Tough Love or Life Boat Ethics, It Is Time for Moral Triage in Medicine
Rick Garlikov

Medicine often prides itself on not judging which patients deserve treatment on moral grounds based on their character or past behaviors; they treat people simply as human beings, not as "good" people or "bad" people, "deserving" people or "undeserving" people.  I think that there are some cases that is at least arguably wrong and foolhardy rather than admirable -- cases where saving someone's life will allow them to go on hurting or killing other people, even the doctors or nurses (and often especially the nurses) who treat them.  But I believe it is definitely wrong in those cases when there are insufficient resources to treat everyone and to save everyone.  In at least those cases, triage about whom to treat and try to save should take into account moral elements about the person's relative responsibility for needing treatment.  Otherwise it is still a moral choice, but without moral reasoning or a sound moral basis.  Deciding not to use morality to determine who can be and will be treated is itself a moral choice, one which will allow people to be treated who should not be and prevent people from being treated who should be.

If news reports are accurate that in this late summer of 2021, hospitals are being "overwhelmed" in terms of space and/or remaining staff by patients with COVID who are willfully unvaccinated by choice -- whether motivated by politics or fear of scientific safety -- it is morally wrong to use the resources they do have to save those patients at the expense of letting patients die or be insufficiently treated who need those resources because of medical conditions over which they had no control or much less responsibility for causing.  And it is foolhardy for it to be acceptable to make or allow nurses, doctors, or other providers to quit and give up their careers or suffer severe, debilitating PTSD instead of making their work load more manageable so that they do not have to quit or suffer.  It is a morally deplorable waste of resources of immense value to work a nurse or doctor to exhaustion that makes him or her quit altogether when that could have been prevented by making moral choices that would prevent their exhaustion in the first place. 

It is not necessarily that willfully unvaccinated people who could have been vaccinated but simply chose not to be are undeserving of care; it is that they are less deserving of care than someone who needs care through no fault of their own, and when care cannot be provided for all, it should be provided to the more deserving rather than the less deserving, assuming all the other principles of triage are also met, such as that the more deserving patient is likely to benefit from treatment so that treatment resources are not simply being wasted.

If medicine is not going to make moral choices about whom to treat or treat first in normal circumstances when resources are available to treat all, it should at least make moral choices about whom to treat when not all can be treated because there are not the resources available to treat all who will need treatment.

That means, in this particular time of the COVID pandemic, when vaccines that would prevent or ameliorate this are readily available to all who can reasonably take them so they do not likely need hospitalization, hospitals need to allocate ICU space and staff time for rest and respite, in order to treat those with health problems not their fault instead of having to turn them away because there the beds and staff are being used to treat the people who are there because of their own poor choices.

Now I realize some will say this would be a slippery slope toward denying people treatment for anything for which they bear some responsibility for their medical predicament in normal circumstances, but that is not true, because we are not talking about normal circumstances where treatment is available for all who need it.  Slippery slope arguments depend on ignoring the conditions for which principles are made and on which they are based.  Making people have to stop for a red light is not a slippery slope for making people have to stop at green ones too. Letting people turn right at a red light after a full stop is not a slippery slope to letting people run red lights no matter what.  All triage is based on limited ability to treat all who need treatment, and triage is not a part of medical practice when everyone can be treated sufficiently in a timely fashion.  I am talking about triage situations here.  But yes, I do also think a legitimate case can be made that moral culpability elements should enter into treatment decisions in any limited resource triage types of cases -- e.g., in an auto accident caused by a clearly drunk driver, all else being equal, first treat/save the people he injured before treating/saving him.

And I realize that there can be economic limitations that require basically what is 'financial triage' -- treating those who can pay -- for determining whom to treat even apart from pandemic conditions.  But that is a different problem, even if it might involve some of the same moral choices if it cannot be solved financially through something like universal health insurance and through more medical schools and nursing schools, better use of nurses, pharmacists, other medically knowledgeable people, and their expertise, etc.  I think it can be solved financially and educationally, however.  But it is a different issue from the current acute resource emergency.

In the current crisis, which is what I am writing about here, it is morally ridiculous for hospitals to admit they have to turn away car injury victims, innocent cancer victims, and others who need surgery or cardiac care because they need to use the resources for people who refused to take a vaccine.  No they don't.  They need to turn away people who refused to take the vaccine in order to have the resources for those who need care through no (or much less) fault of their own.  And it is ridiculous to lose nurses or doctors who could be treating surgery patients and other non-COVID patients because you allow total burnout of nurses and doctors treating people with basically self-inflicted life-threatening conditions.  If there were no effective and safe vaccine, none of what I say here would apply.  But currently there is, and so it does apply.  Hospitals should reserve the number of beds they are likely to need for non-COVID patients and simply tell COVID patients they don't have room for them.  Or if it is impossible to isolate COVID from non-COVID patients in hospitals, than one hospital in an area should be a designated non-COVID hospital while the others fill up with COVID patients.  But people who are dying from willful ignorance should not unnecessarily cause innocent people to die along with them or instead of them.

Four final points: 1) it is said that some people are innocent victims of widespread misinformation and intentional "disinformation" (previously called lies).  But with COVID being a major news story nearly every day on both local and national news, and with the amount of death and near death there has been, one should at least be suspicious of the claims that COVID is a hoax or not really dangerous, and that local and national news organizations are fabricating all this and creating false obituaries, pictures of ICUs with people intubated, hiring hundreds of thousands of crisis actors to play victims and families who lost a loved one, etc.  One should at least ask their doctor, if they have one, for medical advice about whether to get the vaccine or not.  Surely people bear some responsibility for blindly accepting the misinformation and lies.

2) Some people fear medical treatment, including vaccines.  In many cases, that is not unreasonable.  But when the choice is between dying isolated from loved ones and in the terrible way that COVID kills you or worrying about the possible side-effects of a vaccine that so far seems to be safe and effective for millions who have taken it, it is a case where the devil you do know (COVID) is not better than the devil you don't know (imagined possible, but so far hidden, or actual but rare and not deadly, vaccine side-effects). 

3) Some people cannot take the vaccine for various medical reasons.  They still should, insofar as possible, socially distance themselves and wear masks, to be as safe as possible as long as the disease is rampant and not controlled by herd immunity.  Ideally others would try to help protect them through various measures to allow them to be socially distanced, by being masked so as not to infect them, etc. but apparently in this day and age, the decency of others cannot be counted on.  What I wrote above applies to those who could take the vaccine but willfully choose not to.  It does not necessarily apply to people who cannot take the vaccine for sound medical reasons.  However, it does apply at least partially to those who cannot take the vaccine but who willfully choose to ignore masking or social distancing to protect themselves.  If you cannot take the vaccine, but you just 'have' to attend a crowded entertainment event unmasked or where most people are unmasked, then you don't deserve to take an ICU away from someone with random cancer or who was injured by a drunk driver.

4) I included "Tough Love" in the title of this piece because I think that if those who otherwise willfully choose not to take the vaccine know they stand a good chance of not being treated at all if they do get COVID, they may be inclined to change their mind and take the vaccine.  And I don't believe it is unfair coercion, or even coercion at all, to tell someone that you won't help them or put your own life in danger if they are going to behave in a foolhardy and dangerous way that makes them need help.