A new opinion piece published online in the Annals of the American Thoracic Society provides an exhaustive examination of the ethics of using hospital resources on unvaccinated-by-choice COVID-19 pneumonia patients, versus patients with other serious illnesses whose diseases are not progressing as quickly.
In “Caring for the Unvaccinated,” William F. Parker, MD, PhD, assistant professor of pulmonary and critical care medicine and assistant director, MacLean Center for Clinical Medical Ethics, Pritzker School of Medicine, University of Chicago, looked at cases in which hospitals delayed time-sensitive and medically necessary procedures for vaccinated adults when they were overwhelmed with unvaccinated patients who had severe, life-threatening COVID-19 pneumonia and suggested an ethical framework for triaging these patients.
“These vaccinated patients are directly harmed when hospitals use all their resources to care for the many unvaccinated patients with COVID-19,” he writes. “For example, delaying breast cancer surgery by just four weeks increases the relative risk of death from the disease by 8 percent.”
Dr. Parker argues for a contingency care standard that prioritizes emergency life-support, regardless of vaccination status, in order to save the most lives. “Simply rejecting the use of vaccination in prioritization of medical resources without analysis ignores the very real tradeoffs at play during a pandemic. The pain and suffering of the vaccinated from deferred medical care require a deeper defense of caring for the unvaccinated.”
Eliminating the Double Standard That Harms Patients in Vulnerable Communities
He states, “Even though the vast majority of patients who develop life-threatening COVID pneumonia are unvaccinated, hospitals still have ethical obligations to expand capacity and focus operations on caring for them—even if it means making vaccinated patients wait for important but less urgent care like cancer and heart surgeries.”
“If tertiary care centers turn inward and stop taking transfers of COVID-19 patients from overwhelmed community hospitals, this will result in de facto triage in favor of lower benefit care and cause systematic harm to both the vaccinated and unvaccinated in vulnerable communities,” he adds. “Hospitals must justify their nonprofit status by accepting transfers and prioritizing life-saving care during a pandemic surge.”
He points to Los Angeles County during the winter surge, in which the public health department had to issue an order forcing elite hospitals to stop doing financially lucrative elective procedures and accept patient transfers from community hospitals that lacked capacity to handle all of the COVID-19 patients who required intensive care.
Reciprocity and Proportionality
The principle of reciprocity supports a possible tiebreaker role for vaccination status when two patients have equivalent survival benefit from a scarce health care resource. However, a universal exclusion of the unvaccinated from life support during a pandemic surge fails the test of proportionality for reciprocity, according to Dr. Parker.
Reciprocity is rewarding one positive action with another. One example of this principle is giving vaccinated people access to sporting or entertainment events that are off limits to the unvaccinated (even if the unvaccinated test negative for COVID-19). Proportionality is the principle that “payback” should be proportional to the magnitude of the act. For example, living kidney donors get moved way up the waitlist- the equivalent of four years of waiting time on dialysis. This satisfies the proportionality principle.
Dr. Parker points out that while the 8 percent increased relative risk of death from deferring breast cancer surgery is awful, the absolute increase in risk is only one per 100, and perhaps only one per 200 for a two-week deferral.
“After the surge is over, the hospital can catch up on deferred elective surgeries,” he writes. “The harm from a coronary artery bypass or cancer surgery delayed two weeks is real, but tiny in comparison to certain death from denying life support for respiratory failure.”
He concludes, “There is a defensible role for vaccination status in triage as a limited tiebreaker, not as a categorical exclusion, but only in the context of a well-defined and transparent triage algorithm. Despite the enormous financial pressure to do otherwise, elite academic centers are obligated to prioritize life support for emergency conditions to save as many lives as possible during COVID-19 surges.”
Reference: “Caring for the Unvaccinated” by William F Parker, 19 November 2021, Annals of the American Thoracic Society.