Public outrage over the unvaccinated is driving a crisis in bioethics

The pandemic has triggered a new debate over what used to be a settled principle of bioethics — that you don't treat patients differently based on past behaviour that may have contributed to their condition.

"The core fundamental principle of clinical ethics tells us that once a person enters the hospital as a patient, whatever got them there is no longer part of the equation," said Vardit Ravitsky, who teaches bioethics at the Université de Montreal and Harvard Medical School.

"The most extreme example I have ever seen was when I lived in Israel and a suicide bomber detonated on a bus, killing and injuring civilians around him. Somehow he was not killed by the explosion and he arrived at the hospital with his victims.

"Once they entered the hospital, everyone was treated equally. There was no sense of prioritizing the victims in relation to the person who caused the injury."

But the COVID-19 pandemic — which has overturned so many norms and assumptions — is now testing that principle.

Vaccinated majorities in wealthy western countries are growing increasingly impatient with a science-denying minority being blamed for prolonging the pandemic and stretching critical care resources to the breaking point.

Governments are responding to that anger by turning up the heat on the unvaccinated with policies intended to inconvenience them, curtail their social lives, drive them out of the public square, make them pay or even criminalize them — measures Ravitsky said are "politically meant to appease the vaccinated majority."

Quebec plans to impose a financial penalty on unvaccinated people who don't have medical exemptions.

As president of the International Association of Bioethics, Ravitsky has seen how the pandemic has tested a longstanding consensus of bioethics.

"Usually, bioethics is all about protecting and promoting the right of each patient to make their own decisions," she said. "And all of a sudden we find ourselves in a situation where the common good should sometimes be prioritized, and that has caused some unprecedented disagreements within the bioethics community."

When demand for critical care surges beyond what hospitals can provide, triage is the process through which doctors decide who gets care first — a process that sometimes amounts to deciding who lives and who dies.

Canada has a patchwork of triage policies but most follow a fairly standard checklist of priorities designed to maximize benefits and minimize loss of life. Doctors first decide which patients have the best chances of pulling through. If they have to choose between two patients needing treatment and facing roughly equal odds of survival, they'll usually give priority to the patient they judge to have the most years of life ahead of them.

"Where I see some disagreement within the community of bioethicists is precisely on this point — can we use vaccination status as one criterion within triage protocols?" said Ravitsky.

"If we have two patients with the same level of clinical need, same age, same context, but one is vaccinated and one isn't, could we de-prioritize the patient who is unvaccinated by choice? There is a minority of bioethicists who are becoming more accepting of this logic at this point in time."