By: Thomas Fitzpatrick II, MS JD
I am currently an Adjunct Professor at LeTourneau University. I studied law at the Seattle University School of Law and health care ethics at Creighton University. My research and teaching interests include ethical and legal responses to advances in medical technology and the intersection of contemporary social mores and bioethics. The genesis of this paper can be traced to my location and my social media feed. I am currently based in El Paso, Texas, which has unique COVID-related challenges due to its close social and economic ties to Ciudad Juarez and the now heavily restricted border. This paper was inspired by conversations with El Paso residents regarding unemployment and underemployment due to the lockdown and disparaging remarks made by health professional colleagues regarding protesters on social media. My hope is that this paper promotes a dialogue among health professionals regarding how to approach patients who have participated in protests.
National governments have instituted various emergency policies to mitigate the outbreak of COVID-19 - nationalizing the production of personal protective gear, deploying mobile military hospitals, and enforcing social distancing initiatives to prevent overwhelming hospital resources. Initiatives to “flatten the curve” have been met by widespread protests, famously represented in the United States with an image of nurses opposing anti-lockdown protesters in the middle of a street in Denver, Colorado. As frustrated health workers are left to improvise protective gear and construct ventilators, an honest and natural question emerges: should scarce resources be expended on lockdown protesters who contract COVID-19? Our initial intuition to give protestors lower priority may seem justified, especially if one has lost patients or loved ones to COVID-19, but to do so would cause tremendous harm to healthcare systems long after the urgency and scarcity caused by COVID-19 has diminished.
Before discussing whether such a prioritization scheme is ethical, let us first explore the population that would be impacted by such a decision. It would be simple to generalize the protesters and their motivations, especially considering the fact that these protests are situated in an era of rising scientific skepticism. Groups espousing “anti-vaccination”, “anti-climate change”, or “flat-earth” beliefs for example, have become increasingly visible and popular. However, if we simply generalize the motivations of the protestors, we jeopardize the possibility for meaningful dialogue. Just as the acknowledgement of religious or philosophical objections to vaccinations provides a useful foundation from which to develop successful public health policies, understanding the behavior and motivations of lockdown protestors promotes useful discourse rather than conflict.
Because the protests are so recent, a thorough survey of protestors’ motivations has not yet been published, but some ideas may be gleaned from the news. For instance, most anecdotal evidence suggests that the protesters do not espouse one uniform ideology; while some anti-vaccination or “anti-science” presence is noted, they were not the majority, as many protesters appear familiar with the rationale behind social distancing policies, and social distancing and the use of protective equipment is practiced in many observed protests. Thus, it appears that the protests are not necessarily a rejection of the medical reality of COVID-19, but rather a reaction to the government response to the pandemic. This observation does not discount the observed presence of anti-vaccination organizations at protests, but instead should demonstrate that there may be grievances represented at these protests beyond a rejection of medical advice.
Two prominent themes observed at these protests should further illustrate this: economic frustration and diminished liberty. These themes are common not only in those protests occurring across the U.S., but also in lockdown protests in Europe, Asia, and Africa. Observing these themes in a global context diminishes the rather derogatory characterization made of U.S. protesters as vocalizing a politically narrow and ethnically homogenous perspective and places them among the international protesters who are expressing dissatisfaction with the disproportionate economic impact of the national lockdowns. Globally, COVID-19 is expected to result in the loss of 25 million jobs, hitting those already near poverty hardest. In the U.S., this has resulted in nearly 40% of workers in households earning at least $40,000 losing work, much higher than the 13% loss in households earning over $100,000. When mobility is essential to employment or reacquiring employment, it is not surprising that animosity is channeled towards those in politics and medicine, fields which are not only seen as responsible for the lockdown, but also believed to possess a measure of economic security during the pandemic.
Even if the financial insecurity that motivates these protests is ignored, a policy of deprioritizing infected protesters is ethically precarious and politically dangerous. This would essentially impose a sociopolitical litmus-test for access to emergency medical care - a healthcare allocation regime based on factors unrelated to one’s health but rather one’s expression of personhood. Such a regime harkens back to the early days of the AIDS crisis, when physicians cited moral disapproval and fear as reasons to deny care to AIDS patients. Today, we correctly view such discrimination as cruel and ignorant. To take a similar stance regarding COVID-19 infected protesters risks earning the same distinction from future scholars and suggests that the long-held ethical principles of patient autonomy and provider beneficence are not stand-alone but instead are contingent on a provider’s interpretation of a patient’s past activities.
To establish a policy which tiers access to care based on a patient’s political activism would not only diminish the relevance of medical ethics but diminish trust in the institution of medicine itself. In an increasingly polarized nation, few institutions retain the public’s trust, and the already fragile provider-patient relationship can be irreparably eroded with the introduction of a political component. Beyond the individual provider-patient relationship, such a policy would effectively make healthcare providers de facto state agents, if only in the eyes of citizens, who would rightfully see them as limiting access to those who espouse specified methods of political expression. For a liberal democracy to institutionalize such a policy would serve as precedent to authoritarian regimes to openly incorporate healthcare institutions as instruments of state oppression.
It is natural for a provider who is struggling with the COVID-19 death toll to contemplate the justness of a tiered treatment policy for COVID-19 lockdown protesters. The frustration and heartache that they encounter on a daily basis is beyond the imagination for those who are not in their position. To take this viewpoint from frustrated daydream to official policy however risks erasing the goodwill and trust built on decades of ethical and apolitical policies, and negates the legitimate concerns of many of the protesters. To give in to such thoughts, to make them reality, abandons that work, perhaps forever, and ushers in a darker age from which the field of medicine may not recover.