COVID-19: Ethics and the Unvaccinated

Welcome, everyone. I'm Dr. John Whyte. I'm the chief medical officer at WebMD, and you're watching Coronavirus in Context. We're two years in. It's a lot of ethical issues that have occurred during that time. So to help me unpack some of these issues, I'm joined by my good friend Dr. Art Caplan. He's the head of the Division of Medical Ethics at New York University's Grossman School of Medicine. Dr. Caplan, thanks for joining me. Good to see you again.

Thank you, John, for having me.

As always, I want to start with something you wrote. You recently wrote a commentary for Medscape which has grabbed a lot of attention. And you say, "Stop gloating over COVID deaths among anti-vaxxers." And I want to pull out something from your commentary. You have a line in there, and you say, "Is it ever right to say, look, you said all these things and they resulted in your death. So you deserved it or you merited it." Is that OK to say, Dr. Caplan? And if not, why not?

Well, there's really two issues at play, John. When you think about reactions to people who die as a result of a false belief or sometimes not only false beliefs but communicating misinformation, putting others at risk, which is something we want to morally be able to call out. And I'm not afraid to criticize someone who says vaccines don't work or masks don't work. It's not true. It's just not consistent with what the facts show.

But part of the response we have when someone dies is to, if you will, try to change the behavior so that others don't succumb to the same unnecessary death. I don't think gloating gets us there. If somebody dies because they didn't vaccinate, and they got COVID, and they didn't mask, and they engaged in a lot of risky behavior, to me, I don't want their family to wind up dead. I don't want their friends to wind up dead. I don't think I'm going to reach them by gloating. So there--

Maybe gloating is a strong word. But what about you see these posts on social media--

Although let me interrupt you, I do hear and see gloating. I see people saying you got what you deserved, ha, ha, ha. You got what was coming, and I'm glad you did. That's what I mean. I see it online. I hear it sometimes.

I see it too.

I see it sometimes in my own hospital and institution. So we took gloating off--

Is it wrong? Is it wrong if you somehow feel maybe a weird sense of satisfaction that people-- I'm just again quoting from what you said, "have gotten what they deserved?"

I think it is wrong. I think being dumb, misinformed, or even arrogant about being able to deny the facts, that's regrettable. That's sad, but it's not something I gloat over. It's just human nature sometimes to say that virus isn't going to get me, or I think I'm Superman and I'm immune to it, or I believe in an ideology that something. So no, not gloating.

But as you started to lead me, I can still be critical. And I can still say this person advanced these views, told everybody not to mask, not to vaccinate, don't get boosters, and died. They really acted in a way that caused their own death. That was, if you will, bad behavior. Don't emulate them. There's a lesson to be learned here about what real risk is. I don't mind using the death to try and change somebody's behavior. But I don't think, as I said, I don't think you'll get far in trying to persuade somebody if you gloat about it.

Is the media wrong to be covering all these instances? I mean, these people have passed away now. And in some ways, we're having a post and an article that's not exactly complimentary. Don't we always say you don't criticize those people who have died?

So this is a really interesting ethical thicket. It's a tough, tough area because I get into this myself. There are days I get very mad about the unvaccinated. I say things with an edge to try and move behavior. And sometimes I get pushback that says you're being too harsh, and we're not going to listen to you because you're just pushing us too far, and you're not really engaging in a way that, say, my opponents or people who don't agree are going to grasp on to.

OK, I get that. But I do think it's important to tell the stories of what happened to people who didn't take the ultimate precautions, not only who died, but who got sick, who've become disabled, who are long-haul COVID victims, if you will. Those stories really I think are better messaging than having Tony Fauci go on day after day and present the numbers.

I've been following a lot of doctors on social. I still see patients in many areas of the country. ERs are overwhelmed. Intensive care units overwhelmed. And there are some threads going around on social through Twitter and other places that are saying, look, look, Dr. Caplan, it's been two years. You talk about people being misinformed, and let's give them the benefit.

But it's two years. They're not misinformed. They're woefully ignorant. They have chosen not to look at the facts. So now, when they come in and clog the ER and prevent people from getting quick treatment for strokes and heart attacks or prevent people from even managing their pain well because they have to wait 10 to 12 hours in the emergency room, which is not what ERs were designed for.

The cost of bad behavior isn't just borne, as some of those who are anti-vax or COVID deniers insist, by them. Some of them say my choice if I die, so be it. That isn't the reality. And we're terrible at getting across the message that you're harming others because, as you just said, John, the hospital systems are overwhelmed.

Burnout is bad among people who are trying to deliver quality care. Nurses and doctors and even palliative care people that I talked to were burned out. They have way more business, sadly, than they would ever want to be dealing with and ever were staffed up for. So big repercussions, the ripple effect on the rest of us of bad choices.

It's unethical.

It is unethical in this way.

What do you say to these doctors who say we want to triage it differently? This is not three months in. This is two years plus. If they don't know it by now, that's a problem. I'm not saying we're doing that or should do that, but that's what a lot of doctors and other health professionals are saying that we need to start thinking about. And I wanted to ask you if that's ethical.

I get asked about it every day. Should I put the unvaxxed COVID patient to the rear? They don't say throw them out. They just say triage or lower priority. And I think my answer to that is no. We don't want to start triaging according to guilt or bad behavior or irresponsible behavior at the ER or in the hospital. If society wants to really do something about bad choices that harm the rest of us, then we might think about restricting where you can go, no restaurant, no sports event.

And we are thinking about that. But I want to push you, Dr. Caplan. What about liver transplants? Do we give liver transplants to people who are actively drinking alcohol?

Oh, OK.

OK, so we don't do that. So--

Fair point. And by the way, I wouldn't give a liver transplant to someone who was unvaccinated because it won't work. You can't get COVID post-immunosuppression--

So why is that OK? Why is it OK to say we're not going to do that in that situation, but we're not going to triage a little differently? Where's the ethical distinction?

Yeah, so the ethical distinction is if by your bad choices, you make the treatment futile, and transplant is a great example of that going in immunosuppressed without being inoculated prior to your transplant, going into a liver transplant when you're still actively drinking and you're not likely to either be able to do care.

The line here is if it can't work, if you make it futile because you won't comply, you haven't done the necessary precautions, I take that into account. That's relevant. If it's just a matter of saying I could help you or him. He's a heart attack. You're suffering respiratory failure because you have COVID. Then I think less so because both can benefit.

So that's one point, futility. What about scarcity of resources? Let's be realistic, Dr. Caplan. There aren't unlimited ICU beds. If unvaccinated persons are taking up ICU beds, that's taken away the opportunity for other people to get them. And the concept of diversion in emergency rooms, people can't come into the ER because they're full and ICUs are full. Isn't there an issue there?

You try to maximize the benefit you can get with your scarce resources. That's the principle, max the benefit. Someone comes in--

First come, first served? But isn't that what it is?

No, I think what we do do if we're in triage really seriously, we think, John, he's in pretty good shape, but he has suffered a heart attack. But we know that we could get him through this. Art, who has six chronic conditions and a crummy lifestyle and is end stage, let's call it lung failure, might make it. But John's going first because he had-- not because he's a nicer guy or he's innocent. For all I know he had a heart attack because he didn't-- he got in a fight with somebody and acted irresponsibly. We don't even triage, John, suicide attempts. That's a pretty strong effort to say I don't deserve resources. I'm trying to kill myself.

There's a lot of mental health issues going on there.

So they come through, and we take them. But the principle we honor-- and I think we should-- use your scarce resource to get the most bang for the buck. So if it's three young, relatively young people who have COVID, and they're in dire straits but they're very healthy, against 80-year-olds with many, many problems, I'm still going for the COVID patients.

I may grit my teeth. I didn't say it wouldn't bug me. But I think the principle there is maximize the lives saved by the scarce resource. Society really wants to say to the unvaccinated or the COVID denier, you are harming us. You are filling up our ERs. You are infecting others. We're going to limit what resources you can get at the hospital, pass laws, debate it, argue it out. I don't like it putting it just on the ER director.

OK. Dr. Caplan, let's turn to kids. I want to hear your thoughts on this concept that many folks are suggesting you know what? Since when do we vaccinate kids to protect adults? Shouldn't it be the other way around? We're trying to protect kids by the actions that adults take instead of saying, well, kids have to help to protect adults. Is the priority wrong in this approach?

Well, I agree with the principle that we ought to get the adults to do the right thing, but it's clear that a lot of adults won't. So there's risk. Asking the kids to come in and bear some of the burden is partly justified by protecting them against the rare dangers of COVID infection that they might face. It's not zero, but there are kids who died. There are kids who get long-haul COVID. And we don't really want the kids, even if it's flu-like symptoms to be sick.

Let's put it aside. I'll answer your question directly. Vaccines are so safe, work well but are so safe, I have no reluctance to vaccinate kids to protect adults, to protect vulnerable teachers, to protect older janitors if they go to school. Would we add vaccines to the list of required vaccinations someday for kids' school vaccination? I think we will.

And if you look out there and say we're giving tetanus shots or we're vaccinated against a variety of other pediatric diseases that are pretty rare-- now, I admit. They're childhood diseases, but they're rare, rare, rare. But we do it because we think the benefits are big and the risk is-- I'm not saying zero, but it's tiny. Same principle, vaccinate the kids for the adults. I don't mind another principle, which people don't like to talk about. Teach everybody that they're responsible to help others. Kids can now. They're doing it right thing to help their grandfather. Is that bad?

Part of the challenge here that, as a society, it has become very focused on individual actions. It's all about you. And we don't think enough anymore about communities. And that's part of the problem in terms of people's decision making in terms of getting vaccinated. Are we not teaching ethics enough in school and in general practice?

I think one of the things that gets me the angriest is when someone comes up to me and says, I'm free. I have liberty. I can do whatever I want, and nobody can tell me otherwise or restrict anything I do. Not only is that selfish, it's completely incoherent. If I want to drive on the other side of the road or drive drunk, I can't do that. Society rightly restricts my liberty. If I'm going to do something that, like smoke and it blows over to you and you don't like it or it's risky to you, then you have to smoke outside of public restaurants.

That's relatively new in terms of overall respect in terms of recognizing that.

True, true. But nonetheless, the principle your liberty ends at the tip of my nose in terms of swinging your arm. If you keep hitting me, then you're not free to do it. And I do--

Where is the disconnect? Because people are going to push back as I'm sure they had, Dr. Caplan, and say, look, you're talking about hitting someone. You're talking about getting in a car drunk. They're actually active actions they're taking, whereas in not getting vaccinated, they're saying, I'm just choosing not to do something. So how does that really--

Well, I think the consequences, sometimes they're active behavior. Sometimes they're not doing certain things. A million dead people in the US, more than all our wars combined? That's a consequence. Not putting on a mask? That's a consequence. A million-- let me say it again. One million dead people. Are you kidding me? You don't think-- I don't mean you, John. I mean is the proponent of utter liberty to do anything or not not aware of what it means to the society?

And let me add economic cost and let me add disability costs, which we don't even think about next to those million. This is intolerable behavior in a pandemic in terms of being indifferent to the community, in terms of not paying attention to the fallout on others. That does get me angry. And that is something I don't mind calling people out on when I hear, "But I'm free to do what I want or not." That's not true, and it's certainly not true in an epidemic.

You're always asking the tough questions. I encourage everyone to go to your Twitter handle, come to Medscape, read your commentaries. You always give us a lot to think about it and help put into perspective some of these challenging issues that we're all struggling with. I want to thank you, Dr. Caplan.

Thank you, John. And I should add, once in a blue moon I might get something right. But at least if we're thinking about it, I think we'll do better.

It's more than a blue moon.

So hopefully we provoke that.

There you go. And if you have questions, drop us a line. You can email me at [email protected]. Thanks for watching.