Patient responsibilities and ethical behavior in an age of medical debate

Should someone who chooses not to vaccinate against COVID-19 — and as a result becomes ill from the virus — be treated any differently, when it comes to medical care, in terms of priorities and the attention afforded to such a person?

This issue must be analyzed independent of the context of the coronavirus, which carries with it distracting political and social pressures. One of the essential values of medical ethics is that analysis of any specific issue must be carefully separate from whatever other causes may have brought a patient to the given place and time. Our ethical decision therefore must rather be based solely on the medical factors at play and four key general ethical principles:

The first is “all patients are equal.” That is, when people are sick, they are to be treated in accord with the conditions of the present circumstances, and not any transgressions or crimes that may have tainted their characters in the past. As challenging as this might be, even if the person is guilty of acts that may anger or repulse us, we cannot be swayed by our own sensitivities while we analyze one’s right to medical care.

The second value is that patients are not to be blamed for their medical conditions. For many cases, we have no definitive way to determine whether the medical issue being treated is a direct result of any specific action. Take, for example, the case of the heavy smoker who develops respiratory disease. We surely might assume that the illness is due to the habit, but even in this case, there is a chance that it was genetically pre-ordained, and would have developed had the patient never touched a cigarette.

Third is that every case must be weighed on its own individual merits, for all patients have their own medical and personal histories, which have impact the ethical decision-making process. Issues on an individual level include excess weight or specific environmental factors that could affect one’s medical condition.

Finally, a medical professional cannot and should not be concerned with researching or investigating a patient’s behavior or personality that is not directly related to the patient’s health. The job is to treat the patient solely based on medical parameters. That is, after all, what medical professionals are trained to do.

Beyond these inherent concerns, we must also note the role of empathy. A basic system of human values that are driven by compassion and caring takes precedence over all the other considerations, as they rise to the fore when we see fellow humans in distress. We must do everything possible to avoid creating a scenario where a person in pain (physical or otherwise) is denied the proper medical care because of some external factor.

Nonetheless, some cases are extreme, and demand additional analysis that may lead to different conclusions.

For example, the now classic case of terrorists who were seriously injured while perpetrating an attack against innocents, and whether they should be treated before the victims of the attack, in the event of more severe wounds. Given the practical nature of this question, I have been asked to weigh in on it in the past and, despite my awareness that others disagree, my general response is that anyone who believes the terrorist deserves prioritized treatment has surely lost his or her mind. I maintain that to do so conveys a deeply flawed moral equivalence that must be avoided.

Such a flawed approach comes with a deep social cost. Foremost, it affords the terrorists the perspective that they deserve to be treated equally and to enjoy such a status. It also weakens our levels of deterrence by sending the message that terrorists will be treated with the same level of compassion as that afforded the victims. On another level, given the limited nature of medical resources, the terrorist’s care may well come at the direct expense of the innocents.

Torah and Halacha teach us that free choice is a very basic tenet of Jewish practice, something Maimonides describes as a “pillar” of the Torah. Free choice is a right that cannot be taken away, and also reflects our identities as created in the “image of God” (B’tzelem Elokim). This is to say that, while people have the right to choose, both in areas of interpersonal behavior and those between man and God, they also need to appreciate their responsibility for the choices they make.

Finding a halachic path to measure responsibility is challenging and elusive. Take, for example, the deeply complex issue of pidyon shvuyim, redeeming captives. On a basic level, we know that we have a social responsibility to go to great lengths to return captives. But there are certainly more extreme cases where we need to carefully assess the costs of redeeming a captive. For example, can we “trade” the life of one captive to be redeemed for the freedom of a large number of terrorists? For all that we have the right to choose, there are definite limitations in how we choose, and we must act responsibly in that decision-making process.

This case has implications for our analysis of medical ethics.

We are reminded, of course, of the utmost importance of redeeming captives and the value that we place on human life. But we are also reminded that it is not a clear equivalency and that individuals have the responsibility to act responsibly to avoid entering into a situation where they would be taken captive. And then, at the end of the day, we come back to the fact that when it comes to human life, the original analysis prevails: we don’t take people’s irresponsible actions into account when we do our utmost to see them redeemed.

This ethical compass is what must guide us when it comes to medical decision-making, and specifically when it comes to the care afforded one who contracts COVID-19 after having refused the vaccine. On the one hand, when someone’s life is threatened, we do what is necessary to save that life; each person is therefore fully entitled to comprehensive medical care. On the other hand, we recognize that the public should not have to bear the full burden of mistakes made by an individual. Navigating between these two values leads us to conclude that public healthcare prioritizes the welfare of the well-intentioned patient over the patient who acted irresponsibly. To clarify, this would not and does not mean that we would ever deny care to the irresponsible person. Rather, it simply legitimates asking whether we would perhaps manage their care differently – including in terms of transferring more of the costs to the patient, prioritizing others if there was limited time for appointments, accepting changes in the environment in which they are being treated, etc.

It should be stressed that we must avoid interpreting this analysis as an open door to sanction or punish anyone who acts irresponsibly. Given that people have a basic right to choose means that they should not be punished for making the particular choice. Regarding the current vaccination debate in particular, we fully acknowledge that this is a complex and at times emotional issue, and it needs to be approached with utmost caution. But this analysis should re-enforce the understanding that people bear responsibility for their own decisions. We cannot deny a person his or her individual rights and freedoms; but neither is anyone independent of social responsibilities, as one’s actions can have broader implications for society at large.