"I don’t know how you do your job"
January 12, 2022 11:10 PM   Subscribe

My bile rises as I’m asked to move my dying cancer patient out of ICU to make room for an unvaccinated man with Covid Oncologist Ranjana Srivastava writes of what it is like to make a decision so many health professionals around the globe are being asked to make. (Single link from the Guardian.)
posted by Megami (114 comments total) 40 users marked this as a favorite
 
I'm glad she withheld her consent. For once, anti-vaxxers didn't get to call the shots.
posted by They sucked his brains out! at 11:17 PM on January 12 [65 favorites]


Does this ever happen in reverse? A COVID denier in terminal decline being kicked out in favor of someone with a fighting chance (and a lick of sense)?
posted by Rhaomi at 11:21 PM on January 12 [20 favorites]


Wow! What a read.

Thanks for sharing.
posted by freethefeet at 12:03 AM on January 13


So I assumed this was an article from the USA or maybe the UK where COVID has been rampant for a while.

No, it's from Australia. (I am Australian.) The hell, guys. We went through 2 years of lockdowns for what?

And then in some more hubris, wondered if this was a Sydney Oncologist. No, she's in Melbourne. (My home town.)

I know standing up more ICU beds isn't a question of just making beds- it's staffing, something we have been struggling with and will continue to struggle with.

Just- ugh.
posted by freethefeet at 12:28 AM on January 13 [16 favorites]


.
posted by Callisto Prime at 1:18 AM on January 13


"Making patients feel stupid is a treatment all doctors should eschew"
- another great article by the same doctor on a slightly different subject.
posted by polymodus at 1:38 AM on January 13 [11 favorites]


In Germany, they've said ahead of time, if it comes to rationing, vaccination status can't be considered. My question is, why? In normal cases I completely support treating injuries that result from dangerous behaviors. But if everyone is asked not to do a specific dangerous thing at the same time, causing the rationing, why should people who behave properly pay the price?
posted by starfishprime at 1:57 AM on January 13 [35 favorites]


"Much is being said about the courage and sacrifice of health professionals to keep the healthcare system running but almost all of us would rather be on the frontline than anywhere else. When we enter the profession, we consecrate ourselves to serving humanity – there could not be a better time to do this. From the students rolling up their sleeves to the specialists redirected to treat Covid patients, not to mention all the nurses, paramedics and service staff sustaining a threatened workforce, this is an extraordinary and privileged time to be on the frontline.

"But truth be told, we will spare the kitchen orchestra and the free drinks in exchange for a genuine reckoning with the difficulties we are facing. Often, medicine, needs to fix up its own troubles. But this time, there is something every individual has the power to do."


QFMFT
posted by I_Love_Bananas at 2:10 AM on January 13 [22 favorites]


I said from the beginning (like Feb 2020 I was saying this to anyone who would listen) a major repercussion of the pandemic if not properly managed was going to be permanent psychological damage to medical professionals involved in endless decisions about who should live. I claim no credit, but luckily we handled it fairly well here.
posted by memetoclast at 2:11 AM on January 13 [17 favorites]


My father is due for heart surgery (he needs a replacement valve). I'm sure all y'all can see why this worries me more than it would have done in 2019 or before.
posted by Too-Ticky at 2:16 AM on January 13 [30 favorites]


if it comes to rationing, vaccination status can't be considered. My question is, why?

I imagine it's because doctors aren't in the revenge business, they are in the saving people business, so when they make decisions, it's with an eye towards saving the most people, regardless of whether those people might be idiots or jerks.

If it's any consolation, I'm sure there are doctors who will drag thier feet when it comes to treating unvaccinated covid patients. The ICU doctor in the article, for instance, sounds like he might have been looking for ways to not give up the bed. If he hadn't called the oncologist, whose answer he probably knew before he made the call, it sounds like night shift might have moved the cancer patient early.
posted by surlyben at 2:21 AM on January 13 [16 favorites]


Huh, if it's from Australia that changes my reaction a little. In general I think it would be both ethical and logical for hospitals to explicitly have policies that give priority for limited resources to people who are vaccinated or have the (very rare) legitimate medical reason not to be, and I think a lot of them should start doing so.

However, not everyone who fails to get vaccinated is a self-centered Djokovic type. For example, Australia has relatively high vaccination rates (77% of the total population, or about 90% of eligible recipients according to various news articles). But apparently many of the eligible unvaccinated are indigenous Australians, for reasons ranging from well-earned historical distrust of the government to a lack of workforce to administer vaccines because of a (current and historical) lack funding and resources. So hopefully the doctors were able to and did take demographic information to account, because blaming people for the consequences of their own second-class treatment is also a problem.

Meanwhile, there's been a proposal in New South Wales to charge unvaccinated patients for their hospital care, a move that's been happening in a few other countries too.
posted by trig at 2:24 AM on January 13 [13 favorites]


Trig,
I'm Australian, and as pro-vax as it's possible to be (I literally held my child down today so the nurse could inject them after half an hour of debate, and no, I don't feel even slightly good about it - my older child said "I actually kind of hate you for what you just did to [child]" and I can't really argue with that), but actual forced vaccinations of adults or denial of state-supported care to unvaccinated will happen over my dead body. People make bad decisions all the time (me included (and you)), the whole point of the rights of citizens is that they are universal; just being an asshole (or a fool, or I know some antivaxxers who aren't either and I don't know how to understand them, but equally I don't know how to understand religious folk and I certainly wouldn't be cutting off their citizenship) doesn't exempt you from them.
posted by memetoclast at 3:23 AM on January 13 [20 favorites]


I mean, the fact that this question was even ASKED has me incensed.

And it's not even because of Covid or cancer or vaccination status or anything. It's because of simple fair play. Meaning: the cancer patient got there first and was actively on the equipment, as far as I'm concerned, this means they had dibs.
posted by EmpressCallipygos at 3:42 AM on January 13 [55 favorites]


memetoclast, I think we're miscommunicating - I don't support denying care to unvaccinated people. I do in theory support saying "okay, if we have to triage between a vaccinated person and an unvaccinated person who are both in serious condition because we literally don't have the beds, equipment, or manpower to treat both, we'll prioritize the vaccinated person unless there's a serious reason the unvaccinated person couldn't get vaccinated." The reason is that right now, and at various points all over the world for the past year, there have been a lot of people unable to access critical medical treatment -- even dying because of it -- because hospitals are full of covid patients, many of whom chose to forego vaccination and whose calculations for doing so centered on themselves while ignoring the very real costs they were imposing on everyone else. There's a tension in sacrificing patients to treat someone who was not willing to make a (minor, temporary) sacrifice for others; the linked article is about a doctor dealing with that tension.

However, the reason I say "in theory" is because in practice there are also deep-seated systemic reasons that some people aren't vaccinated, as I described in my comment. That's why the fact that the author is from Australia, where the indigenous population has lower vaccination rates than the general population, complicates the article for me in a way that it wouldn't if it were about a hospital in a more egalitarian country.
posted by trig at 3:46 AM on January 13 [25 favorites]


My father is an anti-vaxxer (and general conspiracy theorist). Our relationship has been increasingly strained for years. The COVID denialism was the last straw - we've scarcely spoken since March 2020.

Predictably, he got COVID a few months ago. It was pretty bad - he's 81. He insisted that he just had "the flu". His evidence? The ivermectin he was taking wasn't helping, which therefore proved that whatever he had wasn't COVID!

I would say that he's showing signs of dementia, or that he's a victim of online disinformation.

But he's literally always been like this. My entire life. (And, from what I hear, before I was even born.) He's never met a reactionary charlatan that he doesn't love.

He has this deep-seated need to be contrarian, to stick his middle finger in people's faces. He stakes out the most fuck-you position he can find, and then bitterly defends it in the face of all reason and decency.

He's an asshole, but I obviously didn't want my father to die. I was able to intervene, and he ended up getting monoclonal antibodies and pulling through.

(He's still an anti-vaxxer.)

But if the hospital had to choose between caring for my father, or caring for someone who wasn't sticking their middle finger in the faces of the very people that were trying to save them?

That obviously wouldn't be my choice to make - but, if asked, I'd say "give that bed to the person who's behaving with a shred of decency and common sense".

Enough is enough. People are holding the country, and the world, hostage with this idiocy.
posted by escape from the potato planet at 3:46 AM on January 13 [149 favorites]


In normal cases I completely support treating injuries that result from dangerous behaviors. But if everyone is asked not to do a specific dangerous thing at the same time, causing the rationing, why should people who behave properly pay the price?

A large proportion, even the majority, of hospital presentations are self inflicted. Busiest time for our emergency departments? Alcohol related injuries after wild Friday and Saturday nights. Drug related injuries too. Number one reason for cause of death / serious injury for young adults? Males would be car accidents (speeding, drunk driving, horsing around, illegal racing) and females would be... self harm. Later on? Heart disease, directly adjacent to obesity.

Not to mention repeat "regulars" to the hospital who consume staggering amounts of money and resources. I've heard an ED physician say good riddance after one of his "regulars" got stabbed to death in a drug related altercation.

Being unvaccinated isn't actually too far from any of those "self inflicted" reasons, you don't even have to make very much of a slippery slope argument. You can't preferentially determine the level of care you want to provide someone depending on whether they drove while drunk, were obese, etc.

As for this article... as far as I know, it's not remotely a possibility to turf someone out of a hospital bed early because we think they're going to die anyway and someone needs the bed more. However, we do regularly discharge people and tell them they're fine and to go home if we need a bed for someone else - and this comes down to balance of probabilities. In a world of unlimited resources, would we like to keep them in hospital for an additional day for observation and to provide acute care if they deteriorate? Sure. But we need the bed now, so we pronounce you cured and off you go, if we're 95% sure you'll be ok, just come back if you're not.
posted by xdvesper at 3:49 AM on January 13 [39 favorites]


I’m not a healthcare professional of any stripe, but I imagine, during a surge when every resource is needed, principles of triage might lead to denying treatment to unvaccinated people on the grounds that they are likely to be sicker and need more care for longer and possibly still die, when the same resources could be used to likely save the lives of people with less severe cases, who are likely vaccinated. However, this thinking is also going to doom the elderly, immunocompromised, people with certain disabilities/medical conditions, plus people who couldn’t get vaccinated, for whatever reason. I’m not sure there is an ethical, much less practical, way to triage based on foolishness.
posted by GenjiandProust at 3:51 AM on January 13 [21 favorites]


I guess I had the opposite reaction to most people. When you are hitting the limit of your finite resources, I'm not sure first come first served is the best way of making decisions. No, I don't want I or my loved one to be turfed out of ICU and die a few hours/days early. But if those extra hours make the difference between someone else living and dying at all, then turfing out early is I think the more moral choice. To me it's exactly the same as why we don't give organ donations to someone who is too sick. If there really isn't enough to go round then you do I think need to prioritise people who will recover with the treatment rather than those who either don't necessarily need the treatment or will not recover regardless. (In this context, I don't mean recovery to be either perfect health or normal lifespan).

On the other hand, while you can justify some restriction of treatment based on whether they will be able to benefit in the future (the classic being denying a lung transplant to a smoker who will not give up), I don't think you can justify restriction of treatment based on what you believe got them into this position in the first place. It's not always that cut and dried and there is nothing they can do about that now.
posted by plonkee at 4:10 AM on January 13 [8 favorites]


Most people I counsel(in US) who are unvaccinated are confused between the disinformation and actual risk benefits. More often than not it feels like the conversation that flying is safer than driving with people who are scared of flying. But there are enough loons who are vocal and do more dangerous things like smoking to make me dread having the conversation.
posted by roguewraith at 4:11 AM on January 13 [8 favorites]


roguewraith, may I ask what your job is?
posted by escape from the potato planet at 4:24 AM on January 13


I'm glad she withheld her consent.

I'm glad you summarised this for me. I started reading this article today and just noped out. We (ie Aus) were doing so well about this, and then suddenly the fed policy is "Ah fuck it".

If anyone needs me, I'll be in my bunk(er).
posted by pompomtom at 5:18 AM on January 13 [5 favorites]


Having been in the position of the family of the ventilated cancer patient, I can't imagine how exponentially more traumatic things would have been if the medical staff had been pushing us to hasten the process because they needed to free up an ICU bed. I can't give enough credit for the medical professionals who helped us take our time to arrive at the decision that circumstances had already made for us. This doctor in Australia knew that she's not just treating the patient, but the family as well. Given all the covid-related hardships of limited visitation and anxiety they most likely endured leading up to this moment, she made the right call to stand up for them.

And it sucks that we're in this situation, where hospitals are overwhelmed to the point where these dramas happen. Obviously it's unethical to blame the unvaccinated and deny them care, but you also can't deny that they are unnecessarily consuming resources and inflicting a tremendous injustice upon those who are vaccinated or who couldn't be vaccinated. So what do we do? What can we do?

I hate how everything about this pandemic just so perfectly challenges our morality. We can't hold people who were unvaccinated accountable because they're probably themselves victims of misinformation or have a distrust of authority because of previous injustices inflicted upon them. We can't hold those who spread the misinformation about vaccines accountable because of our belief in free speech and because prosecution might embolden them and cause even more people to refuse the vaccine.
posted by RonButNotStupid at 5:29 AM on January 13 [21 favorites]


Obviously it's unethical to blame the unvaccinated and deny them care...

I'll concede that we probably can't or shouldn't deny them care – but how is it unethical to blame them for the harmful thing they are choosing to do?

After all, in the very next clause, you say:

you also can't deny that they are unnecessarily consuming resources and inflicting a tremendous injustice upon those who are vaccinated or who couldn't be vaccinated.

They've made a choice to refuse a free, safe, easy treatment, in order to spite the people around them. I hold them accountable for that choice.
posted by escape from the potato planet at 5:36 AM on January 13 [30 favorites]


We (ie Aus) were doing so well about this, and then suddenly the fed policy is "Ah fuck it".

I kind of have "some" sympathy to the strategy they're following. NSW and VIC are over 93% double dosed for people aged 16+ and we know that immunity starts to wane 6 months or so after your second dose: there's no better time to allow resumption of social gatherings and international reunions of families and return of international students. Omicron being so much more infectious than Delta wasn't something anyone could have predicted, and by this point both premiers had already made commitments over reopening once we hit over 90% double vaxed.
posted by xdvesper at 5:46 AM on January 13 [3 favorites]


Reading the whole article, I feel very heartened at the decision making in it, actually. The doctor that asked was relieved that the first doctor said no, but had advocated for his patient anyway, and the doctor writing the piece had the space and professional respect to have been able to decide.

The rationing situation is tragic, and for me here in sunny Ontario, where we have fewer hospital beds per 100,000 residents than most developed areas of the world, that's where I am throwing my long-term ire.

Emotionally I agree with the sense that people who have not gotten vaccinated have made a bad decision. But I don't know anyone who only makes good decisions and I am absolutely not prepared to set up a system to try to measure that before you get basic medical care. In overwhelmed situations, there will be triage (even in a great system, which I don't live in) and it will be horrible. We should work harder to prevent it. But I don't believe that's the choke point at which to punish people.

I say this from the perspective of someone who was listening to her baby's heart monitor scream alarms while nurses ran up and down the hallway hoping the OR would clear in time. Reader, it did not. Instead the surgeon ran into my room, bloodied from the person who had the resources my baby needed, did an episiotomy, jammed forceps in, and pulled my grey daughter from my body, which resulted in physical damage to me, and ultimately, a few days later, in her death (when we took her off a ventilator.)

I don't blame in the slightest the person who had the OR I needed regardless of whatever their life choices were. The medical system should not be there to judge people. At the point that judgements need to be made, things have failed, and I do trust (overall) the training of the doctors who have to make those calls, and when they fail, it's because they shouldn't have to make them. I do blame the people who set up the systems knowing the failure points and not addressing them, and that goes up the line to how things are paid for etc.

I blame the politicians for not throwing resources to go door to door and offer vaccines all the time daily. I blame the people at the top of the anti-vax pyramid: The politicians, pastors, Dr. Oz-type medical media, right-wing media, and frankly, people like Ontario's Chief Medical Officer of Health who yesterday stated in a press conference that they are not mandating Covid-19 vaccines in school because they are too new, which was at best a thoughtless comment that is going to keep the pandemic going and kill people. THOSE people can BITE ME and trust me, I would love to ration THEIR care but again...everyone deserves care.
posted by warriorqueen at 6:11 AM on January 13 [70 favorites]


They've made a choice to refuse a free, safe, easy treatment, in order to spite the people around them.

I want to think so, but I know deep down that it's not universally true.

while you can justify some restriction of treatment based on whether they will be able to benefit in the future (the classic being denying a lung transplant to a smoker who will not give up)

Addiction is also a disease which can be treated, and there's nothing "classic" about this example. While lots of factors go into determining who can be eligible for a transplant, this kind of callous morality call is not and has never been one of them. I remember as a kid in the mid-1990s being so upset that Mickey Mantle had received a liver transplant head of more "deserving" people because of his history of alcoholism and "wild" life. And then I grew up and realized that the situation is much more complex than that and doctors at the time had made the most morally sound decision.
posted by RonButNotStupid at 6:12 AM on January 13 [4 favorites]


They've made a choice to refuse a free, safe, easy treatment, in order to spite the people around them.

This is simply untrue. Unvaccinated people aren't all the same, and I doubt any of them are doing this for spite. My sister is unvaccinated, and it's making me crazy, but she is afraid of the vaccines and does not trust the medical establishment, which has a long history of saying things are safe and being ultimately proven wrong. (My mother was given a drug when she was pregnant in the 50s and 60s that she decided not to take. She believed it was probably DES, which caused numerous health complications, including increased risk of cancer, in the daughters of women who took it.)

This situation is frustrating as hell. I'm immunocompromised and undergoing cancer treatment, and I'm scared to death that the unvaccinated will compromise my health care. But it doesn't help to paint them as cartoons.
posted by FencingGal at 6:14 AM on January 13 [27 favorites]


I am from the US and not Australia, and I’m talking about outpatient care versus hospital care, so adjust your grain of salt accordingly. But if I had a dollar for every time I’ve known a doctor to refuse treatment to a noncompliant patient, I’d at least have enough dollars to take myself to lunch.
posted by The Underpants Monster at 6:28 AM on January 13 [8 favorites]


I doubt any of them are doing this for spite

I guess we'll have to agree to disagree, because it's abundantly clear to me that quite a few of them are doing exactly that.
posted by escape from the potato planet at 6:34 AM on January 13 [38 favorites]


The fight between good and evil is always compounded by the fact that good cannot use all the tools evil has at its disposal and remain good.

It's delicious to contemplate health care professionals making life or death decisions based on some perception of the worthiness of the unvaccinated but that deliciousness hides poison; it's exactly what we rail against.

Someone is not less worthy to live just because they've made a stupid choice.

The argument gets really difficult though when you have to consider whether to save someone who's actively trying to kill others, like a Nazi. But who are you to make that decision to kill someone (or through neglect, let them die)? And if you make it, will you be able to live with it? War is hell.

Is the operating room a war zone? No, it is not. If you think it should it be, think about where that would lead should a political party you don't like take power.
posted by seanmpuckett at 6:42 AM on January 13 [35 favorites]


But who are you to make that decision to kill someone (or through neglect, let them die)?

What if the alternative is to allow an innocent person to die?
posted by escape from the potato planet at 6:57 AM on January 13 [7 favorites]


Citizen, your moral purity score is insufficient to access this treatment.
posted by biffa at 6:59 AM on January 13 [8 favorites]


I do in theory support saying "okay, if we have to triage between a vaccinated person and an unvaccinated person who are both in serious condition because we literally don't have the beds, equipment, or manpower to treat both, we'll prioritize the vaccinated person unless there's a serious reason the unvaccinated person couldn't get vaccinated."

Though I'm no spring chicken, I believe I'm on the younger side of the Mefi population, and I remember the AIDS epidemic. How can people who remember the AIDS epidemic, and therefore remember how horrendously a marginalized group was treated for contracting a disease that was "their own fault," say things like this?
posted by praemunire at 7:06 AM on January 13 [30 favorites]


The operating room is now a war zone because a significant portion of the population has tied a simple and effective medical prevention step to being on the other side of a political divide. Talk to some people working in health care, it is very much a war time footing.
posted by Abehammerb Lincoln at 7:07 AM on January 13 [24 favorites]


I've seen a lot of fantasizing online about denying emergency lifesaving care to the unvaccinated. I work in biomedical research, and all my colleagues I have spoken to about this are disgusted by that prospect. The armchair clinicians don't seem to understand the implications of asking physicians and nurses to take unvaccinated people off life support.

This is not the right place to provide an incentive for vaccination, and it's not the right place to add extra resources to the health care system.
posted by grouse at 7:09 AM on January 13 [30 favorites]


If you want people to trust science and, more specifically, the science of medical care, denying them treatment is not going to win them over.
posted by oddman at 7:13 AM on January 13 [7 favorites]


We already accept rationed care for one category of medical procedure: transplants. This is because of the limited donor pool. And we already accept restrictions on who is eligible for certain kinds of transplants. People seeking lung transplants need to be off nicotine. People seeking liver transplants need to be off alcohol. This is because their chances for success post-transplant are higher that way, but that has an ethical reverberation to it: medical practitioners shouldn't "throw away" a scarce resource on someone who isn't going to make the most of it.

We're now facing all medical care being rationed because of one disease, the worst consequences of which are easily avoidable for most people. The scarce resource now is the time and energy of medical practitioners themselves. Why wouldn't they object to "throwing away" that resource on people who not only won't do the minimum to protect themselves, but in many cases are actively hostile toward the help that those medical professionals are offering, and are more likely to be reinfected?
posted by adamrice at 7:14 AM on January 13 [45 favorites]


How can people who remember the AIDS epidemic, and therefore remember how horrendously a marginalized group was treated for contracting a disease that was "their own fault," say things like this?

It's almost offensive to draw this comparison.

There was no AIDS vaccine that was widely shunned by the community at the time. There is no large contingent in the gay community today shunning PrEP or spreading conspiracy theories to dissuade others from using it.

There's lots to criticize about the Federal government's response to Covid, but at least we got a vaccine. Reagan's response to AIDS was "good, let them die."

I just don't think it's fair at all to compare people who died of a disease for which the vector of transmission was barely even understood, to people who actively shun preventative measures for a disease which is well understood.

We're in a real ethical morass here, because people are effectively taking advantage of the ethical requirement to care for them no matter how awfully they behave. But holy fuck, do not compare Covid anti-vaxxers to AIDS patients.
posted by explosion at 7:22 AM on January 13 [138 favorites]


The difference is time, and also post-treatment success. A person who is walking into the ER with Covid does not have time to go back 4 weeks and get two shots. They can't breathe right then.

Additionally, transplants have a limited resource that cannot be planned/ordered up in the same way. I can have 1,000 ventilators in a bunker and I can provide scholarships to train an army of ICU nurses if I started 10 years ago (I am not saying this happened, but it is possible to have happen.) However, I can't go around getting people in motorcycle accidents for their lungs for a particular quarter.
posted by warriorqueen at 7:23 AM on January 13 [1 favorite]


I think one thing that needs to be addressed is why people don't trust the vaccines. There's enough people out there gullible or stupid enough to believe it causes autism in kids, or to listen to the fuckhead brigade like Alex Jones and Dr. Oz. But what makes it so compelling to them? Is it the "well, there is a reason" for something that doesn't make sense? Do they have some kind of inherent contrarianism which causes a deep skepticism in them? Is it a series of pharmaceutical companies being lying assholes (looking at Purdue and their work with the current opioid epidemic they caused by saying 'it's totally not going to cause addiction!'), or times the government said something was perfectly safe only to have people's jaws fall off later?

Is it a combination of some or all of these? And how can we address it properly to fix this? Other than a time machine that I can go back in time and drop an anvil on Andrew Wakefield at his medical school graduation, to start off.
posted by mephron at 7:28 AM on January 13 [6 favorites]


And we already accept restrictions on who is eligible for certain kinds of transplants. People seeking lung transplants need to be off nicotine. People seeking liver transplants need to be off alcohol.

I think you implied this by your choice of wording, but I think it's important to mention that transplant eligibility decisions are not final and they're made while someone is already being treated by a doctor. It's not like someone comes in off the street needing a liver transplant. Someone who's actively smoking may not be currently eligible, but it would be unethical for doctors to not assist the patient in overcoming their nicotine addition in the hope that they might become eligible as part of their current treatment.
posted by RonButNotStupid at 7:28 AM on January 13 [9 favorites]


I think for many of the unvaxxed I know it is a mistrust of "authority", and a lack of understanding of how to evaluate if information is credible. The mistrust in authority, especially by women, POC, and marginalised groups is understandable. Relying on telling them that "Doctors are telling you to get vacineted" getting frustrated with them that that doesn't change their mind is counter-intuative. The lack of critical thinking skills is due to an education system that has focused on making compliant workers and squashing alternate viewpoints (especially from women, POC and marginalised groups) that encourage innnovative thinking.
posted by saucysault at 7:36 AM on January 13 [8 favorites]


Sure are a lot of trolleys in this thread.

One thing I have seen in my life is that knowing who is going to die or pull through is not an exact science. People come in in incredibly sick and get better; they come in with a minor problem and die. Every health professional has those stories. All you really know is the odds, not who will beat them.

Asking anyone to try to decide"who's going to die anyway," is inhumane and traumatizing. You don't have to care about someone dying for being stupid, but you should care about how that effects the humans who are there when that happens.
posted by emjaybee at 7:43 AM on January 13 [25 favorites]


In the case of organ transplants, the important consideration is what happens after the transplant. Whether a patient is able to give up cigarettes or drinking is used in the triage because it has a bearing on what happens after. If you spend your life drinking to irresponsible excess, and it destroys your liver, and then you sober up, you stay on the transplant list just the same as you would if you had never touched a drop.

In the case of covid and anti-vaxxers, it's not so clear that thier anti-vaccine position will lead to worse future outcomes. Surviving covid grants a measure of immunity, and the disease may become more mild over time, and in any case thier reasons for not getting vaccinated may be legitimate.

My dad died of liver failure, about four years after they kicked him off the transplant list because he couldn't stop drinking. He was an alcoholic for 45 years or so (but otherwise a pretty great guy), right up until the drink of whisky that put him into a coma. The astonishing thing to me, and something I am grateful for, was how much the doctors weren't interested in punishing him for his bad behavior. They wanted to see him improve.

(My stepdad died of cancer, probably because he was unable to receive treatment fast enough, due to delays brought about by the covid lockdowns in the spring of 2020. I guess it's not relevant here, because it happened before there were vaccines, but in both cases the ethics of triage applied, and maybe that's fine.)
posted by surlyben at 7:47 AM on January 13 [14 favorites]


There's a lot of outrage about the hypothetical idea of prioritizing vaccinated people when treatments need to be rationed. Why no outrage over the actual reality that we are prioritizing unvaccinated patients and denying treatment to vaccinated people?
The problem is that the supplies of those that work against the Omicron variant are extremely limited. That has forced state health officials and doctors nationwide into the fraught position of deciding which patients get potentially lifesaving treatments and which don’t. Some people at high risk of severe Covid are being turned away because they are vaccinated. [...]

An increasing number of hospitals are imposing restrictions on treatments. In western Indiana, officials at Sullivan County Community Hospital determined last month that they had to restrict eligibility for antibody infusions, after weeks of receiving far fewer doses than they had ordered. They opted to almost entirely exclude vaccinated people.
posted by mbrubeck at 7:47 AM on January 13 [52 favorites]


I run into these kinds of ethical dilemmas frequently (though not usually as acutely as the situation described) as a mental health professional (psychiatric social worker) in a federally qualified health center. And sometimes we do discharge patients because in the opinion of their medical team, they require a higher level of care than we can provide and are not compliant with the prescribed plan of care. In some of those cases, it takes a lot of leg work to find more appropriate resources or referrals for them; I live in a very city that does not have a lot of resources accessible to people who are on Medicaid or who are uninsured. But it is my responsibility to do this, to the best of my ability, even though sometimes this means spending a lot of time working out the plan that is most likely to actually succeed in getting the patient the help they need.

I agree with the commenter about who said the article is heartening, in terms of the decision-making process outlined. The doctor providing the care to the patient with COVID was right to consult with the author of the article; and the author was right to say, "no, I can't ethically discharge this patient." If the roles had been reversed (that is, if the COVID patient had already been in the ICU bed), the outcome may well have been different. Is that fair, a first-come-first-served situation in cases where the doctors for each patient would like their patient to have the bed? Quite possibly not.

But the alternative is dangerous. Consider what it means to introduce more subjectivity into this process. We know that the medical system is racist and classist. People with money and good insurance already have access to a greater number of services and hospitals and providers. Studies also show, for instance, that Black people who present with complaints of pain are less likely to receive adequate pain management than White people with the same presentation. Heart attack symptoms in cis women often look different to the "typical" heart attack symptoms experienced by cis men, and this may lead to underdiagnoses.

There is always an element of subjectivity in medical decisionmaking; there is never an unlimited amount of resources available. Everyone cannot go to the Cleveland Clinic or receive the latest experimental treatment for their condition. And if a provider finds a patient frustrating or annoying or non-compliant, it's going to be hard for them to provide the same level of care no matter how much they try. We're only human.

But as much as possible, medical professionals try to treat people based on how they would treat any other patient presenting with the same symptoms and medical history, not taking into account a moral calculus of their past actions. That's a hard line that we don't follow perfectly -- again, no one is perfect -- but it is the ideal and has been since Hippocrates. I have provided counseling or case management care to people whose personal beliefs or actions I found morally questionable or abhorrent; people who abuse their spouses, people who protest at abortion clinics, people who are living with HIV and routinely engage in unsafe sex without disclosing their status to their partners; people whose addictive behaviors are harming them and the people around them. But my responsibility as an allied health professional is, insofar as I am able, not to judge them or to allow their past decisions to affect my actions or recommendations.
posted by tivalasvegas at 7:57 AM on January 13 [35 favorites]


My father was in the hospital for a stem cell transplant May 2020 and then had a heart attack and needed to be in the ICU instead (in a positive pressure room because by then he'd had chemo), and this was of course before vaccines or anything but had they said "well, we'll take him out of the room because he's got a very fatal cancer and he probably won't live very long", I might have burned the hospital down. (To be clear, they at no point gave him anything but the best care they could, and though I believe with every fiber of my being that he would not have had that heart attack, which he did not survive, had it not been for the pandemic due to a bunch of reasons, he did not have worse care from any of the doctors or nurses because of it.)


However, I can't go around getting people in motorcycle accidents for their lungs for a particular quarter.

You could! This would not be all that hard to do. (Easier than building a time machine, though of course far less ethical, legal, etc.)
posted by jeather at 8:09 AM on January 13 [7 favorites]


It's a very striking article, but the question going through my mind was how the oncologist was allowed to know the vaccination status of a patient she wasn't treating. There's also something that makes me uncomfortable about a doctor writing about potentially identifiable patients.
posted by altolinguistic at 8:10 AM on January 13 [1 favorite]


It's almost offensive to draw this comparison.

There was no AIDS vaccine that was widely shunned by the community at the time. There is no large contingent in the gay community today shunning PrEP or spreading conspiracy theories to dissuade others from using it.


I assure you that at the time (and, for some of them, even today) many of my horrible relatives regarded gay AIDS patients as far more morally blameworthy--literally being tortured to death by a vengeful god in life and then dispatched to eternal torment--than today's unvaccinated COVID patients. If it makes you feel more liberal not to think about the implications of that when setting the parameters of public health policy more generally, well, I guess I can't force you to, but you are thereby actively making your analysis worse and more dangerous to marginalized people.
posted by praemunire at 8:11 AM on January 13 [20 favorites]


In a triage situations when resources are scarce don’t treat patients based on moral judgements of who is the most deserving, treat them based on who has the best chances of survival.

Otherwise it turns into a scenario of:

Who deserves the bed: Cancer patient or unvaxed covid patient, but what if they smoked their whole life, etc. pretty soon you have lawyers showing up to prove that their client was more worthy of the bed compared to that guy over there.
posted by interogative mood at 8:14 AM on January 13 [11 favorites]


Additionally, transplants have a limited resource that cannot be planned/ordered up in the same way.

I have a friend who can't even get onto the heart transplant list, nearly two years into trying. A major hospital system in our area literally turned him away "as in good luck, get out, we can't help you". Fortunately we live in a large metro where the other major hospital system is sort of trying, as long as his family does a huge amount of advocating for itself. I'm just saying a moderately close look at the transplant process is kind of eye opening and not would we would like regular medical care to look like.
posted by The_Vegetables at 8:53 AM on January 13 [6 favorites]


I’m no medical professional but I’m pretty sure some of the basic ethical tenets are a lot older than 2020…
posted by atoxyl at 8:54 AM on January 13 [3 favorites]


I think people are grappling with (at least) two different questions:

1. "Is it just to deny a vaccinated individual (or an individual who can't get vaccinated) potentially life-saving health care resources, in order to provide those resources to someone who has refused the vaccine out of spite and tribalism?"

This is a question about what is just, in the abstract. It assumes that we can know, with 100% reliability, that the second individual is acting out of spite. It does not ask anything about what is practical to implement in the real world.

My answer to this question is a firm "no".

2. "Should clinicians have the prerogative to deny care to unvaccinated individuals? That is, can the medical establishment be trusted to make this judgment accurately, and without introducing other injustices (or other external costs which would outweigh the benefits)?"

This is quite a different question.

Understandably, those whose work puts them closer to actually making these kind of real-world decisions seem to be engaging with Question #2.
posted by escape from the potato planet at 8:55 AM on January 13 [10 favorites]


In the case of organ transplants, the important consideration is what happens after the transplant.

Your past history of medical compliance plays an awfully big deal, at least with kidney stuff -- they check your records to make sure you've gone to your medical appointments and treatments, they make sure you're up to date on regular exams and dental, they check your bloodwork to make sure you're following doctor's orders, they ask you about past and current smoking and drinking, etc.

The idea is that if you're a compliant patient before the transplant, you're more likely to follow instructions, take your medications, and maintain protocols after the surgery.
posted by mochapickle at 9:19 AM on January 13 [6 favorites]


I mean, if we're denying people care based on their likelihood of survival, it's only so long before people are denied for being obese, which has an extremely clear link to the severity of COVID. Not a world I want to live in, thanks very much.

And to answer your second question, potato planet, no, physicians can not and should not be trusted to have the prerogative to deny treatment to anyone, because it would rapidly spiral into a cascade of ever-worsening injustices. I know a lot of doctors, and I'd say maybe 5% of them are trustworthy and sound on an issue like obesity. The rest think that obesity is something that is firmly within the control of the patient, who just needs to be a little smarter, read the right research, lose weight, and never come back to the hospital because losing weight will fix all their problems.

It's quite frankly disheartening to see people here taking the idea of denying medical treatment to anyone seriously.
posted by Cpt. The Mango at 9:22 AM on January 13 [8 favorites]


I notice many people are referring to "triage situations", which feels to me like it's missing the detail that got me upset:

The patient on the ventilator had already been through a triage situation earlier, and he'd passed the triage situation and was undergoing active treatment. The unvaccinated Covid patient was coming in later, and should have been in triage against the current patients under triage, not the people who'd already passed triage and were active patients.

Look at it this way: say that your workplace posts a job opening, they get 25 candidates, and they sort through them all and hire someone who is best qualified out of those candidates. Now suppose that someone else comes along looking for a job 3 months later who would be about as qualified as the person they ultimately hired. No company would dream of dragging the person who already got the job back into a new job interview all over again just because this new guy was coming along later, right?

Of course right. If you're evaluating someone for a job, you evaluate them against the people who applied at the same time as them, not against people who came along later. Triage is the same thing - you're evaluating someone against the other people in triage, not the people who already passed through triage and were already undergoing treatment.

And that's what made me see red. I understand the need to try to find ways to distribute shared resources, but for the love of fuck, you don't fix the problem by stealing treatment from people who were already approved for it.
posted by EmpressCallipygos at 9:24 AM on January 13 [39 favorites]


This is a question about what is just, in the abstract. It assumes that we can know, with 100% reliability, that the second individual is acting out of spite. It does not ask anything about what is practical to implement in the real world.

They'll just tell you its because of spite if that's the reason. At least until the hypothetical triage decision becomes public.

Not agreeing with rationing care based on behavior, just that if someone is doing something to be an asshole they really, really want you to know.
posted by Slackermagee at 9:25 AM on January 13 [2 favorites]


It's quite frankly disheartening to see people here taking the idea of denying medical treatment to anyone seriously.

In a situation where the demand for medical resources outstrips the supply, people are necessarily being denied treatment. It's just a question of who will be denied.
posted by escape from the potato planet at 9:26 AM on January 13 [24 favorites]


the medical establishment... has a long history of saying things are safe and being ultimately proven wrong.

A common trope among the anti-vax crowd, who I'm sure can give some examples, but in general I don't believe this, in fact the opposite seems to be the case in my experience.
posted by Rash at 9:26 AM on January 13 [5 favorites]


the medical establishment... has a long history of saying things are safe and being ultimately proven wrong.

A common trope among the anti-vax crowd, who I'm sure can give some examples, but in general I don't believe this, in fact the opposite seems to be the case in my experience.


In America anyway, it's more often that sound science is just covered up by corporations that don't like the science, and then they just propagandize people otherwise. When it comes to the pharmaceutical industry, this is common.

Two years into this, and I fail to understand why we aren't talking seriously about how our for profit healthcare system and for profit media system are part and parcel to why a huge portion of the population don't trust healthcare professionals or the media. It's a big problem, it's real, and yes, they have plenty of valid reasons to be skeptical of big businesses that don't give a fuck if they live or die. Unfortunately, plenty of people are vastly undereducated, and don't see that the real problem is capitalism gaslighting everyone all the time.

Sure, there's real scientists doing real science, just like with climate science. Based on our media, you wouldn't fucking know it.

I'm angry at anti-vaxxers, too. I think I'm more angry at the rich fucks who are DEFINITELY vaccinated who are pushing this anti-vax bullshit to make money, further increasing the distrust spiral into fascist madness.
posted by deadaluspark at 9:32 AM on January 13 [20 favorites]


Citizen, your moral purity score is insufficient to access this treatment.

Those who died in the 80s from AIDS would like a word.
posted by archimago at 9:34 AM on January 13 [1 favorite]


A common trope among the anti-vax crowd, who I'm sure can give some examples, but in general I don't believe this, in fact the opposite seems to be the case in my experience.

Just because anti-vaxxers believe something doesn't make it wrong.

I'm very pro-vax, and I can give you examples: DES, as mentioned in my post; routine x-rays for pregnant women (my mother was told it was safe); lobotomies (the inventor won the Nobel prize); thalidomide. When my children were born in the 70s and 80s, I was told it was imperative to have babies sleep on their stomach to avoid SIDS- last I heard, it's imperative that you NOT do this. When my back went out in the 80s, I was told it was important to stay in bed for weeks and to get up only to go to the bathroom - they would never say this now. Doctors continue to give people preventative stents, even though they are more risky and not more effective than medical management. This is just off the top of my head - I'm sure there are more.

It's not bad that medical recommendations change as more is known - that's just how science works. But it does happen and will no doubt continue to happen.
posted by FencingGal at 9:34 AM on January 13 [23 favorites]


In a triage situations when resources are scarce don’t treat patients based on moral judgements of who is the most deserving, treat them based on who has the best chances of survival.

This is absolutely something I agree with.

Also, I think most of us would agree that we would really rather that triage situations were rare. Making that happen or not happen in a rich country is a political choice for the most part.
posted by plonkee at 9:35 AM on January 13 [3 favorites]


Oh - and I forgot Fen-Phen.

At an advisory committee convened by the FDA to discuss Redux's approval, there was contentious debate on the drug's safety. Critics cited data from the forthcoming release of the International Primary Pulmonary Hypertension Study (IPPHS) that linked derivatives of fenfluramine to primary pulmonary hypertension, a disease that thickens the capillaries in the lungs and makes breathing very difficult.

What was particularly shocking to me was that on the heels of reporting that this drug caused a fatal, incurable disease in Europe, the company was planning to put it on the American marketplace," says Dr. Stuart Rich, who co-authored the pulmonary hypertension study. Despite testimony from Dr. Rich and the opinions of two experts on neurotoxicity, the FDA approved dexfenfluramine in April 1996. "Just three months after the introduction of Redux, doctors are writing 85,000 prescriptions a week," Time Magazine reported in a cover story titled "The New Miracle Drug?" The article also reported that 58 million Americans were clinically obese.

posted by FencingGal at 9:42 AM on January 13 [3 favorites]


Those who died in the 80s from AIDS would like a word

I assume they would agree with the point that this attitude to medical care is bad.
posted by biffa at 9:53 AM on January 13 [1 favorite]


>the medical establishment... has a long history of saying things are safe and being ultimately proven wrong.

>>A common trope among the anti-vax crowd, who I'm sure can give some examples, but in general I don't believe this, in fact the opposite seems to be the case in my experience.

https://en.wikipedia.org/wiki/Tuskegee_Syphilis_Study
posted by Cpt. The Mango at 9:55 AM on January 13 [2 favorites]


And that's what made me see red. I understand the need to try to find ways to distribute shared resources, but for the love of fuck, you don't fix the problem by stealing treatment from people who were already approved for it.

Which we are already doing, at least in Canada. My FIL died from a surgically treatable condition that he was scheduled to get addressed. Then all surgeries were cancelled two days before his surgery because of the strain of the first wave of COVID. He died a couple months later from that condition before surgeries were resumed.

And my mother has been waiting for surgery to treat debilitating pain for eighteen months. Her surgery dates keep being pushed back as the waves of COVID postpone her treatment because recovery rooms aren't available.

I don't think we should be denying treatment to the unvaccinated whatever their reasoning but boy howdy am I going to think you are a selfish idiot if you can get vaccinated and don't.
posted by Mitheral at 9:57 AM on January 13 [38 favorites]


so long before people are denied for being obese, which has an extremely clear link to the severity of COVID. Not a world I want to live in, thanks very much.

You already live in this world. If you have one ventilator available and two patients and one is obese or has other co-morbidities that indicate a lower chance of survival then that patient has to wait and the patient with the greater chance of survival gets the ventilator and the obese patient has to wait and probably die of asphyxiation.
posted by interogative mood at 10:07 AM on January 13 [3 favorites]


so between someone who wasnt vaccinated and a vaccinated wfh manager who forced their staff back to work in unsafe conditions who gets the bed
posted by mosswinter at 10:09 AM on January 13 [2 favorites]


I'm so sorry Mitheral.
posted by warriorqueen at 10:20 AM on January 13 [6 favorites]


I've got (had) two antivaxer friends. One is a Rudolf Steiner devotee who opposes all vaxes, the other is a "stick it to the libtards" guy. I still talk to the first, I just blocked the second on my phone.
posted by StickyCarpet at 10:27 AM on January 13 [1 favorite]


A common trope among the anti-vax crowd, who I'm sure can give some examples, but in general I don't believe this, in fact the opposite seems to be the case in my experience.

Well I'm watching Dope Sick right now, so Oxycontin and the opioid crisis comes directly to mind, both the marketing and the FDA failures. If you were prescribed Oxycontin for pain and assured it was non-addictive, or anyone in your family was -- and Purdue DIRECTLY MARKETED in communities where the main industries were known to be hard labour -- you may not now trust that vaccines are just fine and dandy.

I agree that overall, I think most medical professionals and most approval processes are conducted decently but let's not forget we are not even decades out from this particular failure.
posted by warriorqueen at 10:27 AM on January 13 [8 favorites]


I don't think we should be denying treatment to the unvaccinated whatever their reasoning but boy howdy am I going to think you are a selfish idiot if you can get vaccinated and don't.

Oh, totally agree with you there.

This scenario just sounded like the even-worse situation of: imagine if your mother was literally being prepped for surgery and someone came to her surgeon and asked to postpone her surgery for the sake of a Covid patient, and I was like how can anyone even.
posted by EmpressCallipygos at 10:31 AM on January 13 [5 favorites]


why we aren't talking seriously about how our for profit healthcare system and for profit media system are part and parcel to why a huge portion of the population don't trust healthcare professionals or the media.

In NYC, they're running a PSA for children's COVID vaxes that shows a woman on the way to pick up her kid from school talking on the phone to someone about her decision to have the kid vaccinated. She says that she had questions, so she called her kids' doctor and talked to her about this aspect and that, concluding with something to the effect of "I finally asked her if her kids were vaccinated, and she said yes, and that clinched it for me."

I keep thinking that it's the damn rare parent in the U.S. in the demographic of that woman who can just call up her kids' (already established!) doctor and talk to them for what must have been at least twenty minutes about the decision, much less have enough of a relationship to know about the doctor's own family.

In a situation where the demand for medical resources outstrips the supply, people are necessarily being denied treatment. It's just a question of who will be denied.

People will always try to foreshorten the context of these "tough decisions" so it reduces to a very simplistic "A or B, you choose, no other options!!!" It's important to resist that.
posted by praemunire at 10:31 AM on January 13 [5 favorites]


The doctors, the patient who has the bed, the patient who needs the bed, their respective families--whose shoes are you wearing?

Triage: You determine a person's life or death in your next utterance; you will revisit those words in your dreams.

Hospital care is already shackled by insurance requisites. I don't want decisions to be made by a Political Officer assigned to the hospital.

Disclosure: I was in a cancer unit for several months, getting a bone marrow transplant. Four of the eight of us (patients) on that ward died while I was there. I saw nurses weeping.
posted by mule98J at 10:32 AM on January 13 [5 favorites]


The unvaccinated Covid patient was coming in later, and should have been in triage against the current patients under triage, not the people who'd already passed triage and were active patients.

I don't think this is accurate, though? Triage assumes dynamic allocation of the resources where that would result in a predicted net positive of outcomes.
posted by praemunire at 10:33 AM on January 13 [2 favorites]


at least we aren't arguing about the number of angels dancing on the head of a pin, I guess

taking a step back or to the side or whatever, there's the fact this discussion exists.. and the fact that multiple far-from-ideal situations are occurring simultaneously, and though many comments upthread are entirely compelling and sound pretty good to me, anyhow.. there's just no way to get around it.. the best we can do here is (hopefully) the least shitty, and that's saying a lot more than what we'll see in all kinds of situations where politics, misinformation, and chronic underfunding have undermined the foundations from which we discuss this
posted by elkevelvet at 10:53 AM on January 13 [3 favorites]


I can't speak to Australia, but I know many folks posting here are in the US, and there are people in our country who are unvaccinated not because of misinformation but because they literally cannot afford to miss a shift or day at work, and they know that the vaccine response can potentially take someone out for a couple of days. Sure there's a lot you could argue with the logic there, but people are just trying to get by and society has failed its end of the bargain in not giving everyone what they need to make vaccination a slam-dunk for people with the greatest economic precarity.
posted by dusty potato at 10:54 AM on January 13 [25 favorites]


I don't think this is accurate, though? Triage assumes dynamic allocation of the resources where that would result in a predicted net positive of outcomes.

I very well may be incorrect about how triage works. Still, pulling someone who is actively already undergoing a treatment off that treatment which they have already started just feels wrong at a gut level to this particular layperson.
posted by EmpressCallipygos at 11:00 AM on January 13 [4 favorites]


How can people who remember the AIDS epidemic, and therefore remember how horrendously a marginalized group was treated for contracting a disease that was "their own fault," say things like this?
It's almost offensive to draw this comparison.

There was no AIDS vaccine that was widely shunned by the community at the time. There is no large contingent in the gay community today shunning PrEP or spreading conspiracy theories to dissuade others from using it.
You’re right about the willful ignorance but there’s another way to take the original comment: once you legitimize saying it’s okay to deny care because the patient could have done something different, where does that stop? If that had been acceptable in the 80s, there are tons of doctors who would have condemned sinners to “their fate”. If that became acceptable now, how long would it be before someone said that they excluded someone for being overweight, drinking too much, not exercising enough, etc.? People already get substandard care for those reasons and I’d be shocked if this same reasoning wasn’t rapidly expanded.
posted by adamsc at 11:21 AM on January 13 [5 favorites]


You're probably right, but that's what we call a slippery slope argument.
posted by escape from the potato planet at 11:38 AM on January 13 [2 favorites]


I can't speak to Australia, but I know many folks posting here are in the US, and there are people in our country who are unvaccinated not because of misinformation but because they literally cannot afford to miss a shift or day at work, and they know that the vaccine response can potentially take someone out for a couple of days. Sure there's a lot you could argue with the logic there, but people are just trying to get by and society has failed its end of the bargain in not giving everyone what they need to make vaccination a slam-dunk for people with the greatest economic precarity.

Not to say that these people don't exist at all -- in a country of hundreds of millions of people there's everybody -- but the US Census Bureau's most recent Household Pulse Survey asked people who weren't vaccinated or didn't "definitely" plan on getting a vaccination to give as many answers as they wanted as to why they weren't getting a vaccine; "It's hard for me to get a COVID-19 vaccine" was one of the least common answers given; under 2% of the unvaccinated gave this as a reason. There were 13 unvaccinated people who answered that "I don't think that COVID-19 is that big of a threat" for every one who reported it was hard to get vaccinated.
posted by Superilla at 11:49 AM on January 13 [24 favorites]


mcphron, "
I think one thing that needs to be addressed is why people don't trust the vaccines. There's enough people out there gullible or stupid enough to believe it causes autism in kids, or to listen to the fuckhead brigade like Alex Jones and Dr. Oz. But what makes it so compelling to them? Is it the "well, there is a reason" for something that doesn't make sense? Do they have some kind of inherent contrarianism which causes a deep skepticism in them? Is it a series of pharmaceutical companies being lying assholes (looking at Purdue and their work with the current opioid epidemic they caused by saying 'it's totally not going to cause addiction!'), or times the government said something was perfectly safe only to have people's jaws fall off later?

Is it a combination of some or all of these? And how can we address it properly to fix this? Other than a time machine that I can go back in time and drop an anvil on Andrew Wakefield at his medical school graduation, to start off."

You're covering a lot of it, but I think people's personal experience with medical incompetence is at least as important as historical and demographic-scale problems.
posted by Nancy Lebovitz at 12:03 PM on January 13 [1 favorite]


People already get substandard care for those reasons

Perhaps the gap between substandard care over doctors being judgmental and triaging care over an active disinformation campaign during a pandemic, forcing decisions about who lives and who dies, is vast enough that it is probably not a useful analogy.
posted by They sucked his brains out! at 12:19 PM on January 13 [1 favorite]


Sometimes I see Herman Cain Award recipients, who have been members of the US military, had first-hand experiences with required vaccinations and government bureaucracy / incompetence, who reasoning is "I don't trust the government to do this correctly"; and I'm actually a bit empathetic. Certainly more than the conspiracy fearmongers.
posted by meowzilla at 12:19 PM on January 13 [1 favorite]


that's what we call a slippery slope argument

No, it's not. Being very direct, it's a "how you can possibly be so unbelievably naive as to think that authorizing withholding care of one group for its perceived moral deficiencies would never be applied to other groups with perceived moral deficiencies when in our living memory we have seen marginalized groups unfairly blamed for a devastating illness in their ranks, and the search for treatments for that illness downplayed because of that marginalization and blame?"

Like, this aspect, at least, isn't at all hard or complicated, folks. If you authorized doctors not to "expend valuable medical resources" on those who "are to blame for their own illnesses," gay people with AIDS (and certain other groups) would absolutely, 100%, have had treatment withheld all over the country in the 80s and early 90s. On a small scale directly, and on a national scale indirectly, that actually did happen. (Just generally not with official imprimatur.)
posted by praemunire at 12:19 PM on January 13 [10 favorites]


And if you think fat people, especially fat people with another marginalized identity, aren't already blamed for their own illnesses and undertreated, and thus couldn't possibly be downgraded in priority under triage when obesity is alleged to affect outcomes, well, there's a whole continent of suffering out there for you to discover.
posted by praemunire at 12:22 PM on January 13 [13 favorites]



Not to say that these people don't exist at all -- in a country of hundreds of millions of people there's everybody -- but the US Census Bureau's most recent Household Pulse Survey asked people who weren't vaccinated or didn't "definitely" plan on getting a vaccination to give as many answers as they wanted as to why they weren't getting a vaccine; "It's hard for me to get a COVID-19 vaccine" was one of the least common answers given; under 2% of the unvaccinated gave this as a reason. There were 13 unvaccinated people who answered that "I don't think that COVID-19 is that big of a threat" for every one who reported it was hard to get vaccinated.


Hrm? Maybe I'm missing something, but I'm looking at the Week 40 data table and out of 799,075 people, 100,325 said "Hard for me to get a vaccine". Also, these additional responses seem equally likely to be the one someone might select for the situation I described: "Concerned about possible side effects" (569,971 people) and "Concerned about the costs" (107,043). And even yet, with due respect, I think a 20-minute online survey with no incentive is going to critically lack participation on the part of people in this specific situation.
posted by dusty potato at 12:27 PM on January 13 [3 favorites]


(Moreover, I'm not in a position to make any claims about how large a proportion of unvaccinated people this demographic is, just that they're real and they matter and they'd be collateral in any imagined policy based on a fantasy of revenge against unvaccinated people.)
posted by dusty potato at 12:30 PM on January 13 [8 favorites]


As pointed out upthread - MOST people who are in the hospital are there through a combination of bad luck and personal behavior 'choices'. I think what we have to be much more honest about in this world is that our 'choices' are deeply influenced by environmental factors and influences which we don't control. And social interventions such as vaccine rollouts and education have to be structurally focused to take that into account, instead of just shaming people who are against being vaccinated.

Also as someone who gives COVID vaccines I can attest that a huge driver of vaccine hesitancy is simply fear of needles and not deep conspiracy thinking. Most hesitant people respond well to interventions like workplace mandates.
posted by latkes at 12:36 PM on January 13 [13 favorites]


It's almost offensive to draw this comparison.

As a gay the comparison doesn't make sense to me. Being unvaccinated is effectively a comorbidity in itself, so people can and should be triaged based on that. This has nothing to do with a person's "choice" or intentions to be unvaccinated.

I actually think the doctor was wrong. The fact that they can call the shots like that rather than use a clear rubric for this was odd.
posted by polymodus at 12:54 PM on January 13 [1 favorite]


It also feels like the argument is “evil people did bad things in the past, so we have to continue to let them do bad things because any tool that might be used to stop them might also be used by them”.

Instead, let’s make sure they don’t even need the tools. Sigh.
posted by notoriety public at 12:58 PM on January 13 [3 favorites]


I think one thing that needs to be addressed is why people don't trust the vaccines. There's enough people out there gullible or stupid enough to believe it causes autism in kids, or to listen to the fuckhead brigade like Alex Jones and Dr. Oz. But what makes it so compelling to them?

Five tactics used to spread vaccine misinformation in the wellness community, and why they work
posted by Lexica at 1:00 PM on January 13 [1 favorite]


Hearsay but last night on TWiV they mentioned a young doctor or nurse who went to a small village of unvaxxed people, set up a popup vaccination site, patiently answered anyone's questions and concerns that they had, and got the entire village vaccinated. So different approaches really do help.
posted by polymodus at 1:04 PM on January 13 [5 favorites]


evil people did bad things in the past, so we have to continue to let them do bad things because any tool that might be used to stop them might also be used by them”.

Are you genuinely under the impression that the norms of who is worthy and who is unworthy of receiving limited medical resources will always remain appropriate, or even under democratic (small 'd') control?

If you are cool with us making it an official principle that "we will formally triage based on vax status because unvaxed people brought it on themselves," then you had better be cool with "we will formally triage based on whether the person has kept good control of their blood pressure, because that increases their risk of bad outcomes and they could've kept it under control, so they brought it on themselves" and "we will formally triage based on whether the person has avoided type 2 diabetes, because that increases their risk of bad outcomes and they could've avoided diabetes by working out more and eating better, so they brought it on themselves." This is not some parade of horribles. These are things a second Trump administration would have no problem with--and all the better that such rules would disproportionately favor wealthy white people, who have better-controlled blood pressure and less type 2 diabetes overall.

Like, maybe you're a white dude who has never, ever had to seriously consider the possibility of being excluded from some necessary protection of society because you're considered unworthy of it, but this is a thing that happens.

(Also, considering withholding care from sick people as a way to "stop evil people" from doing....something bad?...is a viewpoint that I won't characterize out loud for fear of getting benched.)
posted by praemunire at 1:21 PM on January 13 [5 favorites]


In a triage situations when resources are scarce don’t treat patients based on moral judgements of who is the most deserving, treat them based on who has the best chances of survival.
Not by any means a medical professional, but this is my understanding of how triage works in this scenario. It's horrible to contemplate, but a person definitely dying in the near future no matter what must be considered a lower priority than someone who has a good chance of living if they get that treatment (even if that means taking away from them treatment already underway). I don't see it fair to make this simply a 'first in best dressed' scenario, because priorities are fluid depending on how many people need the care vs capacity to provide it at that point in time.

I can absolutely imagine that, where ICU resources are under stress, a person coming in on a Wednesday morning has a better chance of getting a bed than the same person coming in on a Saturday night, because there are different demands. Much of that demand is going to be because of people making stupid decisions. Does making stupid decisions make someone less deserving of health care? If so, pretty much all of us are undeserving because we all make stupid decisions, but a pandemic means there is far more demand and availability hasn't been increased enough to cope, but people go right on making stupid decisions regardless, which shouldn't surprise anyone.

In this particular situation, what makes me angry is that we are over two years into a pandemic with no end in sight and we still don't have sufficient resources to treat the easily predictable demand. People want to blame doctors for making decisions they are forced to make because politicians refuse to provide the funding to increase health care capacity, while shovelling money out to big companies that are making record profits. Don't blame the doctors for making the decision - blame the politicians who are forcing them to make the decisions!

I am absolutely 100% pro-vaccine (vaccinated and boosted, instrumental in having unvaccinated people banned from our workplace entirely) and strongly in favour of protective measures such as masks, but I can understand why people have opposing views (while hating them for their ignorance and selfishness) when the government could boost the communication on science and evidence-based facts, but choose not to do so. When governments visibly make decisions that favour 'the economy' over the lives of people because there's an election coming up, people understandably form a view that money is more important than people or that COVID can't be that bad or the government would do more about it. Yes, people make a choice to believe lies and often do so because it aligns with some level of selfishness in the first place. Bu they make those choices based on communication from bad actors who could be, but are not sufficiently opposed by the very people elected to protect the community from bad actors.
posted by dg at 1:32 PM on January 13 [9 favorites]


Hrm? Maybe I'm missing something, but I'm looking at the Week 40 data table and out of 799,075 people, 100,325 said "Hard for me to get a vaccine". Also, these additional responses seem equally likely to be the one someone might select for the situation I described: "Concerned about possible side effects" (569,971 people) and "Concerned about the costs" (107,043). And even yet, with due respect, I think a 20-minute online survey with no incentive is going to critically lack participation on the part of people in this specific situation.

You are looking at the wrong table. You have the standard error table (health6a_se_week40.xlsx); that is, the survey's estimates of uncertainty. The 799,075 is the standard error around the total estimate (health6a_week40.xlsx) of 36,609,300 people total. "Hard to get a vaccine" is 660,507 people (with the standard error of 100,325; that is, the best estimate is 660K; there's about a 2/3 chance the true value is between 560 and 760K, and a 95% chance that the true value is 460-860K). Similarly, "concerned about side effects" is 19,444,796 people (the most common answer) and "concerned about the costs" is 651,939 people. (From the microdata, about 100K answered both "it's hard" and "the costs".)

No data source is perfect, of course -- although a 60,000 person survey from the Census Bureau is better than most. Marginalized people are often underrepresented in surveys, but let's be absolutely crazy and say that only 20% of people who didn't get a vaccine because it was hard answered the survey (but that 100% of the people who didn't get a vaccine because they "didn't trust the government" did answer this government survey). At that point, it's still under 10% of the unvaccinated who didn't get it because they faced difficulties. The point I'm making is that the mental model that was valid last summer of plenty of people who weren't vaccinated because they couldn't get time off their job is no longer valid; most of the people who aren't vaccinated after six months of free availability are people who have no intention of ever getting vaccinated. (51.5% of unvaccinated people will "definitely NOT get a vaccine", another 20.1% will "probably NOT", while only 5.2% "definitely will" and 7.0% "probably will".)

(Moreover, I'm not in a position to make any claims about how large a proportion of unvaccinated people this demographic is, just that they're real and they matter and they'd be collateral in any imagined policy based on a fantasy of revenge against unvaccinated people.)

Your second point -- that a small proportion of people are still people and deserving of respect and consideration is an important one. That moral truth doesn't need to overwrite the data.
posted by Superilla at 1:38 PM on January 13 [4 favorites]


Hey folks I’m wallowing in despair today and also trying not to be consumed by the endless pit of rage at stupid people so I’m going to share the one thing I’ve heard recently that gave me a slightly mildly tiny bit of different perspective.

Yes, people who refuse to get the vaccine because they listen to Alex Jones or Fox News are making the wrong decision. It is a stupid selfish harmful decision.

And yet — if you look at how human beings make decisions — we are bad at that. Human beings are not rational. 99 times out of 100 we are not in control of our own lives, we are reacting blindly to the inputs we receive, in this case highly manipulative media designed by super-powerful oligarchies to fool us.

Free will is an illusion and we are products of our environments.
posted by bq at 1:54 PM on January 13 [4 favorites]


Thanks, yikes, I was super on the wrong track with that data source!
posted by dusty potato at 2:01 PM on January 13 [1 favorite]


This may get it's own front page post, but since we're here:

Supreme Court Blocks Biden’s Virus Mandate for Large Employers (NYTimes)

..."But the court allowed a more modest mandate requiring health care workers at facilities receiving federal money to be vaccinated."
posted by The Pluto Gangsta at 2:19 PM on January 13 [2 favorites]


I think one thing that needs to be addressed is why people don't trust the vaccines. There's enough people out there gullible or stupid enough to believe it causes autism in kids, or to listen to the fuckhead brigade like Alex Jones and Dr. Oz. But what makes it so compelling to them? Is it the "well, there is a reason" for something that doesn't make sense? Do they have some kind of inherent contrarianism which causes a deep skepticism in them?

Under the circumstances, a person with several risk factors for dying of COVID, but who did not trust vaccination, would be pretty interested in updating a will, double-checking life insurance arrangements, planning a funeral, arranging for a living power of attorney, and so on. Just as a precaution for the sake of the people he or she might leave behind.

But the social media stories that I've seen don't feature any of that stuff. Nobody is proclaiming that they're proudly un-vaccinated and besides they've got their end-of-life arrangements all in order, so why worry? The message is usually focused in an entirely different direction: I'm un-vaccinated and I imagine myself to be very tough, very healthy, and/or very determined, so I'm not concerned because I don't believe the virus can harm me.

Indeed, the icing on the cake in so many of these stories is that they die in such messy circumstances that internet enabled begging ensues to pay medical bills and funeral expenses.

I'm inclined to be skeptical that trust in the vaccines are really the issue, regardless of some of the things they say. It may be more accurate to say that the obstinately un-vaccinated are refusing to make a considered choice at all, pushing acceptance of the issue's reality out of their minds, and telling themselves they will not be effected.

Those are tendencies and skills that also seem to be useful and necessary in a conspicuously overlapping-with-the-un-vaccinated political ideology today.
posted by Western Infidels at 2:49 PM on January 13 [11 favorites]


Biden should immediately play the national security card and mandate the vaccine for all citizens on grounds of needing to protect us from this foreign enemy virus. Let’s see the conservative twist into knots over this.
posted by interogative mood at 2:57 PM on January 13 [2 favorites]


To circle back and be clear, I'm not advocating denying care to unvaccinated people. The ethics are difficult and frustrating, but all the same, pretty clear.

I just think it's kind of disgusting to evoke the AIDS crisis, of all things. It reminds me of how folks on the right will evoke book burning in response to being "censored," when the books burned by Nazis were those of minorities, sexologists, etc. The folks who are still oppressed by the right wing.

Yes, some of the unvaccinated are the victims of a misinformation campaign. But many of them are our would-be oppressors. People who intentionally, or at least negligently got Covid because they were convinced of their superiority or at least, their priority in receiving healthcare over minorities.

Many of these are the same folks who laughed at gay men dying in the 1980s, like literally the same folks. They're evil, awful people, who yes, still deserve healthcare. I just don't love the analogy being drawn.
posted by explosion at 3:03 PM on January 13 [15 favorites]


How can people who remember the AIDS epidemic, and therefore remember how horrendously a marginalized group was treated for contracting a disease that was "their own fault," say things like this?


With all due respect? It is not "almost offensive to make this comparison" (pace another comment), it's deeply offensive. My great-uncle died of AIDS in 1985; it's fairly certain that he contracted it well before anyone knew what AIDS was (which was likely the case for many thousands of other AIDS patients). He also wasn't going out in public and jacking off into people's faces or bleeding on them (unlike your unmasked, anti-vax walking covid vectors).
posted by Pseudonymous Cognomen at 3:20 PM on January 13 [17 favorites]


I'm gay so I find the argument somewhat offensive, but more importantly it is rationally incomplete. People acting within reasonable bounds of ignorance and social behavior, people being in actual minority groups, do deserve fair treatment and protections. But the politicized and tragedy of the commons effect of this antivaccination phenomenon is distinctly different from being gay, at risk of HIV, or having blood pressure/diabetes/obesity. Those are marginalized and minoritized groups, while people who are antivaxxers aren't a marginalized group. So if your moral theory equates the two as if the situations are morally indistinguishable then your argument fails to capture the moral harm that antivaxxers impose on the public.
posted by polymodus at 3:35 PM on January 13 [16 favorites]


Biden should immediately play the national security card and mandate the vaccine for all citizens on grounds of needing to protect us from this foreign enemy virus. Let’s see the conservative twist into knots over this.

Based on today’s SCOTUS ruling, I doubt such a move would legally survive any longer than it takes the ink to dry on Biden’s signature.
posted by Thorzdad at 3:40 PM on January 13 [1 favorite]


This thread by a fellow nurse about the problems with denying care to antivaxxers speaks to me deeply as someone whose work is being FUCKED UP REAL BAD by omicron right now.

Tl;dr: It wouldn’t actually help nurses or doctors, we’re traumatized enough from moral injury as in, and in the US specifically setting a precedent for any exceptions to EMTALA is not a road you want to go down.
posted by I am a Sock, I am an Island at 3:45 PM on January 13 [17 favorites]


But what makes it so compelling to them?

Seemingly irrational decisons are always motivated by factors that are just not obvious to us (or the decision makers themselves). I'd wager a huge segment of the anti-vax population is simply filled with dread about needles, absolutely terrified by needles and when they land upon a narrative and rationalization that lets them say "actually it's an untested experiment that makes you sterile" or whatever, that gives them a way of explaining their aversion without admitting to everyone (and themselves) that in fact they just have a good old fashioned phobia about needles, they run with it.

I'm deeply phobic about having surgery and I've turned it into a little hobby to find all the evidence I can against surgical intervention for a variety of maladies I don't have because I know at heart I'm utterly terrified of someone putting the knife to me, being unconscious while they open you up. Luckily it's not been a real concern for me, but I know if the time comes that I need a life saving surgical intervention, I'll start bargaining with all sorts of "facts" and "reasons" before I (likely) give in. We shouldn't underestimate the importance of unconscious dreads and fears.
posted by dis_integration at 3:52 PM on January 13 [3 favorites]


I'd wager a huge segment of the anti-vax population is simply filled with dread about needles, absolutely terrified by needles and when they land upon a narrative and rationalization that lets them say "actually it's an untested experiment that makes you sterile" or whatever, that gives them a way of explaining their aversion without admitting to everyone (and themselves) that in fact they just have a good old fashioned phobia about needles, they run with it.
Also that having done so means that at any point in the future it’s easier to stick with it because otherwise you have to admit that your earlier position was wrong. This is especially true if they have been confrontational about it, justifying the rudeness by the magnitude of whatever excuses they picked.
posted by adamsc at 5:11 PM on January 13 [5 favorites]


I keep hearing this needle-phobia explanation, and…sure, a few of them, I guess.

Maybe I’d buy that it explained a substantial proportion of “hesitancy” if fewer of the anti-vax plague-accelerationists I know personally didn’t have at least one piercing, tattoo, a history of self-administering insulin or fertility drug injections, or an apparent willingness to get Botox treatments.
posted by armeowda at 6:40 PM on January 13 [9 favorites]


It is a very surprising reality that some of the most tattooed people are some of the most injection phobic! My coworker was just commenting on this today - while giving COVID vaccines. She made the comment while giving someone (who was very tattooed) her very first COVID vaccine dose today (woo!). Why did this person finally choose to get vaccinated today? Her job required it.

Workplace mandates work! So fucking mad at this dumb-ass supreme court - Court packing folks - we need it yesterday!
posted by latkes at 8:00 PM on January 13 [14 favorites]


So, as much as there are grim ethical problems with casting judgement on antivaxxers and letting it affect the care they receive, I think we're ignoring the practical ways in which this case differs from the early days of AIDS.

In the early 80's, once GRID/AIDS was a known diagnosis, what happened was if you showed early signs of it, the doctors gave you the bad news, told you to live your life while you could, and you did, and then when you got sick, you'd be admitted to a regular hospital bed for palliative care. It was not especially common for AIDS patients to show up at the ER, and at no point in the epidemic did AIDS patients overwhelm an ER or even the regular hospital wards. It was also obviously blood borne pretty early on, so the risk to health care workers came from handling sharps (which was also at the time when the state of the art for handling sharps improved greatly.)

Compare to this case. It's not just a matter of triaging which patients get medical care. Covid-19 carries serious risk for the doctors and nurses, and they cannot ignore the risk. The vaccinated covid-19 breakthrough case is a patient who has already taken steps to protect the medical workers whose help he's requesting, while the unvaccinated patient has already shown cavalier disregard for them. Nurses are human. They can't completely block out this knowledge. And we can't either. That vaccinated patient is (most likely) in medical distress because covid is affecting his body in ways that don't affect how much virus he is shedding out of his lungs. (I'm conjecturing here, but if you go to hospital because covid exacerbated some morbidity with your liver, I doubt that would mean shedding more out your lungs, and if you got the shots, you're shedding less. ) So admitting him instead of the unvaccinated patient means more safety for the hospital staff, which means more patients saved next week when those staffers are still covid-19 negative.
posted by ocschwar at 7:33 PM on January 14 [9 favorites]


Update on that transplant angle, from Boston.
posted by saladin at 8:20 AM on January 25 [2 favorites]


« Older "Ted Nugent remembers accidentally shooting a fan...   |   January 13th... Mixed Peppers Newer »


This thread has been archived and is closed to new comments