Vaccination-Sensitive Healthcare Rationing: Overlooked Conditions, Translational Ethics, and Climate-Related Challenges

This article refers to:

Rationing, Responsibility, and Vaccination during COVID-19: A Conceptual Map

Park and Davies (2024) have conducted impressive work on synthesizing the discussion of vaccination-sensitive rationing and relevant theoretical approaches. In this commentary, we build upon their work by addressing three key areas: (1) identifying overlooked conditions and implications of rationing healthcare for the unvaccinated according to luck egalitarianism, (2) drawing attention to the next level of normative and empirical conditions that need to be in place for vaccination-sensitive healthcare rationing to be considered ethically acceptable or politically legitimate in a real-world setting, and (3) sketching new conditions for assessing the ethical acceptability and political legitimacy of such rationing, taking into account the impact of healthcare on climate change and vice versa.

OVERLOOKED CONDITIONS AND IMPLICATIONS OF LUCK EGALITARIANISM

One of the key principles of luck egalitarianism is that individuals should be held responsible for the outcomes of their voluntary choices (option luck). When applied to the context of COVID-19, this principle seems to suggest that the unvaccinated should bear the costs of their higher risk of severe illness, as they have chosen not to receive the vaccine. Conversely, the vaccinated should be responsible for any adverse reactions to the vaccine, as they voluntarily opted to receive it. However, Park and Davies (2024) do not fully explore this latter implication, which adds an important layer of nuance to the discussion and strengthens the argument that people should not be held responsible for their choices in this context.

If we were to follow the logic of option luck responsibility, it would imply that treatment for vaccine-related illnesses, however rare they may be, should not be publicly funded or prioritized. This is because individuals who choose to get vaccinated would be seen as responsible for any adverse consequences of that choice. However, this conclusion is not only counterintuitive but also arguably at odds with most people’s moral judgments. This raises questions about the fairness of penalizing individuals for making a choice that is intended to benefit both themselves and society.

Furthermore, holding the vaccinated responsible for adverse reactions could create a disincentive for people to get vaccinated, as they may fear being denied treatment or support should they experience any negative side effects. This, in turn, could undermine public health efforts to achieve widespread vaccination and herd immunity. Thus, the implications of applying option luck responsibility to COVID-19 vaccination highlight the limitations and potential drawbacks of relying solely on this principle when making decisions about healthcare rationing and responsibility.

Park and Davies (2024) argued that three core aspects of luck egalitarianism—“a robust conception of choice, a rigorous engagement with opportunity sets, and a comprehensive account of the consequences that should attach to choices”—have not been sufficiently recognized as tools for addressing the issue of disproportionate healthcare resource utilization. In a recent paper dissecting the anatomy of health-related choices for which people could reasonably be held responsible, these elements were, indeed, considered jointly (Bærøe, Albertsen, and Cappelen 2023). The aim of this paper was to make a transitional move from principled discussions of responsibility in health into real-world assessments. The paper identified “clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible” (Bærøe, Albertsen, and Cappelen 2023, 384). Furthermore, the paper was based on the crucial conceptual distinction between being responsible and holding someone responsible. It demonstrated that while we might be considered responsible and blameworthy for our health-related actions, there can be well-justified reasons, such as protecting third parties, that make it unreasonable to hold us responsible by giving us lower priority. If unvaccinated individuals are denied hospital treatment, it could lead to a situation in which they are not isolated in a controlled hospital environment. Consequently, these individuals may continue to interact with others in their communities, potentially spreading the virus to a larger number of people. According to the luck egalitarian-inspired framework proposed in this paper, vaccine-sensitive rationing of healthcare would not be considered ethically acceptable.

CONTEXTUALIZED EMPIRICAL CONDITIONS FOR CONSIDERING FAIRNESS AND JUSTICE

Park and Davies (2024) discuss various theoretical justifications for vaccination-sensitive rationing of healthcare. However, translating these theoretical conclusions into practical implementation raises new normative challenges regarding the contextual concerns that must be considered for an ethically justifiable and political legitimate implementation of such a policy (Bærøe 2024). Research on vaccine hesitancy highlights the complex web of personal, social, and structural factors that shape people’s attitudes and decisions regarding vaccination (Larson et al. 2014; Palamenghi et al. 2020). Exposure to misinformation, deeply rooted mistrust of institutions, and experiences of marginalization can powerfully influence individual choices in ways that call into question the degree of truly voluntary control over health-related choices. Thus, an empirically informed, real-world, positioned point of view on responsibility and fairness of health-related choices must consider unequal access to reliable information as well as experiences that build trust in institutions and feelings of empowerment. This perspective likely leads to a negative conclusion on the acceptability of vaccine-sensitive rationing. We ask the following rhetorical question: Should an essentially theoretical or more empirically informed account of responsibility be the basis for practical, real-world healthcare decisions and policies?

Furthermore, when COVID vaccines initially became available, vaccination decisions were made under conditions of uncertainty—rather than calculable risk—regarding their short- and long-term effects and side effects. In such circumstances, the acceptability of vaccine-sensitive rationing would have to be based on extrapolation from previously proven successful vaccination programs. However, it is not obvious that this should be considered a fair policy from the perspective of those who would avoid carrying the burdens of the unknown risk.

While Park and Davies (2024) discuss the need for trust in healthcare services to encourage vaccination, they did not address how a vaccine-sensitive rationing policy could threaten this trust. If the choice not to get vaccinated is based on the fear of potential harm, then a policy of sanctioning people to make this choice may undermine people’s de facto trust in healthcare institutions. Ultimately, this may lead people to avoid healthcare services when they need them. Such distrust would be an effective way to deal with the situation of scarcity but not to promote fair access to healthcare. When assessing the acceptability of a vaccine-sensitive rationing policy, such socially detrimental implications should be considered.

Furthermore, the acceptable transition of a vaccine-sensitive rationing policy into practice should be based on considerations of empirical investigations into the worldviews and rationales of those who will be expected to carry the burdens created by the rationing policy. What are their actual reasons for not taking the vaccine? What are their perspectives on being deprioritized when needing healthcare? What are the opinions of those being prioritized by this policy? This policy might also negatively impact their trust in healthcare institutions, even though they happen to benefit from it on this occasion.

THE IMPACT OF CLIMATE CHANGE ON RESPONSIBILIZATION IN HEALTH

We would like to end this commentary by highlighting how climate change introduces new relevant premises to the academic discussion of holding people responsible for their health-related choices. Healthcare provision across the globe contributes to a significant harmful impact on the environment: “Global health care has an environmental impact that, depending on which indicator is considered, accounts for between 1% and 5% of the total global impact, and more than 5% for some national impacts” (Lenzen et al. 2020, e273). As a consequence of climate change (which is partly influenced by healthcare provision), more extreme weather events such as fire weather, drought, tropical cyclones, and heat occur (Intergovernmental Panel on Climate Change 2023). These events create new healthcare needs. To illustrate, high temperature is associated with hypertensive disorders in pregnancy, such as preeclampsia (Xiong et al. 2020). This means that increased heat places the health of the mother and child at risk, potentially with lifelong health consequences. More generally, climate changes are expected to “disproportionately affect…the most vulnerable and disadvantaged, including women, children, ethnic minorities, poor communities, migrants or displaced persons, older populations, and those with underlying health conditions” (WHO 2023).

As healthcare provisions contribute to climate change, which in turn leads to healthcare needs, global justice demands environmentally-sensitive healthcare ethics (Bærøe, Bhopal, and Gundersen 2024). However, how would such ethics define the role of responsibility for health-related choices, including during a pandemic when resources are scarce? Alongside initiatives to make healthcare services ‘greener’ and avoid overuse on the supply-side in the rich part of the world (Born, Levinson, and Vaux 2023), individuals who use healthcare services can play a vital role by reducing healthcare demands. This can happen by preventing the need for curative care. This shift of focus inevitably draws attention to the importance of preventive healthcare and lifestyle changes, which not only benefit local patients but also the well-being of vulnerable and disadvantaged people in other parts of the world and in future generations. From this perspective, which increases the scope of individual responsibility, it might be tempting to consider individual responsibility as a rationing criterion for access to scarce services, including getting vaccinated during a pandemic. However, as reflected in the Park and Davies (2024) paper and discussed in the literature on luck egalitarianism, this cannot be fair until political efforts have successfully addressed the profound socioeconomic inequities and constraints that shape individual choices and provide people with unequal opportunities to take responsibility for their health-related choices.

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