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Around the world, hospitals and clinicians have widely agreed that Covid and non-Covid patients should have the same triage principles applied, that care should not be first come, first served (due to differences in accessibility), and that the main measure should be to get as many people as possible to leave the hospital alive. Cultural values sometimes come into play as to whether to consider a more subtle prognosis: quality of life, or years lived, or, like, who somehow is most valuable, if that was even calculable. (And triage isn’t the only way to divide vaccinated and unvaccinated people; the fact that private insurers are withdrawing payment for Covid care seems like a pretty good repudiation of the idea of forgoing one’s vaccines.)
One thing ethicists and clinicians have come back to time and time again is to avoid “categorical exclusion criteria,” attributes that take someone out of triage. For example, before the widespread availability of vaccines, elderly Covid patients died at a much higher rate than younger ones. But no one wanted to exclude the elderly from treatment, did they? It would be monstrous. Or, as a team of Swiss ethicists argued last spring, you could distinguish between “first-order criteria,” such as demographics, and “second-order criteria,” more subtle things that do not exist. ‘would come into play only in a tiebreaker – two patients, in every way possible, similar prognoses, similar diagnoses. But deciding which differences to take into account is very cunning. If it’s the state of health, how would you rate that? How can socio-economic status influence the prognosis, and can you take this into account fairly? What the ethicists and the Texas task force were saying was essentially whether vaccination status could be a second-order exclusion criterion – although, to be clear, one of the main points of the task force is that the vaccination status could not, in itself, be a categorical exclusion criterion.
In part, that’s because the whole idea comes with a Texas-sized caveat. Yes, far fewer people who get vaccinated get seriously ill. But no one knows so seriously ill vaccinated people perform better – more survivability – than seriously ill people not vaccinated people. It seems likely that once you are sick enough to be hospitalized, you are sick enough to be hospitalized. But as far as I know, no such published data exists. “Personally, I have that feeling from the data I’ve seen, but it’s very preliminary data. There is no peer-reviewed study that shows this, ”Fine said. “So you have to be careful. “
Be careful indeed. A big part of the rationale for triage guidelines is consistency, so individual physicians don’t have to rely on their hunches. “Covid has taught us a lot of things, but certainly there is a lot of implicit biases within the health system, and certainly with the results of Covid,” Lo said. “And we don’t want to make it worse.”
Moreover, as far as we can all understand and understand the rage and frustration of healthcare workers – emotionally exhausted, epidemiologically at risk – whatever blame we may place could well be misdirected. “We know people are frustrated and angry, but that’s not a basis for decision making,” Fine says.
Vaccination status, as Fine notes, is more complicated than this anger allows. “I think we have to be very careful about saying that someone has chosen not to be vaccinated. Some people do, ”Lo says. “But there are still people who have difficulty making an appointment, who are not good with the Internet, who do not speak English as their first language. Many people work in jobs where they do not have free time, or if they even experience adverse effects from the vaccine for just one day and cannot work, their wages are reduced. And how would a clinician trying to sort by immunization status distinguish between these groups, even if they were allowed to?
Besides, even people who resist vaccination because they think they will never get sick, or that if they do, a horse dewormer will save them, or that the vaccines contain 5G magnetizing antennas. through which Bill Gates can turn them into werewolves (They don’t! None of these things are a thing!) – these people were lied to by leaders they trusted. Bad information is cheap; better information is expensive. And as ugly as the Covid numbers in the South may be, the rabies might be better directed against political leaders who resist basic public health measures rather than the people who suffer from them.
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