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The Official MacNN COVID-19 Thread (Page 27)
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OreoCookie
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Oct 13, 2021, 04:49 AM
 
Originally Posted by subego View Post
For example, an explicit premise of my question is the procedure isn’t a strain on resources.

You offer strain on resources as a reason to deny the procedure. This is a good and correct answer, which I agree with… but it’s an answer to a different question than the one I’m asking. If there’s a strain on resources (i.e., damage to the common good) then the procedure absolutely should be denied, but strain on resources is explicitly not a variable in my question.
Sure, but then I'd say the case under consideration here as it probably violates your fourth assumption (no overstrain on the system).

Clearly, if the health care system could accommodate these extra complications in the future, then this removes some of the arguments I mentioned, but not all of them. Whether additional precautions could mitigate the risks enough to allow for the transplant to go forward, I don't know. In my mind, this scenario will crop up once we are in the endemic phase of Covid-19. On the one hand, almost everyone will either be vaccinated and/or contract Covid-19 at some point. Have the two patients protection against Covid-19 by having contracted it earlier?

We do accommodate people who make personal choices that are suboptimal. (E. g. my mom didn't stop smoking after her stroke some years ago. Many other patients are obese, which carries with it a whole assortment of risk factors.) Not getting vaccinated is one of those choices. Outside of a pandemic, I have no objection to accommodate them if that makes sense. However, right now in the middle of a pandemic, I have no qualms of being stricter on people who choose not to get vaccinated.

Hence, the risk calculus would be quite different in my mind, both, on the individual and the societal level. However, I reckon that vaccination status factors into your ranking on transplant waiting lists, and I don't think that the Covid vaccination would be any different. So perhaps not getting your Covid shot will effectively remove you from the transplant waiting list (because you are ranked so far down that getting a transplant in time is highly unlikely). The latter is a medical decision that should be made on scientific grounds. Even though I don't like when people refuse vaccines without having any good reason, I don't think my and other people's anger should be a criterion.


PS By the way, reader noticed that I had included one bit twice. That was because macnn does not like iPad OS's privacy feature that uses relay servers. So a first post was eaten and I was reconstructing what I wrote from a partial post and memory. Sorry about that. I would have edited it, but you were quicker to reply.
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Laminar
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Oct 13, 2021, 09:27 AM
 
Originally Posted by subego View Post
Unfortunately, the way civil liberties work, you have to go to the mat all the time to defend utter morons, because if you don’t, the liberty isn’t there anymore when someone needs to make legitimate use of it.

I agree though, liberty is not unlimited, and comes with qualifiers. So far, that list is:

1) Direct donor (i.e., no waiting lists)
2) Must still be a fit candidate with the added risk
3) Must be able to be admitted COVID-free
4) Does not overstrain resources

If these qualifications are met, on what grounds do we deny the transplant?
These seem fair, and your idea of quarantine seems valid, as long as it doesn't strain resources.

But analyzing each of these scenarios on a case-by-case basis is also a strain on administrative resources, which is where the blanket policy comes in handy.
     
Laminar
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Oct 13, 2021, 09:28 AM
 
Originally Posted by OreoCookie View Post
Are you talking about doing harm/minimizing harm for the individual or for society?
He's referencing the Hippocratic Oath.
     
subego
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Oct 13, 2021, 10:02 AM
 
Originally Posted by OreoCookie View Post
However, I reckon that vaccination status factors into your ranking on transplant waiting lists
I said this was a direct donation of a kidney, right?
     
subego
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Oct 13, 2021, 10:08 AM
 
Originally Posted by Laminar View Post
He's referencing the Hippocratic Oath.
You got it!
     
subego
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Oct 13, 2021, 10:31 AM
 
Originally Posted by Laminar View Post
These seem fair, and your idea of quarantine seems valid, as long as it doesn't strain resources.

But analyzing each of these scenarios on a case-by-case basis is also a strain on administrative resources, which is where the blanket policy comes in handy.
I only see that having an appreciable effect with 3.

1 makes it less work than normal, and they need to do the analysis for 2 and 4 with everyone, we’re just adding a variable we presumably have data for already.
     
Laminar
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Oct 13, 2021, 01:40 PM
 
Would you say that if all four conditions can be met and the hospital still refuses to do the procedure, that counts as punishment for not being vaccinated and seems a bit...icky?
     
ghporter
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Oct 13, 2021, 03:21 PM
 
COVID is just one more consideration for qualification, on top of a bunch of others. Kidneys are actually less ethically challenging than livers; if you drank yourself into liver failure, do you "deserve" a second chance with a new liver? (Keep in mind that a liver transplant can be done with only a portion of a donor liver - I think they can get at least three transplants out of one donor liver, but don't quote me on that.)

Read this National Institutes of Medicine paper, particularly the last section, for more insight.

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Thorzdad  (op)
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Oct 13, 2021, 05:25 PM
 
     
OreoCookie
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Oct 13, 2021, 07:30 PM
 
Originally Posted by Laminar View Post
He's referencing the Hippocratic Oath.
Yes, I know. But triage is also practiced in case the need calls for it (e. g. a mass casualty event or a pandemic), so this isn’t really unusual, it is just that global pandemics on this scale happen infrequently.

That’s why I said that when the situation normalizes, experts need to think this over how to handle people who refuse the Covid vaccine specifically or are not vaccinated generally. I would expect that the resulting policy is more nuanced than now. We do and should accommodate personal choices and failings to some degree. (Obviously, we do not accommodate every whim of a patient: if an alcoholic with a failing liver continues to drink, they are not going to get a transplant.)

In fact, I think one point of disagreement is that some people seem to think the situation already has normalized even though it hasn’t.
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subego
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Yesterday, 12:24 AM
 
Originally Posted by Laminar View Post
Would you say that if all four conditions can be met and the hospital still refuses to do the procedure, that counts as punishment for not being vaccinated and seems a bit...icky?
I’ll be charitable and say they’re trying to strong-arm the person. Of course, punishment is part of that strategy.
     
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Yesterday, 05:40 AM
 
Originally Posted by subego View Post
I’ll be charitable and say they’re trying to strong-arm the person. Of course, punishment is part of that strategy.
I don’t see any evidence of that.
The simpler explanation is that in reality your fourth assumption is not satisfied, in the middle of a pandemic people who choose not to get the Covid vaccine do put unnecessary strain on the health care system. I think that is a far easier explanation that is consistent with what we see. In the present situation asking patients who can to get vaccinated is like asking someone who hopes to have a liver transplant to stop drinking alcohol — would you also say that we strong arming that person into compliance?

Lastly, specialized procedures like organ transplants, they can only be performed at a smaller number of hospitals by highly specialized staff. So if these fail because of staff shortages or a Covid outbreak among at-risk patients, the impact would be higher than the loss of hospital beds may make it appear.
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ghporter
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Yesterday, 08:55 AM
 
If we consider that “not following basic medical advice for everyone” is a predictor of poorer outcomes from any medical intervention (from “eating right” to “taking your anti-rejection meds” to whatever), then not being vaccinated against COVID - on purpose - predicts negative outcomes that other patients would not have.

Also, let’s look at the ethics of doctors not treating unvaccinated people. Read this article from the director of the division of medical ethics at NYU’s medical school.

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subego
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Yesterday, 11:47 AM
 
Originally Posted by OreoCookie View Post
The simpler explanation is that in reality your fourth assumption is not satisfied
That my fourth assumption was satisfied was an explicit condition of the (hypothetical) question.

As I said earlier, you are giving good and correct answers that I agree with, but they’re answers to different questions than the one being asked.
     
OreoCookie
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Yesterday, 07:43 PM
 
Originally Posted by subego View Post
That my fourth assumption was satisfied was an explicit condition of the (hypothetical) question.
This was in response to you writing that the vaccine requirement was to strongarm people into getting their shot, and that one of the motivations was punishment. Inferring people’s motivations from flawed premises inevitably to lead you misattributing people’s and organizations’s motivations. I’m not quite sure what the point of that exercise is. :shrug:
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OreoCookie
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Yesterday, 08:03 PM
 
Originally Posted by ghporter View Post
If we consider that “not following basic medical advice for everyone” is a predictor of poorer outcomes from any medical intervention (from “eating right” to “taking your anti-rejection meds” to whatever), then not being vaccinated against COVID - on purpose - predicts negative outcomes that other patients would not have.

Also, let’s look at the ethics of doctors not treating unvaccinated people. Read this article from the director of the division of medical ethics at NYU’s medical school.
That is an important point that becomes more relevant when Covid has become endemic: if getting vaccinated is part of the treatment plan and people partially refuse it, it is a difficult ethical question to decide how far people can go to refuse to follow their doctor’s recommendations. Depending on where you live, insurance companies might be barred from raising prices for specific risk groups, for example. Or to decide against treatment for certain groups? An example that comes to mind are joint replacements. Is it worth it to replace hip or knee joints when the patient is very old or severely overweight? This isn’t just about money, but about the risks for the patients themselves. With age the probability to react badly to the anesthetic increases and patients take a lot longer to recover. The bone density decreases with age, which, in turn, increases the risk of failure of the artificial joint. Similar arguments can be made for overweight patients. As a result the patient might be bound to a wheel chair for the rest of their lives. Where do you draw the line? I think on an individual level you almost always make a case for why you should make an exception.
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reader50
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Yesterday, 09:51 PM
 
Pharmacy in Indiana makes a mistake.
Joshua and Alexandra Price say they and their two children were mistakenly given the Covid-19 vaccine instead of a flu shot a week ago at their local pharmacy -- and they are now dealing with some adverse symptoms.
The Prices took their 4- and 5-year-olds to the Walgreens in Evansville, Indiana, on October 4 for their yearly shots. About 90 minutes later the pharmacist called saying they had made a mistake. The entire family had been injected with adult doses of the Covid-19 vaccine.
...
"They will probably do OK," said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine. "The difference is they got a three times higher dose of a vaccine than is being tested in clinical trials."
"It is concerning they got a higher dose, and they have to be monitored, but they should do really well," Hotez said. "There is a lot of data out there now in 5-year-olds and older."
He added that Alexandra and Joshua's extra dose of the vaccine is similar to receiving a booster shot.
Some potentially-serious symptoms continue a week after the mistake. I hope for a followup story in a few days to another week.

In theory, they should all be fine, as the vaccine is a straw man. It doesn't fight back. But I would have expected all symptoms to pass by now. It would be a significant concern if things got worse.
     
subego
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Yesterday, 11:39 PM
 
Originally Posted by ghporter View Post
If we consider that “not following basic medical advice for everyone” is a predictor of poorer outcomes from any medical intervention (from “eating right” to “taking your anti-rejection meds” to whatever), then not being vaccinated against COVID - on purpose - predicts negative outcomes that other patients would not have.
The importance of this due to waiting lists. If it’s a direct donor, or condition one on my my list, that’s irrelevant.¹



¹ Unless the patient’s behavior is so self-destructive that performing the transplant would make their life expectancy worse than doing nothing.
     
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Today, 01:16 AM
 
Originally Posted by subego View Post
The importance of this due to waiting lists. If it’s a direct donor, or condition one on my my list, that’s irrelevant.¹
I don't see why this is supposed to be limited to transplants via waiting lists. Not following essential parts of treatments (selectively or as a whole) is a significant factor no matter how you get the organ.
Originally Posted by subego View Post
¹ Unless the patient’s behavior is so self-destructive that performing the transplant would make their life expectancy worse than doing nothing.
This isn't just about life expectancy, but also quality of life (see my example of joint replacements) and the impact on others (because e. g. doctors and staff who can perform transplants are rare).
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OreoCookie
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Today, 01:21 AM
 
Originally Posted by reader50 View Post
In theory, they should all be fine, as the vaccine is a straw man. It doesn't fight back. But I would have expected all symptoms to pass by now. It would be a significant concern if things got worse.
Given that Pfizer/BioNTech seems to have the performed trials and intends to ask for approval for use in children 5–11 soon, I seriously doubt that there will be lasting ill effects. Sure, AFAIK children get 1/3 of an adult's dose, but still.
Originally Posted by reader50 View Post
Pharmacy in Indiana makes a mistake.

Some potentially-serious symptoms continue a week after the mistake. I hope for a followup story in a few days to another week.
Most of the people I know had a some side effects after getting one of the mRNA vaccines. But in the end you know that it is only limited and soon you will be over it.
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ghporter
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Today, 11:05 AM
 
Originally Posted by subego View Post
The importance of this due to waiting lists. If it’s a direct donor, or condition one on my my list, that’s irrelevant.¹



¹ Unless the patient’s behavior is so self-destructive that performing the transplant would make their life expectancy worse than doing nothing.
However, because of the depth and complexity of the ethical issues involved, direct donors don’t get “a pass” for any of the qualifications. That looks like a form of favoritism, and isn’t allowed.

It comes down to “everyone must be treated equally,” even if their situations are nowhere near the same.

There’s a case to be made for both encouraging more direct donation and avoiding it. On the one hand, direct donors don’t have to be “found,” which makes coordinating the whole thing a lot easier, less costly, etc. But it also opens the door to the potential for Bad Things; under-the-table payoffs of donors, donation under threat of X, etc.

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subego
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Today, 12:34 PM
 
Originally Posted by ghporter View Post
However, because of the depth and complexity of the ethical issues involved, direct donors don’t get “a pass” for any of the qualifications. That looks like a form of favoritism, and isn’t allowed.
Here’s a question.

In general, do they kick alcoholics (for example) off the list, or just put them at the bottom?

Strictly in terms of conserving a precious resource (organs), does not putting a person at the bottom of the list successfully achieve that goal?
     
Thorzdad  (op)
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Today, 01:30 PM
 
I'm not sure they allow active alcoholics on the list in the first place.
     
subego
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Today, 01:31 PM
 
Originally Posted by OreoCookie View Post
I’m not quite sure what the point of that exercise is. :shrug:


The point of the exercise is to learn about and from each other by playing pretend.

Pretend performing the transplant on the vaccine refuser is safe by an objective measure.

Would you still refuse the procedure? If so, why?

If not, what do you think would motivate someone to refuse it anyway? This was the question my “strongarm” comment was an answer to.

These aren’t questions about a real-wold case. You don’t have to worry about misattributing the motivation because the person you’re attributing it to doesn’t exist. They’re hypothetical. You have been granted permission to hypothesize.

To bring this back around to the beginning, the point of these questions is to learn about and from you by the answers.
     
subego
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Today, 01:39 PM
 
Originally Posted by Thorzdad View Post
I'm not sure they allow active alcoholics on the list in the first place.
Off-the-cuff, that sounds unethical to me, unless the procedure will make things worse. If it won’t make things worse, and there’s no one else who can use it, what’s the justification for not allowing it?

I can be sold on deprioritizing. Refusal I’m having trouble with.
     
 
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