Our principles are never more tested than when we are angry, scared, or frustrated. After all, it is easy to speak high-mindedly when in comfort and security. Principles are only tested under stress, and our society in general is under stress now. Well-understood bioethical values are being cast aside by politicians, some media, and the public in the harmful and destructive stigmatization of the unvaccinated.
This has taken the form of restrictions on freedom of travel, to retain employment, to engage in social activities, and has entered the conversation on access to medical care.[1] [2]To some degree, we have let our anger and/or fear run away with our principles. We should know better, for we have been here before. This is not the first time medical ethics have been discussed, and it is far from the first time some segment of society has been vilified for their choices. We have learned to behave more productively toward these situations in the past, and it is incumbent on us to do better now.
Reports continue to be disseminated across North America and the world that, in some cases, COVID unvaccinated patients may be refused medical treatment.[3][4][5]While there is little evidence that the refusal to treat the unvaccinated is widespread or common, the discussion has occurred in the United States, Italy, Canada, and elsewhere. Anger and frustration toward the unvaccinated are common, and readers need look no further than any popular social media platform to see this. The COVID-19 pandemic has had a major impact on the world for more than a year-and-a-half, in numerous waves, affecting the lives and livelihoods of virtually everyone to some degree. And the frustration for this negative situation has turned on the unvaccinated, with many politicians and media pundits calling this the “pandemic of the unvaccinated”.[6]
Bioethics are well understood
In this article, Examining the ethics of triage in a pandemic, BIG Media outlined the history and theory of triage and bioethics.[7]There are four broadly accepted, fundamental principles in the ethics of medicine.[8]They are:
- Autonomy – the patient has the right to make choices regarding their own health care.
- Nonmaleficence – this is the principle to first do no harm as stated in the Hippocratic Oath.
- Beneficence – this is the promotion of good and the removal of harm through direct and beneficial action.
- Justice – the ideal that resources will be distributed fairly or equally.
The principles of autonomy, nonmaleficence, and justice all protect individuals from being punished by society and the medical community for their choices. Medical procedures are not to be forced, by any methods of coercion, on patients. It is also well understood that stigmatizing patients for their choices and making them worry that their treatment may be denied or delayed is, in fact, a form of psychological – and possibly physical – harm. This would violate the principle of beneficence.
Hammer not the prescribed treatment
The temptation to judge has weighed heavily on society and the medical profession many times in the past, and each time we have learned that we should not punish patients for their choices. When the HIV epidemic began, stigmatization of patients was a major issue. It was learned that patient outcome and disease management were improved when stigmatization and judgment were addressed. This was seen as particularly important in marginalized communities.[9]In a similar fashion, we are now urged not to blame the opioid addicted. Passing moral judgement regarding how or why someone became sick is not productive. Helping and supporting them is.[10]Similar arguments apply to shaming the obese, or women with unwanted pregnancies.[11][12]
Most people know better than to denigrate overweight people or teenage mothers-to-be, so why are so many abusing the unvaccinated for their choices?
The issue of smoking falls into the same category, though it has nuances. The medical community and most societies in general are working to reduce smoking due to its harmful health effects, and stigmatization has been a tool that has been employed purposefully. Stigmatization of smoking was deemed necessary to counter the tobacco industry’s manipulation of smoking’s cultural acceptance. This has been successful to some degree, but the medical community is questioning the continuum between the helpfulness of the stigmatization versus the harm it may cause.[13]Low-income and disenfranchised groups are seen to receive the least help and potentially the most harm from this. More positive, proactive, outreach-style approaches have been found to be more effective in helping these groups.[14]
Ostracizing or isolating patient groups is not seen as helpful to patient or societal outcomes in any of these groups.
Why so much frustration?
Pandemics cause unusual stress on health care systems that is difficult to alleviate because they affect such broad geographical areas. Patient load may be difficult to share between health regions.[15]It has been just more than 20 months (March 11, 2020) since the World Health Organization designated COVID-19 as a global pandemic, and there are indications that it will last significantly longer. In this article on Aug. 16 of this year Predicting vaccination rates and outcomes for the Delta variant, we reported that it was mathematically unlikely that COVID could be eradicated.[16]This was reiterated in this article Taking a long-term view of the decision to vaccinate along with the suggestion that we may have to learn to manage repeated cycles of COVID spread for years to come.[17]Of course, virtually no one wants their lives to continue to be affected by COVID, especially for a long period of time. The unvaccinated are being blamed for this.[18]It is human nature to vent frustration, but it is not a helpful approach.
Our healthcare systems are being affected by COVID. The everyday lives of people, variously, around the world are being affected. Frustration is natural. And while the unvaccinated may logically be an exacerbating factor on the load on health care systems, just as obesity, smoking, and other choices that affect health also create load, we should exercise caution in how we approach the issue. We have learned that abuse and stigmatization are not acceptable, ethical, or generally helpful in other situations, so why are we allowing rage such free reign regarding vaccination choices?
A productive way forward
We would all like to manage this era more productively, and there are many variables involved, but what is a productive path forward regarding those who opt out of receiving COVID vaccines? In this Aug. 30 article, Prisoner’s dilemma and vaccination, I discussed rational game theoretic approaches to the vaccination question.[19]The analysis showed that a key factor in the rational decision to vaccinate was the ratio of morbidity of the vaccine risk versus the disease. In other words: how bad is the vaccine versus how bad is the disease?
Studies relating to the vaccination choice have been made worldwide, and they have borne out that trust over vaccine safety is a critical issue. An online study completed in April of 732,308 Americans showed that 48% expressed concerns over COVID vaccine side effects. Greater than one-third of respondents reported that they did not trust the government. Hesitancy was highest in blue-collar jobs.[20]It could be argued that stigmatizing the unvaccinated is also the stigmatization of low socioeconomic groups. Many other studies worldwide have shown similar findings: it is the fear of side effects that is most concerning, and that fear often manifests more powerfully in rural or low-income groups.[21][22] [23] [24]Concern over vaccine safety is of particular concern for parents of children.[25] Making trust and vaccination a political issue is also not helpful as indicated in studies of relatively low vaccine uptake among those who identify as Republicans in the U.S. [26]
Vaccine safety and perceived risk levels were known long before COVID as driving factors in uptake. Although the perceived fear of vaccines is often exaggerated, the concern is rational. A sensible go-forward position for vaccination uptake is to reasonably and rationally discuss vaccine safety rather than to stigmatize or coerce the unvaccinated.[27]
Vaccine effectiveness is also an issue in the rational uptake of vaccines. Although this subject continues to evolve, evidence cited in this article Taking a long-term view of the decision to vaccinate supports high vaccine effectiveness against severe outcomes.[28]
The main issue is trust, and our society will not build trust through stigmatization. Consistently positive communication, education, and outreach present a more effective approach.
Could the unvaccinated be denied treatment?
There are very few situations in which being unvaccinated could ethically be a factor in treatment. Family practices have wide latitude in choosing their patients, particularly if they believe that their advice will not be followed, so vaccination status could be a factor for some family physicians. [29]In exigent triage situations such as the ER or a busy ICU, it is unlikely from the principles of bioethics that a patient could ethically be refused treatment based on their vaccination status.
Triage ranking favours those who will suffer the most adverse consequence if left untreated. At the extreme end of disease are the patients whose treatment is considered futile; that they will likely die regardless. Vaccination status could be a factor in the denial of treatment where a patient’s case was thought to be futile due to their vaccination status. Decisions on futility are, however, normally considered very carefully, and from many angles.
Interpretation
We have long ago, and many times, learned that abuse and stigmatization are neither productive nor ethical in approaching patient choices in healthcare. Even when we know that obesity or smoking are statistically harmful health factors, we have realized that both the patient and society respond better with a more positive and co-operative treatment. The bioethical principles of autonomy, justice, and beneficence stand firmly against coercion, ostracization, and denial of treatment, and these principles are supported in every analogous medical situation in the past. Why are we allowing such tyranny and abuse in our society this time around?
Our society’s treatment of the unvaccinated is largely a product of frustration. Allowing resentment to run away with our principles will harm many and help no one.
References
[1] Hunt, Lee, August 30, 2021, Prisoner’s dilemma and vaccination, BIG Media
[2] Hunt, Lee, Sept 25, 2021, Examining the ethics of triage in a pandemic, BIG Media
[3] Noor, Ibrahim, Nov 5, 2021, COVID-19: Can doctors refuse unvaccinated patients? Reports suggest this is already happening, Global News
[4] Miller, Emily, Nov 8, 2021, Texas Doctor Will Only Treat Unvaccinated, Emily Post News
[5] Roberts, Hannah, Sept15, 2021, Italy gets tough on the unvaccinated, raising ethics questions, Politico
[6] Tayag, Yasmin, September 16, 2021, Stop Calling It a ‘Pandemic of the Unvaccinated’, The Atlantic
[7] Hunt, Lee, Sept 25, 2021, Examining the ethics of triage in a pandemic, BIG Media
[8] Beauchamp, Tom, and James Childress, 1979, Principles of Biomedical Ethics, Oxford University Press, ISBN 9780195024876
[9] Pulerwitz, Julie, et al, 2010, Reducing HIV-Related Stigma: Lessons Learned from Horizons Research and Programs, Public Health Reports, V 125, 272-281
[10] Rieder, Travis, March 1, 2018, It’s time to stop blaming patients for the opioid epidemic, Quartz
[11] Sindhu, Kunal and Pranav Reddy, August 24, 2019, When doctors fat-shame their patients, everybody loses, NBC News THINK
[12] Smith, Whitney, et al, 2016, Social Norms and Stigma Regarding Unintended Pregnancy and Pregnancy Decisions: A Qualitative Study of Young Women in Alabama, Perspect Sex Reprod Health. V 48, No. 2, 73-81
[13] Steinberg, Marc, 2018, Harms and Benefits of Stigmatizing Smoking, Nicotine & Tobacco Research, V 20 No 3
[14] Hammet, Patrick, et al, 2018, A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma, Nicotine & Tobacco Research, V 7 No 20, 286-294
[15] Hunt, Lee, Sept 25, 2021, Examining the ethics of triage in a pandemic, BIG Media
[16] Hunt, Lee, August 16, 2021, Predicting vaccination rates and outcomes for the Delta variant, BIG Media
[17] Hunt, Lee, Sept 21, 2021, Taking a long-term view of the decision to vaccinate, BIG Media
[18] Tayag, Yasmin, September 16, 2021, Stop Calling It a ‘Pandemic of the Unvaccinated’, The Atlantic
[19] Hunt, Lee, August 30, 2021, Prisoner’s dilemma and vaccination, BIG Media
[20] Murez, Cara, April 29, 2021, Poll Reveals Who’s Most Vaccine-Hesitant in America and Why, WebMD
[21] Owen, Taylor et al, Understanding vaccine hesitancy in Canada: attitudes, beliefs, and the information ecosystem, McGill University Media Ecosystem Observatory
[22] Danabal, Kenneth, Shiva Magesh, Siddharth Saravanan, 2021, Attitude towards COVID 19 vaccines and vaccine hesitancy in urban and rural communities in Tamil Nadu, India – a community based survey, BMC Health Serv Res. 21, 994
[23] Sallam, Malik, 2021, COVID-19 Vaccine Hesitancy Worldwide: A Concise Systematic Review of Vaccine Acceptance Rates, Vaccines, V 9, No, 2, 160
[24] CDC, Murthy, Bhavini et al, May 21, 2021, Disparities in COVID-19 Vaccination Coverage Between Urban and Rural Counties—United States, December 14, 2020 – April 10, 2021, CDC Morbidity and Mortality Weekly Report, V 70, N 20, 759-764
[25] Rozbroj, T, A Lyons, J Lucke, 2020, Vaccine-Hesitant and Vaccine-Refusing Parents’ Reflections on the Way Parenthood Changed Their Attitudes to Vaccination, Journal of Community Health, V 45, No 1, 63-72
[26] Summers, Juana, March 12, 2021, Little Difference In Vaccine Hesitancy Among White and Black Americans, Poll Finds, NPR.org
[27] Hunt, Lee, Sept 25, 2021, Examining the ethics of triage in a pandemic, BIG Media
[28] Hunt, Lee, Sept 21, 2021, Taking a long-term view of the decision to vaccinate, BIG Media
[29] Caplan, Arthur, October 13, 2021, It’s Okay for Docs to Refuse to Treat Unvaccinated Patients, Medscape
