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Should Vaccination Status Affect ICU Admission?

By Ben Davies and Joshua Parker

Intensive care units around the country are full, with a disproportionate number of patients who have not had a single COVID-19 vaccination. Doctors have been vocal in describing the emotional cost of caring for critically unwell patients suffering from the effects of a virus for which there is an effective vaccine. Indeed, one doctor has gone so far as to argue that the unvaccinated should contribute financially for their care. It is easy to understand doctors’ frustrations given the relentless pressures and difficult decisions they’ve had to face. In the face of very real dilemmas about how to allocate scarce ICU beds, some might wonder whether the NHS should adopt a policy of ‘no vaccine, no ICU bed’.

One argument in support of a ‘vaccinated-only’ policy is utilitarian. By denying ICU beds to the unvaccinated, the NHS generates the most benefit from a limited resource. The average length of stay on ICU for a patient with COVID-19 is 15 days in the UK, three times higher than ICU patients admitted with other conditions. Roughly, then, for every patient on ICU with COVID, we could have treated three patients with conditions that require only 5 days in ICU. Unvaccinated COVID patients are more likely to need ICU than vaccinated patients, so refusing access to the unvaccinated will improve the number of patients ICU can treat. Given the purpose of ICU, this equates to saving more lives. Imagine an ICU with 10 beds and 10 COVID patients needing one, 5 of whom are unvaccinated. Each COVID patient has an expected stay of 15 days. Admitting all 10 would save 10 lives in 15 days. Refusing the unvaccinated and treating other conditions we would save five COVID patients (the vaccinated) and those other five beds could each have 3 patients through them in the 15 days meaning we save a further 15 lives; 20 in total.

Capacity to benefit quickly is not usually how ICU resources are rationed. Even if it were, this criterion alone doesn’t tell us why we should admit only unvaccinated COVID patients rather than simply COVID patients generally. To justify excluding only unvaccinated COVID patients we need a further moral claim, e.g. that these patients are culpably likely to occupy beds for too long.

One reason doctors are frustrated at providing critical care resources to those who failed to get vaccinated is because it seems like those patients are ‘free-riding’. The unvaccinated enjoy the benefits of having high levels of vaccination in society, but the costs of them becoming critically ill are passed on to others. Intensive care resources are costly and limited; directing them towards unvaccinated patients means that others lose out. Those who remain unvaccinated have made a choice; and we often expect people to bear the costs and consequences of their choices. If somebody is responsible for not being vaccinated and passes the costs on to somebody else in the form of denying them intensive care, some doctors may feel this is unfair. Between the many opportunities to be vaccinated and a concerted public health campaign, setting aside legitimate vaccine exemptions, it can be hard to think of excuses for not having had a single vaccine.

But the reasons that people don’t get the vaccine are complex. Some philosophers argue that individuals can be only held accountable for their choices if they take place against a fair background. Many unvaccinated individuals are from communities where their choices are shaped by numerous structural injustices. If a decision not to get vaccinated is a result of injustice – for instance, a lack of trust in institutional medicine due to previous bad experiences, or a lack of opportunity to get vaccinated due to poverty and overwork – then it is unfair to hold a person accountable for this. Indeed, it is doubly unfair to deny life-saving treatment to individuals already experiencing injustice because of choices that were made as a result of that injustice. In a different context, John Harris has called such approaches ‘double jeopardy’.

Confidence and trust in the COVID vaccine depends on what one believes about it. The internet is awash with targeted misinformation and conspiracy theories, these shape individual beliefs regarding vaccine effectiveness and safety. Some do not get vaccinated because of these powerful forces on their beliefs. Since these individuals hold false beliefs, at the very least this diminishes their responsibility for acting on those beliefs.

Still, some might object here: both constraints on time, and susceptibility to misinformation, come in degrees. Some people will be genuinely unable to distinguish truth from lies, or to take the time to get vaccinated. But the fact that making a decision is difficult or burdensome doesn’t automatically remove responsibility. Imagine a patient who had sufficient opportunity to access vaccination, and who could have taken more care in assessing misinformation. Such a patient might well be responsible for their choice.

But there is a further  distinction to be made here, between what is fair and what makes a workable policy. Intensive care doctors act as gatekeepers to ICU and they face two problems in sorting the culpable unvaccinated from the non-culpable. The first is the issue of false positives. It is not clear that we can be sufficiently confident in ICU doctors being able to determine who is morally responsible for failing to be vaccinated such that they don’t accidently refuse a patient who hasn’t been vaccinated but does deserve ICU. The second is the burden of undertaking the morally charged task of assessing the spectrum of reasons people have for foregoing vaccination and figuring out who gets intensive care on that basis. It hardly seems fair to expect this of ICU doctors.

Vaccines were a symbol of hope in the long road through COVID-19. The need to continue to care for critically unwell patients because they haven’t been vaccinated erodes that hope. A sense of unfairness is understandable. However, as a policy for admission to ICU, relying on COVID vaccination status is misguided. The moral outrage felt by some doctors caring for critically unwell COVID patients who might have avoided this through vaccination should motivate doctors to campaign to remove structural barriers to vaccination and act as a corrective to misinformation. But access to ICU should be based on clinical need and capacity to benefit, not whether you’ve had the jab.

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