By Alex Gillham, Carole McNall and Adam Odolil

Many hospitals across the U.S. are near, at or over capacity. We hear many people react to that by advocating a policy that hospitals should refuse to treat patients who become infected with COVID-19 and are not vaccinated against it but could have been.

By “could have been” vaccinated we mean that the individual does not have a medical or religious exemption against vaccination. (We will call them the voluntary unvaccinated.) We don’t think people advocating the policy above mean to say that hospitals should refuse to treat those infected with COVID-19 who could not have been vaccinated against it because of their religious beliefs or some underlying health condition.

To some extent, we understand why people are advocating this kind of policy. We’re all frustrated by how the pandemic has affected everyday life. People who are not vaccinated are contributing in some sense to the continuation of the pandemic and putting additional pressure on a health care system that is already under extreme stress from shortages of medical supplies, workers, etc.

Is it morally justified for hospitals not to treat patients in these circumstances? We interviewed four philosophers with expertise in biomedical ethics to find out.

One common way to assess whether a biomedical practice is morally justified involves applying the major principles of bioethics: autonomy, nonmaleficence, beneficence and justice. By “morally justified,” we mean that the practice in question is allowed and not prohibited by morality.

Although somewhat imprecise, the major principles of bioethics express our commitment to certain values. The principle of autonomy says that patients’ voluntary and informed decisions ought to be respected. The principle of nonmaleficence says that health care professionals should do no harm to patients when possible. The principle of beneficence says that health care professionals should benefit patients when possible. The principle of justice is the vaguest of the four principles, but it basically says that we should distribute medical resources in a just way.

How would these principles apply to a policy whereby hospitals deny treatment to the voluntary unvaccinated who become infected with COVID-19? All four philosophers we interviewed agreed that the principles of beneficence and nonmaleficence would be inconsistent with such a policy. If hospitals refuse to treat the voluntary unvaccinated, then hospitals would be harming them or at least failing to benefit them.

But what if resources are scarce?

If a hospital must decide between treating two patients, one vaccinated and the other voluntarily unvaccinated, it would be harming and/or failing to benefit one, so that one of the two principles might be violated no matter which patient is treated.It’s not clear where the principles of nonmaleficence and beneficence point in these cases.

On the other hand, if treating one of the patients over the other is more likely to produce a benefit or avoid a harm that treating the other would not, then the principles of nonmaleficence and beneficence would support treating the former over the latter.

How about the principle of autonomy?

At first glance, it seems inconsistent with the kind of policy described because the policy seems to treat patients differently based on their autonomous decision not to be vaccinated. Refusing to treat someone who is voluntarily unvaccinated seemingly would disrespect the autonomous decision of the patient not to be vaccinated.

Interestingly, the bioethicists we interviewed all agreed that this is not as obvious as it might seem. A decision must be voluntary and informed for it to be autonomous.

We talked with Russell Woodruff, who is the chair of the philosophy department at St. Bonaventure University and has published on ethical issues at the end of life and in the philosophy of aging. Woodruff doubts whether any decision not to be vaccinated could even be informed and voluntary. Indeed, Woodruff claims that it is difficult to imagine an individual who is well-informed about the COVID-19 vaccine but voluntarily decides not to receive it. He thinks that with the proper information, individuals would see vaccination as the appropriate decision.

Carter-Beau Benson, who is writing a dissertation on vaccine ethics at the University at Buffalo, expressed a similar worry about the voluntariness of the decision to be vaccinated. Suppose a patient comes to the hospital who was only vaccinated because his or her employer required it. Would this count as voluntary? It’s unclear why someone who was only vaccinated in order not to be fired should receive treatment while another patient who was not vaccinated should, at least according to Benson. Ultimately, the bioethicists we interviewed weren’t sure whether the principle of autonomy would undercut such a policy.

How would the principle of justice apply to the policy in question? We think that the principle of justice is what people who support the policy have in mind. Some of them seem to think that the voluntary unvaccinated should not receive treatment for COVID-19 because they don’t deserve treatment and giving people what they don’t deserve is unjust.

All of the bioethicists we interviewed cautioned against an understanding of justice that stresses what people do and don’t deserve like this. Understanding justice in this way, all four bioethicists warned, has worrying implications. Suppose someone badly injured after driving drunk comes into the emergency room. Wouldn’t it be morally wrong of a health care professional to ignore this patient outright, saying to herself “Well, the patient should not have been driving drunk. These injuries are partly her fault and so she doesn’t deserve treatment.”

Phillip Reed, a philosopher with expertise in bioethics who is associate dean of The College of Arts and Sciences at Canisius, said that the principle of justice in bioethics requires being as fair as possible, but that deserving doesn’t factor into fairness like this when it comes to biomedical decisions. According to Reed, “That’s just not how medicine works. The task of medicine is to treat patients. It should not be in the business of judging people for their suboptimal lifestyle choices.”

Suppose my physician tells me that I need to exercise more or else I’m at risk for a heart attack. If I don’t take my physician’s advice, have a heart attack, and then go to the emergency room, wouldn’t it be morally wrong for my physician to ignore me, saying to my wife “Your husband should have exercised more. He doesn’t deserve treatment now?”

If the principle of justice does not take deserving into account like this, then how should we understand justice? Travis Timmerman, an assistant professor of philosophy at Seton Hall, has published widely on issues in normative and applied ethics. He understands the principle of justice to require the maximization of well-being. Put otherwise, biomedical decisions should make the greatest number of individuals as well off as possible.

On this understanding of the principle of justice, whether someone is vaccinated or not is irrelevant to whether a biomedical decision is morally justified. Health care professionals should be deciding whom to treat and in what order after considering factors such as the likelihood of the treatment’s success, how long the patient will go on to live if treatment is successful, quality of life, etc. Interestingly, all four bioethicists we interviewed thought that the best understanding of the principle of justice requires maximizing well-being and is thus inconsistent with considering whether a patient deserves the treatment or not because she made some suboptimal decisions about her health.

So, at the end of the day, would it be morally justified for a hospital to refuse to treat patients with COVID-19 who are not vaccinated but could have been? Not according to the bioethicists we interviewed. Benson summed it up well: “It’s not the nature of medicine to punish or treat people like pariahs.”

However, the bioethicists we interviewed also took care to explain that their opposition to such a policy does not mean they would support a decision not to be vaccinated when someone can be. Reed put it this way, and we agree with him: “Every adult who can should get vaccinated, but that doesn’t mean that we should punish people for not getting vaccinated or that withholding treatment to them is justified.”

Alex Gillham is an assistant professor in the Philosophy Department at St. Bonaventure University. Carole McNall is an assistant professor in the Jandoli School of Communication at St. Bonaventure. Adam Odolil is a student at St. Bonaventure.

Categories: hybrid journalism, Jandoli Institute