Is vaccination status an acceptable factor in triage?

By Angela Wentz Faulconer.

More than 625,000 people in the United States and over 4.4 million people worldwide have died from Covid-19. As the Delta variant surges, many hospitals find themselves caring for patients in hallways, with no ECMO available and every ICU bed taken. A growing number of physicians have suggested that as hospitals become overwhelmed, we might weigh vaccination status as a factor in triage or even deny care to the unvaccinated. However, these suggestions should be approached with extreme caution. While rationing lifesaving resources is always ugly, some criteria are more defensible than others. Saving the most lives can be defended as a criterion, decisions based on moral desert cannot.

Does including vaccination status as part of triage save lives? If hospital triage policies taking vaccine status into account were widely publicized, this would a) communicate how serious the situation is believed to be by medical professionals and b) educate people as to the serious consequences they might face for remaining unvaccinated. Likely some would then choose to receive their vaccines. However, in the US where it is estimated that as many as 20% of adults are firmly opposed to vaccines—and likely unpersuadable—this might not save as many as we hope. Additionally, in an environment of growing division and distrust, the social cost must be considered.

Some have argued that we should consider vaccination status in order to direct scarce resources towards those most likely to survive. If in each situation where there was only one ECMO machine or ICU bed remaining, the resource were directed to the person most likely to survive, more lives would ultimately be saved. But does knowledge of an already hospitalized (needing the ICU or even an ECMO machine)  patient’s vaccination status offer a better or more reliable guide to their likelihood of survival beyond the other medical data we have about them? (lung imaging, O2 levels, course of disease, etc.) This has not yet been demonstrated. If true, then vaccination status could be considered in triage as a way to save more lives.

Some believe vaccination status should figure in triage decisions because they believe that the vaccinated “deserve” scarce medical resources over the unvaccinated. There is a desire to punish those seen as responsible for the extension of the pandemic, for the fact that the immunocompromised and children are at risk, for our inability to reach herd immunity, and for the continuing need for even healthy vaccinated people to mask up.

However, questions of moral desert have no place in triage. One person’s life is not more valuable than another’s because of actions either of them took or didn’t take. Commitment to the principle of fundamental human moral equality demands that we distribute lifesaving resources equitably, on the basis of medical utility. Linking moral desert to denial of lifesaving resources is a consequence too heavy for being unvaccinated, one that stands apart because it is different in nature from lesser consequences like higher insurance rates, responsibility for hospital bills, or loss of employment.

Pragmatically speaking, allocating scarce resources on the basis of factors like “patient contribution to illness” breaches our privacy in unacceptable ways. For example, obesity is a significant risk factor for Covid. Judging moral fault or desert on the basis of BMI would be inappropriate. However, assigning points for a healthy diet and adequate exercise instead necessitates asking questions many don’t want to be asked. Where moral desert is concerned, the potential questions are open-ended and potentially far reaching. While it is true that insurance companies already ask invasive questions, denying life-saving resources on the basis of the answer to those questions is a yet more serious matter.

Finally, allocating scarce resources on the basis of patient contribution to illness is both unfair and unacceptable. Unfair—because spot judgement (taking only one of a patient’s actions or non-actions into account rather than the whole picture) is misleading; universal judgment is impossible. Vaccination status isn’t the only factor worthy of punishment or reward. Further, it isn’t clear that the vaccinated neighbor who takes risks to travel to Lollapalooza is more deserving of lifesaving resources than the misinformed fearful (unvaccinated) neighbor hunkered down at home. Unacceptable—because while many considerations about human behavior might be at least as worthy of weight as vaccine status, as equals we don’t have a vantage from which to judge the value of another person’s whole life.

We must be extremely cautious about considering vaccination status as part of triage. The burden is on those who argue for this practice to show that it would actually save more lives. It is both a pragmatic error and a moral wrong to punish those we are frustrated with by adding vaccination status to the factors weighed in triage.

Author: Angela Wentz Faulconer

Affiliation: Department of Philosophy, Brigham Young University

Competing interests: None

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