health. Of course we play an active role in recovering from whatever ailments we might have. That said, if you have the education/capacity to understand why it's important, does the blame really fall on you? Throughout the 1600s, smoking was said to have medicinal as well as recreational value and it was even used to ward off the plague. In much the same way as burning incense, the pungent smoke was thought to protect against the toxic fumes of 'miasmas'—based on the belief that diseases were caused by airborne vapours, characterised by their foul smells. At the height of the plague, smoking was actually made compulsory at the elite boys' school Eton College. Not only this, radium even used to be in everything from patented medication to cosmetics to skincare products, and even “radium spectacles'' were advertised
Do we look back and say “Well, they made horrible choices for their health. They should have known better and been held accountable. It's ridiculous!”
I`ve never seen that in a history book.
Generally, what we say is “Well, we can only assume that they didn`t have the information at that point. Or that there wasn't scientific knowledge at that point. We can't judge by today's standards. That wasn't something they knew about or could control. So it isn't a moral failing on their part. They can`t be held accountable.“
Now of course, we have more information, access to resources etc. today. I`m not disputing that. We have strong scientific evidence that vaccines are safe and effective, and don't cause autism. So the natural thing to assume is, well, given that, shouldn't everyone just take vaccines? I mean, there`is sufficient information available now.
Well, in an ideal world, yes
Believe me, as a microbiologist by qualification, I would love that
However, that's based on a few assumptions
It assumes that everyone across the world has equal access to information (they don`t). It assumes that everyone across the world has the same quality of education (definitely not true). It assumes that all 7 billion people on the planet have the time, capacity, and energy to understand scientific topics and papers (again, they don`t). Now, I`m not saying that you shouldn`t access information if you can, and learn about why vaccines and public health interventions are effective. The point I`m making is that if we`re making broad statements like “They need to just read the evidence”, we need to check what assumptions we are making in saying that. However, check whether or not those assumptions actually apply to everyone.
And I'm completely in support of vaccines and all public health interventions, to clarify. I studied Microbiology as I said, as well as having written a paper on HPV vaccination. Nobody is more in support of these measures than me.
At the same time, though, I`ve got to ask;
What's the distinction between the examples I've given, and unvaccinated/ unmasked people? Remember, not every factor that might influence someone to vaccinate can be controlled, as I said. Same with the other disorders I mentioned that we wouldn't deny care to.
So there`s a real lack of consistency here. Further, there's another point I don't see many people talking about:
It would exacerbate a major cause of vaccine hesitancy and anti vaccine rhetoric. Mistrust. Many of these people don't vaccinate in the first place because they don`t trust the healthcare system. Not all, of course, but many. I see this a lot when discussing vaccine hesitancy with people online. Studies back it up too. Mistrust is a major cause.
So wouldn`t denying them treatment only confirm these fears? And make them even less likely to vaccinate? Or even to listen to healthcare professionals and vaccine advocates?
This could also have serious implications in future pandemics (which will happen, maybe sooner rather than later). I know that sounds dark and dreary, but it's all the more reason why it's essential to work on building that trust now. Especially because there's potential for very deadly and infectious pathogens to cause pandemics in the future. If strong trust is built, there will be less issues with this in these future pandemics. Not none, of course. There will always be outliers and extremists. There always were and always will be. But we can reduce the problem to the greatest extent possible.
Let me paint a picture for you. It's late in the hospital emergency department. A patient runs in with life-threatening symptoms. Maybe they can't breathe, maybe they have symptoms of a heart attack. What's the ethical thing to do here? Do you prioritise getting them the help they need? Or, do you check vaccine passports? Remember, you may only have minutes to spare.
So, on a practical level, it isn`t always possible to ensure someone is vaccinated before treating them. It would genuinely surprise me if anyone, or many people, would check the vaccine passport first. I would say there is a genuine duty of care to anyone who needs any kind of medical treatment. Never mind lifesaving treatment like I outlined above. It's not just neglecting duty of care. It's a direct violation of the Hippocratic oath.
Let's talk about something else. How many hours do you suppose the average physician spends treating patients in a given day?
According to a study at the University of Chicago, if they were to follow national recommendation guidelines for preventative care, chronic disease care and acute care, it would take a primary care physician 26.7 hours per day to see an average number of patients, the study found. The lead author states what frustrates patients most about medical care they receive is that they don`t get enough time with the physicians. This can very often be attributed to a lack of empathy. However, he states, the reality is that it is time constraints. Coming back to the theme of vaccine hesitancy, this lack of time together can weaken the patient-provider relationship and cause mistrust
Not including lecturing, research, consultation, or any other kind of clinical work they have to do. Not even to mention responsibility in their personal lives ie. family. They need time efficiency wherever they can get it in. As we all do, I think, regardless of our chosen field of work. While at the same time providing the best care possible to each and every patient they see.
So is it pragmatic to suggest all these patients should have vaccine passports with them? Or is it best to generalise and say, OK, I have an ethical responsibility to provide the best duty of care possible to my patients. That means whether or not they`re vaccinated
Of course, there are exceptions to the rule. Absolutely, there might be some scenarios where mandates for patients are unavoidable. For instance, maybe you`re visiting a doctor who has immunocompromised patients in the waiting room/hospital beds etc. Maybe they have HIV/AIDS. Other immunocompromising conditions like lupus, multiple sclerosis, or psoriasis. All these make patients very vulnerable to infections like pneumococcal disease or the flu. Maybe they're on immunosuppressant medication following an organ transplant, like corticosteroids such as prednisone. On chemotherapy, radiation therapy, or many other types of cancer treatment..There are many different scenarios. It's highly dependent on the circumstances.
So for all these reasons I have outlined, no, they should not be denied any kind of treatment. Yes, actions have consequences. That's absolutely true. Nobody is actually denying that. Despite that, it certainly is important to communicate that to people. It is certainly important to vaccinate, and adhere to all public health measures.
However, here's the thing. It's important to promote these measures in a way that resonates with people. That will stick with them for the long term, and that they`re not likely to forget. It's useless telling them otherwise. It's a waste of time, energy, resources etc. It doesn't make sense. We don`t do this for other patients ie. smokers, obese patients etc. Further, it would only fuel mistrust in the healthcare system. However, it might not always be practical to check patient history, especially in cases where they need emergency medical treatment. I`m going to sum up with a key principle of medical ethics;
“Primum non nocere” - First, do no harm
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