A LOOMING ETHICAL DILEMMA

We may soon discover how far society is willing to go to accommodate a segment of the population who, by refusing to get vaccinated, willingly light the spark of the next viral conflagration

Clinical professor of medicine and endocrinology at the University of Calgary

There is a palpable sense of relief in the Canadian air these days as COVID-19 case counts drop to levels so low that public-health officials have stopped the daily news briefings. Reports of hospitalizations now appear in the middle of the day’s stories and local governments make rapid moves toward an “un-lockdown.” But in south of the border and now in Canada as well, case counts are rising once more, in the summertime no less. The U.S. is also seeing a rise of hospitalizations, almost exclusively among people who are unvaccinated.

While politicians rush to open the doors of social economy and interaction, health workers and officials are quietly talking about the possibility of an impending fourth wave of COVID-19 hospitalizations. Should that come to pass, however, this wave in Canada will be different than the previous ones: This will be the chosen wave of COVID-19.

For sure, lack of access to vaccination is a continuing problem and one that must be solved by publichealth officials. Thankfully, we are regularly seeing new and creative initiatives from our leaders, who are finding new ways to reach underserved or “hidden” populations. Their efforts must be supported and encouraged.

With access to vaccines that prevent 99 per cent of hospitalizations, the balance of power in this pandemic has shifted from virus to host: The tools to eradicate serious complications are on offer at nearly every local pharmacy. As a country, we face a unique challenge from those for whom access to vaccination is not the problem: A personal choice to decline vaccination is the modus operandi.

The freedom of self-determination is one of the most attractive features of our culture and is likely a major factor in terms of what draws people to want to migrate to Canada and similar countries. We respect people’s right to chart their own course in life and, in a particularly admirable fashion, we are gladly willing to provide a measure of support to those whose course in life takes a wrong turn.

However, the COVID-19 pandemic is now raising a novel ethical question within the old debate pertaining to the balance of public and private responsibility. The question is, exactly how far is our society willing to go to accommodate the segment of the population who, by their choice, will light the spark of the next viral conflagration?

This is not the first time we have had to contemplate the blurry line between public versus private liability in health care. It is an indisputable fact that smoking, alcohol abuse, drug use and other self-destructive behaviours are responsible for a sizable chunk of the morbidity that ends up at the door of the health care system. In the past, occasional people have raised eyebrows with suggestions that smoking cessation be a prerequisite for coronary bypass surgery.

Similarly, alcohol abstinence has been a mandatory requirement for anyone who needs a liver transplant, but even that is now under scrutiny. The reason for such criteria is likely based in the long-standing belief that alcoholism is a personal choice and, therefore, high-cost life-saving measures such as transplantation cannot be offered (on the public dime) to those whose personal, and sometimes continuing, choice has incurred the massive public expense.

However, this is becoming ethically questionable as we increasingly recognize the medical nature of addiction and the limited role of personal choice in such outcomes. This is the same reason that no one seriously considers a mandatory quitsmoking policy for lung-cancer treatments. There is a certain amount of broad social culpability that underlies the social and psychological ills among us and we accept the need to cover the costs of the consequences even as we work to address the root causes.

So, in the face of a possible fourth wave, does continued vaccine refusal represent the same thing as drug addiction in terms of powerlessness? Is there a biomedical explanation analogous to addiction that prevents people from getting vaccinated?

And if not, one wonders if we are just as willing to bear the public expense of those who suffer the consequences of their free choice to decline the jab. In the case of coronavirus infection, this means even more than just direct health care costs – it includes the shared costs of a return to fourth-wave social restrictions as well. The appetite for a vaccine passport as entry ticket to normal social venues seems to be small. But what about health care?

I’ve already heard some people quietly propose a low-cost, separate COVID-19 asylum for the unvaccinated unwell. Such a position seems unthinkable in Canada. But therein lies the ethical problem: When individual free choices affect both the public purse and the prospect of free choices among others, there is a high chance that division and bitterness will arise among the payers – in this case, those who chose to get vaccinated, even though the risk of COVID-19 death to them personally may have been very small.

We will therefore have to face this looming ethical quandary: What is the more ethical approach – to preserve self-determination at all costs, or to take steps to avoid social disharmony (not to mention mounting costs) over situations where the notion of isolated, individual risk tolerance is demonstrably illusory?

This is central to the current coronavirus vaccine situation and nothing short of near-total population vaccination will relieve us of the impending dilemma. Therefore, there are lots of reasons to get vaccinated, but I find the most compelling of all is that it is simply a way of saying, “I care about you.” We get vaccinated in some respects for our own safety but, in larger measure, for the safety and prosperity of our families, neighbours and, yes, even the people out there that we don’t know personally.

Therefore, I’d like to draw upon this to come up with a very Canadian reason to get vaccinated, for those who have not yet done so. I’m not going to try to convince you (again) of the medical safety or necessity, I’m not going to be drawn into a debate about political ideology and personal rights, and I’m not going to waste more breath debunking conspiracy theories. I don’t want this to turn into a shame game or a twotiered vaccine caste system and certainly don’t want to have to entertain the possibility of taking away your free choice to get or not get vaccinated.

Instead, my Canadian approach is this: I’m just going to say please, be reasonable. We don’t need more anger and bitterness to divide us. We don’t want to divert resources from those who are suffering from other medical disorders. We don’t want to ask our children to sacrifice their education to support the free choices of a small number of otherwise responsible adults.

For all of us and for our continued Canadian way of living together, please join us in the vaccination effort. Please. Think about it as acting on the famous Canadian expression, “Roll up your sleeve to win.” Let’s choose to stop the fourth wave and avoid the beckoning ethical quagmire altogether.

What is the more ethical approach – to preserve self-determination at all costs, or to take steps to avoid social disharmony (not to mention mounting costs) over situations where the notion of isolated, individual risk tolerance is demonstrably illusory?