Commentary: Can you be denied a kidney because you’re not vaccinated against COVID-19?
Vaccination improves clinical outcomes of organ donation, but vaccine requirements for transplants might lead us down a slippery slope of inequality, says bioethicist Michael Wee.
DURHAM, United Kingdom: Last month, a health system in Colorado, United States, told a woman she’d be removed from the kidney transplant waitlist, if she refused to get a COVID-19 vaccine, according to a New York Times story.
As transplant recipients take immunosuppressing drugs to prevent rejection of the donor organ, they are at higher risk of severe, life-threatening COVID-19. Some countries, including Singapore, recommend such patients receive a three-dose vaccine regime, instead of two.
The news provoked strong reactions: Is this a legitimate way to decide who gets an organ?
Or unjust discrimination, since vaccination should be a free choice? Would more medical services be made conditional on COVID-19 vaccination status?
HEALTHCARE RESOURCES: ALWAYS SCARCE?
The idea that we must pick and choose who receives a kidney may seem unpalatable at first. But this isn’t the first time the pandemic has made us face up to the difficulties of allocating finite healthcare resources.
Not too long ago, the idea of countries running out of intensive care unit (ICU) beds and ventilators, and doctors having to decide who gets treated, seemed unthinkable.
That changed when COVID-19 first hit Italy. The surge in infections put unprecedented pressure on healthcare resources, shining a global spotlight on triage: How should doctors decide who to save in the event ICUs could not cope?
Ordinarily, hospitals prioritise patients based on urgency and need. This is equitable, respectful of everyone’s equal worth and allows medicine to do its job of saving lives without favour or discrimination.
This is why going to accident and emergency department with a sprained foot will keep you in the waiting room longer than someone wheeled in unconscious with a stroke.
But in the “nightmare scenario” facing Italian doctors, many ethicists concurred that patients could instead be prioritised by their likely ability to benefit from ventilator treatment, which could be influenced by factors such as age and underlying conditions.
When we cannot save everyone, we have to find a way to maximise clinical outcomes with scarce resources.
We can draw an analogy with the kidney transplant case. Donor organs are probably one of the scarcest medical resources in the developed world, relative to need.
Waiting lists are often long – in Singapore, the average waiting time for a kidney transplant is nine years, according to the Ministry of Health.
Furthermore, transplantation is a major surgical procedure with risks, such as organ rejection. Hence, we could think of organ allocation as a special case, where a patient’s ability to benefit relative to others should be considered as one criterion among others.
The US and the UK practise “longevity matching”, for example. Younger patients, who generally live longer with better clinical outcomes, are prioritised for younger donor organs, which usually last longer.
Seen in this light, COVID-19 vaccination status would be a legitimate aspect of assessing the ability to benefit, since transplant patients have a significantly higher mortality rate if infected with coronavirus.
It’s also consistent if other vaccinations have already been required for receiving donor organs, as is the case in the Colorado health system in question.
How have hospitals been dealing with the COVID-19 surge in Singapore? Listen to two doctors discuss the situation on CNA's Heart of the Matter:
Maximising clinical outcomes with scarce resources therefore presents a compelling case for making transplants conditional on COVID-19 vaccination, among other health requirements.
FAIR TREATMENT OF UNVACCINATED INDIVIUALS
But there is another side to the story which shouldn’t be forgotten: Equality. If we think primarily in terms of efficiency and outcomes in a crisis, will certain vulnerable groups in our community be left behind?
While many were sympathetic towards Italian doctors when they had to make some hard choices, some thought things went too far when an Italian medical institute suggested imposing an age limit on ICU admission.
This would be a blunt approach, reducing patients to just one characteristic, without individual assessment of their ability to benefit.
This concern was particularly pronounced in the UK when care homes were found to have placed blanket “Do Not Resuscitate” orders on whole groups of patients without individual assessment or consultation. Many feared they would be sacrificed to avoid straining healthcare resources.
Is vaccination status a similarly blunt criterion for triage, with the unvaccinated deemed “not worth saving”?
In theory, transplants can be deemed a special case because of scarcity, where we demand stricter requirements for triage.
But in practice one also has to consider the wider social context in which unvaccinated patients would be denied potentially life-saving treatment. A well-intentioned desire to maximise resources can easily segue into neglect of a whole group of patients.
Transplants might well lead us down a slippery slope where other medical services are also denied to unvaccinated citizens.
For instance, there is already discussion among US doctors about refusing to treat unvaccinated COVID-19 patients, because it is their own fault for not protecting themselves.
This may be the result of hardening attitudes towards the unvaccinated, where vaccination status becomes a quick binary framework for understanding others: “Vaccinated” and “unvaccinated” become synonymous with “responsible” and “irresponsible”, “safe” and “unsafe”, “informed” and “misinformed”.
This, of course, is overly simplistic. A vaccinated person may also behave irresponsibly, by flouting restrictions and taking liberties in socialising in large groups, and even end up with COVID-19.
But once we start evaluating patients’ moral choices, where do we draw the line?
We need, therefore, to maintain the prevailing principle that in healthcare we do not deprioritise patients based on moral choices. This is important for any society striving for justice and equity.
Someone admitted to hospital due to binge drinking is not given a lower priority than other patients simply because their condition is self-induced. Neither do we rethink access to diabetes care based on assumptions about an obese person’s lifestyle choices.
Vaccination-based triage could embolden those intolerant of unvaccinated people, particularly where there are widespread restrictions in society. Many US companies already require employees to be vaccinated, while in Singapore, unvaccinated individuals face stricter rules for accessing shopping malls and the workplace.
Further differentiation in how unvaccinated citizens are treated may cause further intolerance and neglect. It would, arguably, be a disproportionate penalty for what is still a free choice.
DE-ESCALATING VACCINE TENSION
Hence, the question of making organ transplants conditional on COVID-19 vaccination status is a matter requiring prudent judgement and careful weighing of both sides.
While the desire to maximise clinical outcomes with limited donor organs is good, we cannot escape the wider societal context that COVID-19 vaccines are still a highly politically-charged matter.
Vaccination status is taking a toll on our families and friendships.
The move to make certain civic freedoms dependent on an individual’s healthcare choice can breed resentment among the unvaccinated and generate false expectations among others regarding the purpose of vaccines.
We should seek to de-escalate social friction surrounding vaccination status by reassessing our perspective on vaccines. For example, we know now that vaccines confer good protection against severe illness. But protection against infection itself, and against being able to transmit the virus, is not as strong as hoped, in part due to the Delta variant.
This means mass vaccination, though still an indispensable public health tool, will not snuff out the virus completely. Many of us, even if vaccinated, will still have a good chance of catching COVID-19 over time.
The less we see vaccines as a silver bullet for ending the pandemic, the less harshly we will view those who are unvaccinated by choice. COVID-19 vaccines will become more normalised in social discourse and less contentious because they will not carry the weight of exaggerated expectations.
In such a case, it might then be reasonable to introduce COVID-19 vaccines as a requirement in specific medical scenarios with scarce medical resources, like donor organs.
But to do so now may lead to unintended effects of increasing inequality. Amid the damage COVID-19 has already had to mental health and livelihoods, that is something we should be wary of.
Michael Wee is a Singaporean philosopher and bioethicist based in the UK. He is a philosophy tutor at Durham University and a member of the Holy See’s bioethics advisory body, the Pontifical Academy for Life. He writes in a personal capacity.