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Geoff Gratwick is a retired rheumatologist. He represented Bangor and Hermon in the Maine Senate where he was chair of the Health and Human Services Committee.

Because of the number of  COVID patients requiring intensive care, ICU beds are currently at a premium. Should those who have not been vaccinated for COVID be at the end of the queue?

The issues raised by Mainers who refuse to get COVID vaccinations are unique. By choosing not to be vaccinated, whatever their motivation, they are putting others at risk. They are more infectious than the vaccinated, are delaying the achievement of herd immunity, are fertile ground for the development of viral variants such as Delta, and are disproportionately consuming our health care dollars. COVID is now largely an epidemic of the unvaccinated.

If refusing vaccination affected only the involved individual, it could be excused as a matter of personal choice, but there are few other instances in which a personal choice affects the health of others so dramatically. Drunk driving and mass shootings come to mind.

Profound ethical challenges arise when intensive care resources become scarce. Usually, caregivers prioritize treatment according to a patient’s medical needs and the resources available. Medical treatment on a chaotic battlefield or during a mass catastrophe is given first to those likely to survive; those unlikely to do so come second.

When I was a medical intern working in the Harlem Hospital ER on a busy Saturday night, we had to triage patients, to make rapid decisions as to who should go directly to the ICU, who should wait, and who should be referred to a clinic. There was one case involving a head-on car crash – a family of three in one car and a man with a toxic blood alcohol level in the other. A dilemma for me and the other doctor on duty. We cared for the family first. Because of our limited resources we prioritized care.

The U.S. health care system already prioritizes care in multiple ways. Factors such as wealth, insurance, ethnicity, geography, and smoking are major determinants of who gets care, how much, when and how. Should COVID vaccine refusal, a personal choice, be added to this list when the demand for care exceeds capacity?

As a physician, this ethical dilemma is difficult to consider. But, here are some reasons to answer “yes.”

Actions have consequences. The unvaccinated must accept the consequences of their decision and be prepared to suffer the effects of COVID should they contract it. Personal responsibility works both ways: they have chosen their bed and should lie in it.

If they do not trust the science behind RNA vaccinations and monoclonal antibodies despite current data, it is hypocritical for them to demand hospital care based on the same science.

They should not deny an ICU bed to an elderly grandparent (or anyone else) who has just had a heart attack, stroke, or acute illness.

It is unethical to risk the health of the medical personnel assigned to their care by exposing them to a potentially deadly infection.

Our democracy rests on the concept of shared responsibility. Soldiers who die on the battlefield have given their lives so that their neighbors may live. If the unvaccinated are unwilling to contribute to the health of their neighbors, then it is reasonable that they be second in line for COVID related health care.

There are also arguments for answering “no.”

Prioritization on the basis of personal behavior or vaccination status imposes an intolerable ethical dilemma for caregivers. In the Harlem Hospital ER, the dilemma for me and my colleague was real and acute.

Providers do not deal in blame and punishment for those who have made bad choices. The Hippocratic Oath requires that doctors treat sinners and the pure of heart alike.

How should a hospital verify an ill COVID patient’s statement that he/she has been vaccinated?

Is there a legitimate reason that a person has not been vaccinated? This could be a documented allergy to an antigen in the vaccine, needle phobia, difficulty getting time off from work, geography, poverty.

Society can come up with other ways to encourage vaccination — increased insurance premiums, employment and government mandates, traveling clinics, better data, and restrictions on travel, school and employment.

As a society we have decided to care for people who suffer the consequences of having made an unwise life decision — substance use, alcoholism, smoking, or riding a motorcycle without a helmet. However, unlike those who refuse vaccinations, these decisions typically do not directly harm others. The individual alone suffers the major consequences of their actions.

The unwise decision not to get vaccinated has consequences for you and me. It hurts us all. If ICU beds are full, it may force us to consider yet another variety of triage and require us to make decisions that run counter to all that medicine and our humanity represent. Empathy and caring lie at the heart of health care. If it becomes necessary to restrict medical care for the unvaccinated, we will all be the lesser. The problem must be dealt with before it gets to the emergency room.