By Tina Rulli & David Wendler
There is a shortage of resources needed to fight the SARS-CoV-2 pandemic, including ICU beds and ventilators. As a result, many hospitals must prioritize who is offered care first, and inevitably some patients will be denied needed care. At the same time, with a more transmissible variant of SARS-CoV-2 arriving in the U.S., the number of infections and hospital admissions has increased precipitously.
To minimize deaths, people will need to take precautions, such as wearing masks and social distancing for months longer, until enough of the population is vaccinated. To this end, President Joe Biden has proposed 100 days of mask wearing and has issued an executive order for a mask mandate for federal buildings, lands, and employees. Yet, many individuals are failing to take precautions on a consistent basis, or declining altogether. They believe that protecting themselves is optional, and they cannot be required to help others. To them, taking precautions to protect others is like cooking dinner for an ill neighbor. It may be a nice thing to do, but it is not ethically required.
Similarly, many politicians oppose steps to require reasonable precautions on the grounds that individuals have a personal right to decide what are “the best decisions for themselves and their loved-ones.” This view is likely to become more common as fatigue with COVID precautions increases. Absent an effective response, widespread endorsement of this view could significantly undermine efforts to bring the pandemic under control.
It has been argued previously that, when some have a duty to provide assistance, individuals can be obligated to take precautions against needing it. In the setting of a pandemic, this principle has critical implications. Clinicians have a duty to provide care for COVID-19 patients that poses risks to them and takes scarce resources away from others. It follows that individuals have an ethical obligation to minimize the chances of needing such care. To discharge this obligation, they are ethically required to take reasonable precautions against infection with SARS-CoV-2. In addition, the fact that individuals have this obligation supports regulations to require them to take reasonable precautions.
THE MEDICAL DUTY TO PROVIDE CARE
Individuals who take precautions reduce the risks they pose to others and play an essential role in curbing the pandemic. In contrast, individuals who do not take precautions willfully increase their risks of becoming infected and infecting others, while free-riding on those who take precautions.
When care needs to be rationed, one might think these individuals should receive lower priority. However, denying care or lowering individuals’ priority based on the level of personal responsibility for their medical situation is inconsonant with medical ethics. When allocating scarce, vital organs, potential recipients’ culpability for their medical crises is not taken into consideration in assigning their priority level. Under EMTALA, clinicians are ethically and legally obligated to provide acute and emergency care for those in need regardless of the circumstances.
The reasons why clinicians have a duty to provide needed care without judging individuals’ responsibility are many. It can be difficult to ascertain whether an individual’s medical need traces to their own choices and impossible to do so in a medical emergency. And some choices which increase risks, such as choice of profession and assisting others, are laudable. More importantly, clinicians should not stand by while those who made bad choices suffer for them. Paying for bad choices with one’s health or life is too great a cost.3 For these reasons, clinicians have a duty to provide nonjudgmental critical care to patients.
THE DUTY TO TAKE PRECAUTIONS
When some individuals have a duty to provide assistance, potential beneficiaries can gain duties to reduce the chances of needing assistance. For example, hikers have an ethical obligation not to go into especially dangerous backcountry, not only for their own safety, but because of the risks it poses to those who would need to rescue them and the burdens rescue places on scarce public resources. Specifically, individuals can incur a duty to take precautions against needing rescue when four conditions are satisfied:
- Others have a moral duty to provide aid if needed
- The individual’s probability of needing aid is high
- The burdens of providing aid are substantial to rescuers and others
- The costs of taking precautions against needing aid are reasonable
In the current pandemic, these conditions suggest individuals have a duty to take reasonable precautions against infection with SARS-CoV-2. First, clinicians and hospitals will provide needed care to people regardless of how they contracted the virus. Second, individuals who do not take precautions have a high probability of contracting SARS-CoV-2 and a non-negligible chance of needing hospital care and utilizing scarce resources.
Third, the burdens of providing care are high. These include the risks to health care workers, as well as the opportunity costs to others who could benefit from the expended resources.
Fourth, a number of reasonable precautions, especially wearing a face mask when within 6 feet of others, pose minimal burden for most people. Social distancing can cause loneliness and boredom. People may need to miss important life events like births, baptisms, and weddings. These are real costs, but they are outweighed by the risk to others’ health and the cost of overburdening health care resources. While those whose livelihoods do not allow them to social distance may not have a duty to do so, they can still take other precautions.
The conclusion that individuals are ethically required to take reasonable precautions supports requirements that they do so. Just as state parks can mandate that hikers avoid dangerous terrain, individuals can be required to take precautions against infection. This suggests that requirements by governments, businesses, and organizations that individuals take reasonable precautions are not unjustified attempts to enforce ideal behavior. They represent acceptable measures to prevent individuals from imposing costs and harms on others through unduly burdensome behavior. President Biden’s 100 days of masking commitment and federal mandate is well-defended on these grounds.
WHAT ABOUT LIBERTY?
Libertarians argue that the only justified restrictions on individual behavior are those that protect one individual from harming another. However, even if one accepts this view, it does not undermine the present argument. The duty to take precautions against infection with SARS-CoV-2 is not based on a duty to promote the public good. It is based on the duty we all have to reduce the risks and costs we impose on others. Libertarians should agree: people are free to pursue their own conception of happiness, but not at the expense of imposing costs on others.
Clinicians voluntarily incur the risks associated with assisting others by choosing to become medical professionals. One might think it follows that the rest of us are not obligated to take precautions to minimize such voluntarily-incurred risks. Yet, even if that were true, we are still obligated not to act recklessly in ways that divert scarce resources away from others.
Moreover, the fact that some individuals voluntarily incur a duty to provide assistance does not imply that potential beneficiaries are free to act recklessly. Firefighters voluntarily incur the duty to put out housefires.4 Individuals are not free, in light of that fact, to hold bonfires right next to their house. Indeed, they have a greater responsibility to act with care knowing firefighters will risk their lives to save the house and its occupants.
Clinicians and hospitals have a non-judgmental duty to provide care to those in need. Providing care for COVID-19 poses health risks to clinicians and, given scarce resources, opportunity costs on other patients. As a result, individuals incur an obligation to mitigate these costs by taking reasonable precautions against acquiring SARS-CoV-2. Measures to require reasonable precautions are acceptable attempts to prohibit behavior that unjustifiably burdens healthcare workers.
Authors: Tina Rulli & David Wendler
Affiliations: Tina Rulli, University of California, Davis Philosophy Department
David Wendler, National Institutes of Health Clinical Center Bioethics Department
Competing Interests Statement: The authors have no competing interests.