Is Very Important Patient treatment justified?
Medical ethics professor explores why a VIP may get access to care before your grandmother.
In UM-Dearborn’s medical ethics course, COVID-19-focused discussions include how to best allocate scarce resources like ventilators or future vaccines. But Philosophy Lecturer and Bioethics Fellow at Henry Ford Hospital Joseph Dunne says VIP medical treatment hasn’t typically been a part of the lesson plan.
“That’s because it's extremely rare. Instead of focusing on the exceptions, I want to focus on the scenarios that students are more likely to encounter.” However, 2020 is a time where exceptions to the rule have become the rule.
By now, President Donald Trump’s recent Coronavirus diagnosis and his access to top COVID-19 treatment has been a topic of conversation at many (socially distant) gatherings.
So we recently reached out to Dunne to talk about VIP treatment in a medical setting, if it’s justified from a medical ethics standpoint, and — if it is — why.
You are a bioethics fellow at a major hospital. How are VIPs treated differently than the rest of us?
Medical centers try and do the same things they always do when anyone comes in—which is to provide the best medically indicated care possible for the patient at hand.
I can assure you that hospitals don’t have super-secret machines hidden in the back or technology saved for just such people! The only difference in treatment, if there is any, comes instead with more practical measures like locking or restricting the patient's chart access—to protect against snoopers and gossipers—and providing additional security personnel to protect the vulnerable patient.
What are the ethical pressures physicians face when treating VIPs?
It’s this scenario: "Doctors save lives. So when we bring you our VIP, you should save their life, right? Don't you know how important they are!?"
I am not a physician, but there seems to be an intense pressure facing the physician treating the VIP to “do everything possible” and simply make them well again because of how necessary or integral they are to the function of whatever important institution(s) they are connected with.
Do these pressures change the medically indicated care plan?
Pressures typically apply to not-purely-medical things like requests for the most experienced medical personnel, access to window rooms (or requests against them so no one can see in) and heightened 24/7 monitoring. Pressures to treat VIPs don’t typically affect what is medically indicated—if at all.
If a prominent person comes in for a myocardial infarction (heart attack), then they will be treated, medically speaking, in the same way as other patients suffering from that issue. That’s because there’s not much that can be done outside of routine medically indicated care for the issue.
Here’s a related situation that is fresh in the American mind: the passing of former Supreme Court Justice Ruth Bader Ginsburg. I'm very confident that her care was VIP in the sense that her chart was not available for everyone to access and she probably had top-tier 24/7 monitoring and a security presence. Socially, she was treated differently than other patients — and I think that unequal treatment was justified based on her level of importance in our society. But her cancer was treated as any cancer would be with respect to what is normal, medically indicated care.
The only deviation from this general trend is when the medical care may involve novel treatments, meaning not yet approved by the FDA, for novel conditions—for example, new treatments for COVID-19. Where there is no clear routine or medically indicated care yet, physicians will typically exercise their best judgment under the developing umbrella of justifiable treatment options — some of which can be more or less risky, more or less efficacious, and more or less scarce. Physicians would most likely begin by utilizing the less risky, more efficacious and less scarce options and see if those work first.
In philosophy, people are considered morally equal. So why does a VIP get scarce COVID treatment when my grandma doesn’t?
The worry is that social inequality, in some sense, trumps—pun not intended—medical equality. Is this justified or is it a moral calamity?
Here's one reason to think that it's not unjustified: Suppose a hospital system gets a limited supply of COVID vaccines and has to figure out how to distribute them. Who should get them first? You might think that we should give them to people based purely on who is the most vulnerable (older, obese, etc.). But most hospitals won't distribute the vaccine like this — in fact, they have been recommended not to by the NIH and CDC via the National Academies of Sciences, Engineering and Medicine.
Instead, hospitals will likely give those scarce vaccines to their own staff who work primarily with COVID patients, with their most vulnerable employees getting the vaccine first.
So why is the medically vulnerable hospital employee getting the scarce COVID vaccine when my medically vulnerable grandma isn’t? It’s because the vulnerable hospital employee arguably serves a more important social function with respect to the virus overall, is more essential in combating the virus on the frontlines, and leaves the social-medical context worse-off in their absence.
If we think it's morally permissible to give scarce COVID vaccines or treatments to healthcare personnel for social or practical reasons, then I think it's also morally permissible to give scarce COVID vaccines or treatments to others (VIPs) for social or practical reasons.
That is a good point. Why does it still feel a little unsettling?
These are difficult questions because all people, without question, are morally equal and equally morally valuable. But we know through personal experiences and CDC data that there are issues with how this is reflected in our healthcare system because the people who tend to be most sick — residents of socially and economically impoverished areas — are least likely to get good access to good care. And the people who tend to be less sick and need healthcare the least are residents of socially and economically wealthy areas, where VIPs typically live. Social and economic wealth seem to go hand-in-hand and can mutually reinforce each other. I do not know how to fix this — although I wish I did — but it is important to acknowledge it.
Another reason this may feel unsettling is because so much around us is politicized.
In an attempt to clarify thinking on this issue, consider the following thought experiment: If a person who plays a central role in our society contracts COVID, would we think it morally justified for that person to get access to whatever medical care is available or developing — even if it isn’t accessible to all yet? Since we’ve mentioned President Donald Trump, you might be thinking about him.
But does your answer change if the person who contracted COVID was Justice Ginsburg? She played a central function to society and was arguably the most influential Supreme Court Justice on the Court at the time of her passing. Would you have wanted her to have access to scarce treatments or a vaccine?
I do think there are justifiable instances of special treatment that are roughly analogous to prioritizing our healthcare workers over medically equal non-healthcare workers. But those justifications should focus on common good and public benefit.