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Opinion Doctors should be allowed to give priority to vaccinated patients when resources are scarce

A nurse looks out the door of a covid-19 patient room in the CoxHealth Emergency Department in Springfield, Mo., on July 16. (Nathan Papes/The Springfield News-Leader via AP)
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I’m going to come right out and say it: In situations where hospitals are overwhelmed and resources such as intensive care beds or ventilators are scarce, vaccinated patients should be given priority over those who have refused vaccination without a legitimate medical or religious reason.

This conflicts radically with accepted medical ethics, I recognize. And under ordinary circumstances, I agree with those rules. The lung cancer patient who’s been smoking two packs a day for decades is entitled to the same treatment as the one who never took a puff. The drunk driver who kills a family gets a team doing its utmost to save him — although, not perhaps, a liver transplant if he needs one. Doctors are healers, not judges.

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But the coronavirus pandemic, the development of a highly effective vaccine, and the emergence of a core of vaccine resisters along with an infectious new variant have combined to change the ethical calculus. Those who insist on refusing the vaccine for no reason are not in the same moral position of the smoker with lung cancer or the drunk driver. In situations where resources are scarce and hard choices must be made, they are not entitled to the same no-questions-asked, no-holds-barred medical care as others who behaved more responsibly.

There are a number of reasons. It’s hard to quit smoking, stop drinking, lose weight or even take up exercise. So even those whose health problems can reasonably be blamed on their own lapses deserve the best care possible. After all, for the most part, they are their own victims.

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Vaccine resisters are different. Their refusal to take the shot doesn’t just affect their own health — it poses a known risk to the health of others, especially now, with the spread of the delta variant. To decline to be vaccinated is to fail to live up to your duty to your community. And it should mean that you forfeit — if necessary — your claim to equal medical treatment.

Emphasis on “if necessary,” because that is the other part of the equation. Scarcity has consequences for the distribution of medical resources; the limited supply of donor organs is one reason why it is acceptable to take a patient’s history of alcoholism, and likelihood of continued drinking, into account in distributing livers.

If hospital and health-care resources were not severely strained, if there were not areas where vaccination rates are dangerously low and the delta variant is spreading fast, there would be no problem. The vaccine refuser, although morally blameworthy, would still deserve the best care possible.

But that is not the case in too many parts of this country. Say one person arrives at an emergency room suffering a massive heart attack. The other, defiantly unvaccinated, has come down with covid-19 and is struggling to breathe. ICU beds are scarce at this hospital; so are ventilators — the foreseeable result of the decision by this covid patient, and scores of others like him, not to live up to theirresponsibility to be vaccinated. It is not only ethical to discriminate against him, it would be morally wrong not to give priority care to the heart attack victim.

One argument against this position is that it puts health-care providers on a slippery slope toward becoming free-ranging moral arbiters. Nope, I don’t think the slope is unduly slippery. This is a unique setting that combines the availability of lifesaving treatment, the imperative of individual responsibility and the attendant, pandemic-created shortage of resources. Carving out a justifiable exception from ethical rules doesn’t mean risking that they will be routinely ignored.

Another argument is more practical. Hospitals and physicians aren’t going to explicitly implement the kind of policy I’m advocating for fear of lawsuits. When a group of Texas health-care providers began exploring a scaled-back version of the idea, proposing that “vaccine status therefore may be considered when making triage decisions as part of the physician’s assessment of each individual’s likelihood of survival,” the project was quickly abandoned as a “homework assignment.”

No one is going to yank a ventilator from an unvaccinated patient to treat a vaccinated one in desperate need of treatment, and that’s not what I’m endorsing. In the real world, these decisions are going to be made in split-second assessments upon arrival. My argument is that doctors aren’t acting unethically by putting a finger on the scale in favor of the vaccinated — they’re behaving rationally and justly.

Emergency physician Dan Hanfling has written extensively about how to triage care, and he agrees. “If you believe there’s a certain degree of accountability that we as citizens have to take for each other to protect our community, then that group of individuals who have willingly chosen not to vaccinate, for illegitimate reasons, it would be fair to place them at the back of the line. Not kick them out of line, just move them back,” he told me. “At the end of the day, if you have willingly chosen not to do something that benefits the public good in the setting of a national crisis, then there are certain consequences.”

This is an uncomfortable conversation. The irresponsibly unvaccinated have made it a necessary one.