COVID-19: Ethics and the Unvaccinated

JOHN WHYTE: Welcome, everyone. I’m Dr. John Whyte. I’m the chief medical officer at WebMD, and you’re watching Coronavirus in Context.

We’re 2 years in. It’s a lot of ethical issues that have occurred during that time. So to help me unpack some of these issues, I’m joined by my good friend Dr. Art Caplan. He’s the head of the Division of Medical Ethics at New York University’s Grossman School of Medicine. Dr. Caplan, thanks for joining me. Good to see you again.

ARTHUR CAPLAN: Thank you, John, for having me.

ARTHUR CAPLAN: Well, there’s really two issues at play, John. When you think about reactions to people who die as a result of a false belief, or sometimes not only false beliefs but communicating misinformation, putting others at risk, which is something we want to morally be able to call out. And I’m not afraid to criticize someone who says vaccines don’t work or masks don’t work. It’s not true. It’s just not consistent with what the facts show.

But part of the response we have when someone dies is to, if you will, try to change the behavior so that others don’t succumb to the same unnecessary death. I don’t think gloating gets us there. If somebody dies because they didn’t vaccinate, and they got COVID, and they didn’t mask, and they engaged in a lot of risky behavior, to me, I don’t want their family to wind up dead. I don’t want their friends to wind up dead. I don’t think I’m going to reach them by gloating. So there —

JOHN WHYTE: Maybe gloating is a strong word. But what about you see these posts on social media —

ARTHUR CAPLAN: Although, let me interrupt you, I do hear and see gloating. I see people saying you got what you deserved, ha, ha, ha. You got what was coming, and I’m glad you did. That’s what I mean. I see it online. I hear it sometimes.

JOHN WHYTE: I see it too.

ARTHUR CAPLAN: I see it sometimes in my own hospital and institution. So we took gloating off —

JOHN WHYTE: Is it wrong? Is it wrong if you somehow feel maybe a weird sense of satisfaction that people — I’m just again quoting from what you said — “have gotten what they deserved”?

ARTHUR CAPLAN: I think it is wrong. I think being dumb, misinformed, or even arrogant about being able to deny the facts, that’s regrettable. That’s sad, but it’s not something I gloat over. It’s just human nature sometimes to say that virus isn’t going to get me, or I think I’m Superman and I’m immune to it, or I believe in an ideology that something. So no, not gloating.

But as you started to lead me, I can still be critical. And I can still say this person advanced these views, told everybody not to mask, not to vaccinate, don’t get boosters, and died. They really acted in a way that caused their own death. That was, if you will, bad behavior. Don’t emulate them. There’s a lesson to be learned here about what real risk is. I don’t mind using the death to try and change somebody’s behavior. But I don’t think, as I said, I don’t think you’ll get far in trying to persuade somebody if you gloat about it.

JOHN WHYTE: Is the media wrong to be covering all these instances? I mean, these people have passed away now. And in some ways, we’re having a post and an article that’s not exactly complimentary. Don’t we always say you don’t criticize those people who have died?

ARTHUR CAPLAN: So this is a really interesting ethical thicket. It’s a tough, tough area because I get into this myself. There are days I get very mad about the unvaccinated. I say things with an edge to try and move behavior. And sometimes I get pushback that says you’re being too harsh, and we’re not going to listen to you because you’re just pushing us too far, and you’re not really engaging in a way that, say, my opponents or people who don’t agree are going to grasp on to.

OK, I get that. But I do think it’s important to tell the stories of what happened to people who didn’t take the ultimate precautions, not only who died, but who got sick, who’ve become disabled, who are long-haul COVID victims, if you will. Those stories really, I think, are better messaging than having Tony Fauci go on day after day and present the numbers.

JOHN WHYTE: I’ve been following a lot of doctors on social. I still see patients in many areas of the country. ERs are overwhelmed. Intensive care units overwhelmed. And there are some threads going around on social through Twitter and other places that are saying, look, look, Dr. Caplan, it’s been 2 years. You talk about people being misinformed, and let’s give them the benefit.

But it’s 2 years. They’re not misinformed. They’re woefully ignorant. They have chosen not to look at the facts. So now, when they come in and clog the ER and prevent people from getting quick treatment for strokes and heart attacks or prevent people from even managing their pain well because they have to wait 10 to 12 hours in the emergency room, which is not what ERs were designed for.

ARTHUR CAPLAN: The cost of bad behavior isn’t just borne, as some of those who are anti-vax or COVID deniers insist, by them. Some of them say my choice if I die, so be it. That isn’t the reality. And we’re terrible at getting across the message that you’re harming others because, as you just said, John, the hospital systems are overwhelmed.

Burnout is bad among people who are trying to deliver quality care. Nurses and doctors and even palliative care people that I talked to were burned out. They have way more business, sadly, than they would ever want to be dealing with and ever were staffed up for. So big repercussions, the ripple effect on the rest of us of bad choices.

JOHN WHYTE: It’s unethical.

ARTHUR CAPLAN: It is unethical in this way.

JOHN WHYTE: What do you say to these doctors who say we want to triage it differently? This is not 3 months in. This is 2 years plus. If they don’t know it by now, that’s a problem. I’m not saying we’re doing that or should do that, but that’s what a lot of doctors and other health professionals are saying, that we need to start thinking about. And I wanted to ask you if that’s ethical.

ARTHUR CAPLAN: I get asked about it every day: “Should I put the unvaxxed COVID patient to the rear?” They don’t say throw them out. They just say triage or lower priority. And I think my answer to that is no. We don’t want to start triaging according to guilt or bad behavior or irresponsible behavior at the ER or in the hospital. If society wants to really do something about bad choices that harm the rest of us, then we might think about restricting where you can go, no restaurant, no sports event.

JOHN WHYTE: And we are thinking about that. But I want to push you, Dr. Caplan. What about liver transplants? Do we give liver transplants to people who are actively drinking alcohol?

ARTHUR CAPLAN: Oh, OK.

JOHN WHYTE: OK, so we don’t do that. So —

ARTHUR CAPLAN: Fair point. And by the way, I wouldn’t give a liver transplant to someone who was unvaccinated because it won’t work. You can’t get COVID post-immunosuppression —

JOHN WHYTE: So why is that OK? Why is it OK to say we’re not going to do that in that situation, but we’re not going to triage a little differently? Where’s the ethical distinction?

ARTHUR CAPLAN: Yeah, so the ethical distinction is if by your bad choices, you make the treatment futile, and transplant is a great example of that — going in immunosuppressed without being inoculated prior to your transplant, going into a liver transplant when you’re still actively drinking and you’re not likely to either be able to do care.

The line here is if it can’t work, if you make it futile because you won’t comply, you haven’t done the necessary precautions, I take that into account. That’s relevant. If it’s just a matter of saying I could help you or him. He’s a heart attack. You’re suffering respiratory failure because you have COVID. Then I think less so because both can benefit.

JOHN WHYTE: So that’s one point, futility. What about scarcity of resources? Let’s be realistic, Dr. Caplan. There aren’t unlimited ICU beds. If unvaccinated persons are taking up ICU beds, that’s taken away the opportunity for other people to get them. And the concept of diversion in emergency rooms, people can’t come into the ER because they’re full and ICUs are full. Isn’t there an issue there?

ARTHUR CAPLAN: You try to maximize the benefit you can get with your scarce resources. That’s the principle, max the benefit. Someone comes in —

JOHN WHYTE: First come, first served? But isn’t that what it is?

ARTHUR CAPLAN: No, I think what we do do if we’re in triage really seriously, we think, John, he’s in pretty good shape, but he has suffered a heart attack. But we know that we could get him through this. Art, who has six chronic conditions and a crummy lifestyle and is end stage, let’s call it lung failure, might make it. But John’s going first because he had — not because he’s a nicer guy or he’s innocent. For all I know, he had a heart attack because he didn’t — he got in a fight with somebody and acted irresponsibly. We don’t even triage, John, suicide attempts. That’s a pretty strong effort to say I don’t deserve resources. I’m trying to kill myself.

JOHN WHYTE: There’s a lot of mental health issues going on there.

ARTHUR CAPLAN: So they come through, and we take them. But the principle we honor — and I think we should — use your scarce resource to get the most bang for the buck. So if it’s three young, relatively young people who have COVID, and they’re in dire straits but they’re very healthy, against 80-year-olds with many, many problems, I’m still going for the COVID patients.

I may grit my teeth. I didn’t say it wouldn’t bug me. But I think the principle there is maximize the lives saved by the scarce resource. Society really wants to say to the unvaccinated or the COVID denier, you are harming us. You are filling up our ERs. You are infecting others. We’re going to limit what resources you can get at the hospital, pass laws, debate it, argue it out. I don’t like it putting it just on the ER director.

JOHN WHYTE: OK. Dr. Caplan, let’s turn to kids. I want to hear your thoughts on this concept that many folks are suggesting: “You know what? Since when do we vaccinate kids to protect adults? Shouldn’t it be the other way around?” We’re trying to protect kids by the actions that adults take instead of saying, “Well, kids have to help to protect adults.” Is the priority wrong in this.

https://www.medscape.com/viewarticle/966628?src=soc_fb_220117_mscpedt_news_mdscp_covid&faf=1#vp_1

Créditos: Comité científico Covid