Rational rationing?

Rational rationing does not occur in a vacuum. Vaccine mandates are far from new. State and local public school systems, for instance, have had long-standing vaccine requirements for the protection of children (1). There is an existing robust ethical framework supporting universal vaccine mandates. Specifically, there is a societal moral obligation for harm prevention, the need for herd immunity and consequently, drive for minimizing the free-rider dilemma. With respect to resolving the conflict between the ethics of business and the ethics of medicine, one can look at the impact of universal masking and social distancing compared to vaccine mandates. If treating these two dichotomously, the adverse effects of social distancing and masking on the economy, effective education, and mental health greatly outweigh the adverse effects of vaccine mandates (2).

In many ways, unfortunately, the unvaccinated continue to impose a disproportionate burden on the healthcare system. Inpatient or ICU hospitalizations require bed capacity which is then made more limited for other chronically ill or co-morbid patients. We have seen the significant consequences of this first-hand, with accounts from emergency department physicians across the country calling dozens of hospitals to transfer a critically ill patient needing an inpatient bed. Just two months ago, the UC Health hospital was operating under crisis standards of care precisely because of the heightened scarcity of available resources (3).

One can’t help but wonder about the impact this has had on those already marginalized in our society. Crisis standards of care yield increased barriers to healthcare in frontline and safety-net settings, such as the emergency department, that patients with complex social needs often rely on. Are unvaccinated people driving further rationing of other healthcare goods and exacerbating existing health inequities?

Ultimately, UCH made the right decision to require COVID-19 vaccinations in transplant patients. Hospitals have always used strict guidelines on who is eligible for organ transplants and vaccine requirements are nothing new (4). Transplant patients are already immunocompromised after accepting a scarce resource, with vaccine-preventable infections representing a significant burden of disease in these patients (5). Organ recipients need to play their role in preserving that precious resource by taking all precautions necessary – including getting the COVID-19 vaccine.


1. Centers for Disease Control and Prevention. (2016, November 15). State vaccination requirements. Centers for Disease Control and Prevention. Retrieved February 17, 2022, from https://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html (Links to an external site.)

 (Links to an external site.)2. Wynia, M. K., Harter, T. D., & Eberl, J. T. (2021, November 3). Why a Universal covid-19 vaccine mandate is ethical today: Health Affairs Forefront. Health Affairs. Retrieved February 17, 2022, from https://www.healthaffairs.org/do/10.1377/forefront.20211029.682797/

3. Matthew Wynia, C. N. D. 24. (2021, December 24). The excruciating choices facing Colorado Hospital staff in covid ‘crisis standards of care’. Colorado Newsline. Retrieved February 17, 2022, from https://coloradonewsline.com/2021/12/24/the-excruciating-choices-facing-colorado-hospital-staff-in-covid-crisis-standards-of-care/

4. Danzinger-Isakov, L., & Kumar, D. (2009). Guidelines for vaccination of solid organ transplant candidates and recipients. American Journal of Transplantation9. https://doi.org/10.1111/j.1600-6143.2009.02917.x

5. Stucchi, R. S. B., Lopes, M. H., Kumar, D., & Manuel, O. (2018). Vaccine recommendations for solid-organ transplant recipients and donors. Transplantation102(2S). https://doi.org/10.1097/tp.0000000000002012


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