I don’t ask “Why?” when a patient with Covid-19 tells me they are unvaccinated for the same reason I don’t ask why someone whose alcohol level is four times the legal limit decided to drive, or the badly burned grandmother with emphysema lit a cigarette with oxygen prongs below her nose. Nor do I ask it when I find myself elbow deep in a bag of chips after an overnight shift even though I am fighting high blood pressure.
We humans are beautifully flawed creatures with inexplicable needs and impulses that run counter to our best interests.
Sure, I’m curious why someone didn’t take steps to stave off the threat that has, as I write this, infected more than 38 million Americans and has claimed more than 630,000 lives. Recent reports showed 301 new Covid-19 cases in one day in my small state of Rhode Island and the highest transmission rate since April 2021. Yet 40% of Americans are unvaccinated against the disease.
The worried looks in the eyes of my Covid-19 patients hint that questioning motives isn’t necessary. When they have oxygen masks strapped to their faces, previously passionate arguments rooted in individual liberties, misinformation, and mistrust deflate like punctured balloons. And the blame I might have harbored before turns to sorrow.
I’m not free of the frustration and anger about unvaccinated people voiced by my clinician colleagues as we once again don N95 masks and goggles and other protective gear. Mustering sympathy for patients who don’t take precautions to protect their health and safeguard the well-being of others can be difficult, whether they’ve chosen not to wear masks or get vaccinated, drove drunk, or lit matches near flammable oxygen. But this challenge cuts to the heart of what it means to be a physician in a moral profession.
I recognize that “moral” is a term open to distrust and eye rolling. The premise that medicine is a moral profession might sound like a hallucination in today’s profit-driven health care climate. But medicine has a rich tradition as a moral profession based on ideals — placing patients’ interests first, using medical knowledge to benefit others, and acting in a manner that promotes societal trust — that are foreign to health care providers today or often flouted by them.
The anger I feel toward vaccine-hesitant people becomes a more complicated emotion when I witness them reckoning with their choices. Many of the unvaccinated people I’ve talked with are hard-working, loving individuals struggling to catch a break in a life that hasn’t been fair. They’re unmoored and don’t know what to believe when truth itself has supply-chain problems and the health care system has been letting them down for years.
Belonging to a moral profession implies the possibility of moral distress and even moral injury, described as the emotional strain that results when the right thing to be done in a situation conflicts with what the situation permits, producing “mental, emotional, and spiritual distress.” Moral injury was a hot-button topic for clinicians long before the pandemic upended our lives and raised the ante for all of us.
Covid-19 rehitched many of us to this forgotten moral force. “This is why I went into medicine” was a frequent refrain from fellow nurses and physicians during the pandemic’s first wave, even as we donned suboptimal personal protective equipment. The moral distress that had weighed on many of us before the pandemic was balanced by worry and fear as well as a reminder of what it means to be part of a moral profession.
This time around, the unanticipated crisis driving the surge of cases was avoidable if enough people had taken the necessary precautions and got their Covid vaccines. This time around, my moral tank is leaking. The same thing is happening with many of my colleagues.
This frustration is echoed on Twitter, where vaccine exhortations are often punctuated with caps, exclamation marks, and emojis. At times, however, Twitter functions as a bottomless salad bar of group certainty and ego affirmation. I respect that frustration and I feel it, too. But I don’t believe that loud punctuation changes minds or creates conditions for shared understanding.
What we need is a harm-reduction strategy. If shortages of personal protective equipment exemplified a fatal shortcoming at the start of the pandemic, I feel that we’re now dangerously low on meaningful dialogue.
I remember how skeptical I was years ago about intentional harm reduction approaches to substance use. These focus on the many contributing psychosocial factors that make abstinence difficult and aim to improve the harmful consequences of substance use by partnering with patients. I initially resisted the then-radical strategy of giving take-home naloxone kits to overdose patients with opioid use disorder that could be used to revive them should they overdose again. Then, one morning, my colleague and prominent opioid researcher Dr. Liz Samuels, who spearheaded this now-national model, happened to stop by my office. I expressed my concern: providing an overdose-reversal agent felt like tacit permission to continue a life-threatening behavior. “But Jay, we can’t help a person with their substance use if they’re dead,” she responded.
Samuels reframed my understanding and, once I implemented it, this harm-reduction approach provided other benefits beyond the purpose of rescuing people from avoidable deaths. By meeting patients’ daily challenges without judgment, more of them shared with me their struggles with addiction and sobriety. By being open and curious, I was trusted enough to take a step or two into their lives, which often was enough to change my perspective and connect with them in unexpected ways.
I recognize that getting vaccinated and wearing masks make many people uncomfortable. It’s a sacrifice, an infringement of their liberty. But suffering the consequences of Covid-19 seems to be a more significant sacrifice, and death the ultimate and irreversible infringement on personal freedom.
That’s something I would love to talk about with people who are vaccine hesitant and those reluctant to wear masks. Unfortunately, the voices on the extreme right and the extreme left drown out, even obliterate, the opportunities for the conversations we should be having. Harm reduction seems impossible in an age of unfettered and dangerous ideology, but it’s a partnership opportunity worth taking on. I believe that the road out of this pandemic is through the messy middle, an imperfect but open-minded community of people willing to explore the conditions that will let us all move forward together.
In this middle, we need clinicians and patients, the vaccine selfish who jumped the queue and the vaccine hesitant who don’t want to get in line, the morally injured and those in moral recovery. It’s a place for dialogue where people listen for understanding and not rebuttal, that honors respectful disagreement, and that invites a range of ideas, opinions, and experiences.
Many leading organizations believe we must target misinformation about Covid-19 vaccines by focusing our attention on debunking myths and improving science communication. I think we also need to design community spaces, starting with multimedia platforms, that honor personal stories and highlight the emotional experiences of individuals and families trying to make sense of these destabilizing times with the pandemic, vaccines, and one another. Stories can be more powerful than data. To persuade people, to get them to think, you must first get them to feel. Stories move people emotionally, and the best stories reveal how people face, cope, surmount, and succumb to the obstacles in their lives and make their way in a world we all share.
Let’s tone down the rhetoric and create opportunities whose purpose isn’t to convince people with contrary opinions that they’re behaving irresponsibly, but to invite them into our lives and appreciate why each of us might feel morally injured.
I believe there remain islands of shared values and purposes for building further discussions. The only way out of this pandemic is by supporting one another, shifting the focus from judgements about right and wrong and exploring ideas that ask what degree of discomfort each of us is willing to accept to put the current crisis behind us. Hard discussions, without a doubt. But they are better than the alternative: listening to gasping breaths and whirring machines and frantic distress of people sick with — and sick of — Covid.
Jay Baruch is an emergency physician, professor of emergency medicine, director of the medical humanities and bioethics scholarly concentration at the Alpert Medical School of Brown University, and author of the forthcoming book, “Tornado of Life: Constraints and Creativity in the ER” (MIT Press, Fall 2022). You can read the First Opinion essay that gives the book its title here.
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