It’s Not Our Job to Judge Who Is Morally Worthy of Care

Despite the broad availability of a safe and effective FDA-approved vaccine in the U.S., the COVID-19 Delta variant continues to cause high rates of infection, hospitalization, and death, particularly in regions with low levels of vaccination. Overwhelmed hospitals have forced Idaho and Alaska — two states with significantly below-average vaccination rates — to activate crisis standards of care. These are policies designed to fairly and consistently allocate scarce life-saving medical resources such as ventilators, ICU beds, hemodialysis machines, and extracorporeal membrane oxygenation (ECMO) circuits when there are too few resources for the patients who need them.

Given that vaccine hesitancy is fueling the ongoing public health emergency and the need for rationing, some have argued that vaccination status should be taken into account in crisis standards of care, and that scarce medical resources should be withheld from those who chose not to receive a vaccine. The argument is that those who chose to receive a vaccine (or who were not able to receive a vaccine due to age eligibility criteria or medical circumstance) should be prioritized to receive scarce resources over “those who caused this disaster.”

Such a policy — allocating healthcare according to moral desert — would be contrary to the fundamental ethical commitments of physicians and public health; would set a dangerous precedent of physicians and healthcare administrators making judgments about who is morally worthy of receiving medical care; and would exacerbate racial, ethnic, and socioeconomic health disparities.

Healthcare is recognized as a human right by a broad range of health and legal organizations and bodies. Martin Luther King, Jr. declared “of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” The World Health Organization’s constitution envisions “the highest attainable standard of health as a fundamental right of every human being.” This does not imply that rationing and other health trade-offs cannot be made — in a world of scarcity they will be made — but rather that trade-offs should only be made to promote human health, to achieve “the highest attainable standard of health.” Rationing should never be done on the basis of race, ethnicity, socioeconomic status, religion, creed, or moral worth; it should be done only to attain greater human health. This is a fundamental ethical commitment of physicians and of the public health enterprise, which becomes especially important during public health emergencies.

Published crisis standards of care attempt to uphold this ethical commitment — often imperfectly — by allocating scarce resources to patients judged most likely to survive as a result of receiving the resources, thereby saving the most lives possible. It’s true that vaccination dramatically reduces one’s risk of COVID-related hospitalization or critical illness. However, there is no evidence that those who are vaccinated but nonetheless become sufficiently critically ill to require resources such as ventilators or ECMO circuits are any more likely to survive or benefit than critically ill unvaccinated patients.

Using vaccination status to allocate healthcare would therefore set a dangerous precedent for future healthcare allocation decisions. Unlike published crisis standards of care, which attempt to triage patients based on their likelihood to benefit from medical resources, policies involving vaccination status would use patients’ perceived moral responsibility for the ongoing pandemic as a basis for healthcare allocation decisions.

If moral culpability were a valid basis for such decisions, convicted violent criminals would arguably be even less deserving of medical care than those who simply neglected to take a vaccine. Furthermore, in our polarized political environment, many partisans believe that members of the opposing political party bear significant responsibility for the failure to contain the pandemic. Might leaders or even members of the political party not in power be restricted in their use of healthcare resources? More generally, if responsibility for one’s own illness were legitimate grounds for restricted access to healthcare, those who smoke, drink alcohol excessively, or eat unhealthy processed foods should receive less access to healthcare than those who adhere to healthier lifestyles. Of note, smoking and alcohol consumption are factored into heart and liver transplant listing decisions, respectively, but this practice is based on evidence that these factors portend worse health outcomes following allocation of an extremely scarce resource. In other words, this is a measure of stewardship intended to maximize health benefits, not a practice intended to “punish” or discourage certain behaviors.

Allocating healthcare on the basis of vaccination status would be a small but real step toward using healthcare as a tool of punishment and moral retribution rather than as a human right to be maximized wherever possible. Most clinicians take enormous pride in their professional ethical commitment to caring for all patients regardless of personal differences or disagreements, including those who deviate from medical recommendations, criminals, and even enemies in wartime. For these dedicated healthcare professionals, a vaccination-based triage policy is a dangerous dereliction of a central ethical obligation.

Perhaps most importantly, rationing medical resources on the basis of vaccination status would also have a predictably negative impact on racial and ethnic minorities, the socioeconomically disadvantaged, and other marginalized populations who have lower vaccination rates than the general population — in many cases due to lack of trust in the government or the medical profession stemming from a history of institutional racism. These marginalized groups are already infected, hospitalized, and dying from COVID-19 at disproportionate rates. Health disparities, amplified during the pandemic, would be further exacerbated if ventilators, ICU beds, and other resources were withheld from the unvaccinated. At a time when racial minorities and other marginalized populations are especially in need of improved access to healthcare, triage on the basis of vaccination status would worsen these groups’ access to life-saving resources.

To argue against vaccine-based crisis standards of care is not to diminish the importance of universal vaccination nor to argue against vaccine mandates. It is entirely consistent with healthcare as a human right for employers and the government to require vaccination with a safe and effective vaccine as a public health measure, and even to punish lack of vaccination with loss of employment, fines, and other legal penalties — so long as those punishments do not include restrictions on access to healthcare. In the end, access to healthcare should never be used as a moral or legal cudgel, even for a purpose as legitimate as promoting vaccination during the pandemic.

Benjamin Tolchin, MD, MS, is a neurologist at Yale School of Medicine and the Yale Comprehensive Epilepsy Center, and the inaugural director of the Yale New Haven Health System Center for Bioethics. Sarah C. Hull, MD, MBE, is a cardiologist at Yale School of Medicine and associate director of its Program for Biomedical Ethics.