After watching footage of an anti-lockdown protest in Michigan, Dominic Sisti, a Penn Medicine medical ethicist, started imagining a disturbing scenario: Suppose he took a rule-following relative who was sick with the coronavirus to the hospital. The relative needed a ventilator, but all the machines were used up by protesters who had refused to wear masks and had attacked public health restrictions meant to protect everyone.
That led to a provocative essay in Harrisburg’s Patriot-News that lends academic weight to an idea that has been making the rounds on social media as anti-maskers have become more visible. Sisti and three fellow bioethicists — Emily Largent of Penn Medicine, Moti Gorin of Colorado State University, and Arthur Caplan at New York University — argued that protesters should voluntarily sign documents saying that they won’t accept scarce medical care if they get sick.
“We’re not arguing that hospitals should refuse to treat people,” Gorin said. “We’re saying that people should put their money where their mouth is.”
The ethicists said their main goal was to make protesters think about the possible consequences of their actions: an increase in serious illness that could affect them, their families, and others in their communities. These theoretical documents would not be binding unless protesters treated them as advance directives and took them to the hospital. Doctors are bound to treat everyone, the ethicists said. They could not ethically use political activities or risky behavior to triage patients who needed care.
“Doctors have a duty to treat anyone and everyone, even enemy combatants,” Sisti said.
When resources are scarce, however, health systems may have to establish guidelines for who can get care.
People who have protested Pennsylvania’s lock-down orders scoffed at the idea that they should get any less medical treatment.
Christopher Dorr, a professional gun-rights activist who lives outside Columbus, Ohio, said he has organized a handful of protests in Columbus and Harrisburg. Asked whether he wore a mask at rallies, he said he had a medical condition that prevents that: “It’s called freedom.”
He said most protesters just want to get back to work. Although everyone is being asked to sacrifice for the common good, the economic pain has not been distributed evenly. He said he thinks the overwhelming majority of Pennsylvanians would agree to lower priority for a ventilator if it meant they were “exempted from the tyrannical precedent being set and exempted from the terrible economic destruction that is being foisted on so many millions of Pennsylvanians right now as the result of Gov. Wolf’s draconian and overreaching actions.”
Russ Diamond, a Republican state legislator who represents part of Lebanon County, has attended protests and supported local commissioners who went against Gov. Tom Wolf’s wishes and moved the county from red to yellow restrictions. He wears a mask in public only if he’s within six feet of someone. He still shakes hands and hugs. “I believe I have already had COVID-19.” He was sick in late February after a staffer returned from China.
He said that ventilators have not been scarce and that it’s an “anathema to liberty” to say that “healthy people are sick and dangerous." He bristled at the idea of withholding care based on health choices. What about people who eat too much? he wondered. “What they’re suggesting is rationing of health care. They are traveling down a dangerous, dangerous pathway. ...
“These ethicists ought to get out of whatever egghead bunker they’re living in. We don’t do that in America.”
Largent said she supports giving more help to people who are suffering financially. “I pay taxes and would be delighted to see the state and federal governments direct significantly more money than they already have to people who are unemployed as well as to small-business owners,” she said. “Providing financial support to sustain people during these public health measures is a kind of social solidarity akin to wearing a mask and social distancing.”
Historically, Caplan said, even the most ardent proponents of individual liberty did not imagine that it came unfettered by responsibilities. We’re not allowed to hurt others, for example. “You don’t just get to go around screaming `Freedom!' all day and do what you want,” said Caplan, the former chair of medical ethics at Penn.
The coronavirus is brand-new, so everyone is susceptible to it. Large numbers of people can get it — and spread it — without having symptoms, which makes it an especially wily foe. Public health officials have asked people to stay at home, not only for their own protection but to keep hospitals, and equipment such as ventilators, from being swamped. Pressure to loosen restrictions has mounted as case numbers in some states, including Pennsylvania and New Jersey, have fallen and unemployment has surged.
Sisti noted that his wife is out of work. “I get it,” he said. “The economic impact is incredibly devastating.” However, this virus calls for unusual measures, he said. “During a once-in-a-century pandemic, you have to recalibrate what you think of as freedom."
The idea of a ventilator waiver sits atop more than one slippery slope.
America’s hospitals and doctors’ office are (normally) full of people who smoke, drink, and eat too much or badly, and rarely exercise. They still get expensive care, although Caplan points out that they might pay more for life and health insurance and may not be considered good candidates for some surgical procedures. The primary harm in these cases, the ethicists said, is to the individuals themselves.
Then there’s the question of where you draw the line on coronavirus risk-taking. At one extreme is the group the ethicists are most concerned about: protesters who refuse to wear masks in crowds and question the value of scientific expertise. But what about Elon Musk, who defied local orders to reopen his Tesla plant in California? Small businesses such as hair salons that reopen early?
To varying degrees, the ethicists said anyone who takes chances should think about where they should stand if hospitals become inundated, but Sisti sees organized protests as worse than poor individual decisions. “This is an intentional assault on the public health regime that we have in society that’s meant to keep everyone healthy.”
Nancy Berlinger, a medical ethicist at the Hastings Institute, has written ethical guidelines for approaching COVID-19, but was not involved in the new op-ed. She sympathizes with the writers’ ideas.
What Sisti’s group is talking about, she said, is what’s known in the field as “ethics free riders," people who "are benefiting from a system that they have undermined.”
She doesn’t think document-signing would have much effect, though. She doubts that people who threaten public officials with guns “would be open to these arguments.”
Public health officials need to develop a strong set of messages for how we’re supposed to act as lock downs are loosened, including talking about pro- and anti-social behavior, she said. “We need public health guidance backed by science about what is safe and unsafe.”
Donna Lea Merritt, a Berks County Republican who is running to be a Trump delegate to the Republican convention, is among those unswayed by the ethicists’ proposal. She has gone to several protests and wears masks only when stores require them. She doesn’t think she needs one, and says it’s bad to breathe her own carbon dioxide. “These people are telling us lies, and I don’t believe it,” Merritt said. She said she has a “good immune system” and feels capable of making her own decisions about distancing and prevention.