The health care system in the Netherlands is characterized by its fundamental moral values like solidarity, fairness, humaneness and non-discrimination.
Solidarity means that anyone contributes to the cost of health care by paying into a basic insurance plan that covers oneself and all others as well. We care for each other. By supporting this cause as an individual, you can also trust to receive close to unconditional basic care, should you need it. That’s a comforting thought.
Fairness as a core value, denotes a honest distribution of limited resources among people who are in need, amidst times of shortage. Fairness is about the fair allocation of scarce resources, like for example a donated organ, an ICU-bed or an expensive treatment. For this purpose we uphold clear and transparent selection criteria. An important standard is the probability of a proposed treatment leading to a successful outcome for the patient in question. If we give you an organ that is in short supply, how likely is it that you will live with it for many years ahead?
Humaneness mainly addresses how we treat others in a similar way to how we would like to be treated ourselves in times of need (reciprocity). And, that we are treated considerately and compassionately. As a fellow human being. With equal necessities. Patients are often literally exposed to their carers. They should be able to trust that they are not judged by who they are or by how they look.
Non-discrimination is anchored by Article 1 of the Dutch Constitution:‘’All who remain in the Netherlands, are treated equally, under equal circumstances. Discrimination on grounds of religious belief, ideology, political preference, race, gender or any other grounds, is not permitted.”
During the 44 years that I have been involved in the care for hospital patients, I have found non-discrimination to be a precious and comforting thought. Anyone can turn to the health care system to seek help, indiscriminately and without being questioned or judged by health care providers. The hospital as a safe haven, where help is reliable and always readily available when you need it. In all those years that I spent working in hospitals, I saw people of all walks of life come in: old people, young people, very old people and newborns, white people, dark-skinned people, Asian people, Christians, Jehovah Witnesses, Muslims, Jews, Atheists, Buddhists, and followers of all sorts of other faiths and religions, the physical and mentally challenged, people with a handicap, athletes, meat eaters, vegetarians, vegans, omnivores, boys and girls with anorexia nervosa, people with a perfect BMI, people with overweight, morbid obese people, alcoholics, drug addicts, drug dealers, murderers, people who abuse children, wife-beaters, transgenders, heterosexuals, homosexuals, bisexuals, pedophiles, repeat traffic offenders, drunk people who fell down the stairs or collided with a tree, while driving under the influence, smokers with lung cancer or COPD, people with type 2 diabetes who continued to binge unhealthy food, people with recurrent STD’s etc. etc. We helped them all. And rightfully so!
People get sick. Contrary to most animal species, humans happen to be morally conscious creatures with certain high values. We want to prevent and otherwise reverse suffering, and that’s why we help each other when we are in distress. Most animals leave their sick and injured individuals behind to die mercilessly, we don’t. We don’t even abandon animals when they need us. We treat animals according to our human values (at the same time we kill countless of animals each year for our satisfaction, but that’s a different discussion). We call for help for a distressed animal, shelter wounded animals, ask the vet to treat them and alleviate their agony, and if no options are left, we relieve them permanently from their suffering. It is our desire to do something. Something meaningful. That does us credit as moral creatures. We always help our fellow human beings. Without making a distinction between individuals. Doctors, nurses and other healthcare professionals treat all their patients equally. Occasionally, with some degree of resistance, for example in the case of an infirm criminal. But they too always get treated. Even at war, neutral physicians and nurses will treat allies and enemies, regardless. And that is how it should be. Health care is for everyone. We need that reassurance. That’s how mankind differs from animals. That is non-discrimination and humaneness.
When the first COVID19-patients started being admitted in Dutch hospitals in March 2020, it soon became clear that certain risk factors where associated to severe illness after an infection with the SARS-CoV-2 virus. Those affected were primarily people of an old or a very old age, and people with an underlying illness. Overweight and obesity proved to be common risk factors, as did hypertension, type 2 diabetes, cardiovascular disease, chronic infections and conditions that resulted in a failing immune system. In many cases these health problems were the results of a Western lifestyle, in which unhealthy foods and opportunities for risky behavior are in oversupply and the temptation is always palpable. This consequently can lead to a chronically unhealthy lifestyle, which significantly increases the risk of illness. Certain common health conditions are therefore considered to be lifestyle diseases.
However, patients with illnesses caused by an unhealthy lifestyle are treated in health care without distinction. Attempts are made to offer advise on how to improve their lifestyle. But any form of condemnation, insistence or compulsion are not part of the health care provider’s armory. When patients are not willing to change their lifestyle, instead of judging, we control their symptoms with medication, regulating their blood pressure or blood sugar levels. We treat the manifestations of the disease, without eliminating the cause (for example by inserting a coronary stent or performing bypass surgery without treating the underlying atherosclerosis).
Last year, when ICU’s in the Netherlands started receiving numerous patients with COVID19, they received treatment without making any distinction between individuals. That is solidarity and non-discrimination, humaneness and a sign of civilization. Unless there is a clear medical reason not to treat, like in the case of end-stage cancer or very old age. In those cases we act according to the principles of humaneness and fairness. The likelihood of being treated successfully in the ICU is extremely abysmal. They won’t survive the ICU. Prolongation of life converts in prolongation of suffering and postponing death. That usually doesn’t serve any purpose. Refraining from treating is then appropriate.
Over the last few months there is a growing and worrisome polarization noticeable in the community. Currently the most apparent is between a part of the large group of individuals who were vaccinated and the small group of people who didn’t get vaccinated. Particularly those who didn’t receive their vaccination, for whatever reason, are the ones who are being criticized, dehumanized, ridiculed, and even discriminated against. As a minority, it doesn’t take long to become the underdog.
Civilized people are keeping a straight face while they write in the media or appear in talk shows to voice their approval and support for the public exclusion of people who have not (yet) received a vaccine. They advocate to no longer permit them to visit festivals, concerts, cinemas, museums, restaurants and other public facilities that generally bring people joy. The heat is closing in fast. Exclusion of those who do not obey to the prevailing moral standards. They need to be punished for their lack of solidarity and immoral behavior, is what is said. Deprive them from everything that makes life enjoyable, as they are not on the side of the community who is suffering and who defines the moral standards.
Some are already suggesting to take things to a more extreme level, and deny unvaccinated people access to grocery stores for example.
All of this is obviously unfeelingly hard discrimination and dehumanization, and that is by definition, always immoral and in conflict with article 1 of our Constitution, the non-discrimination principle and international human rights. But it is happening in front of our eyes: exclusion of the faulty. There are plenty of examples in the history of humankind, of where it led us to, when minorities were treated as being inferior. Those examples of which we repeatedly said” “never again” and the reasons why we established monuments in remembrance of the immoral oppression of the past. But history has the tendency of repeating itself.
What I find especially unsettling is that I now also witness experienced health care providers declare in public that they are finding it difficult to admit and treat unvaccinated patients. It startles me.
After all, we never take that stance. For any reason. Everyone has always been welcome. It is said that unvaccinated patients are the ones who will put a strain on the health care system this fall, and that vaccination is key to prevent this from happening. That is not said about patients who experience illness as a result of excessive smoking, or has become seriously ill due to years of unhealthy eating habits. They could also be held accountable for not taking off some of the pressure on our health care system, by living a healthier life style. But (fortunately) that doesn’t happen. ‘’All who remain in the Netherlands, are treated equally, under equal circumstances. Discrimination on grounds of religious belief, ideology, political preference, race, gender or any other grounds, is not permitted.” Amen.
I don’t have a moral opinion on people who do or don’t get vaccinated. I am , for sure, not an anti-vaxxer, but I do keep an open mind to understand their arguments. Some of the reasons brought up by pro-vaxxers are borderline perverted (to be allowed to go on holidays for example) and some anti-vaxxers are simply “seriously confused”. But those are extreme cases. Neither people who are pro or against the SARS-CoV-2 vaccine happen to be homogenous groups. I believe that vaccination, in line with all other medical treatments, should be a personal health choice or consideration, and that anyone should also consider factors such as solidarity and the social pressure of the present collective moral values. The dictatorship of those moral values. I hear very reasonable arguments from people who opted in favor of the vaccine, and also from those who explicitly opted out. Listen to the people around you, instead of judging and discriminating each other, under pressure of the current moral standards.
Based on the idea of solidarity, you could say that as many people as possible who pose a high-risk of a COVID19 infection and their close contacts should get vaccinated, as a way of relieving the pressure on the health care system. That is true and it has always been the goal of vaccinating people against Influenza. You would expect the same approach now. But vaccine hesitancy has never been a reason to exclude people from health care in times of need. Living a healthy or an unhealthy lifestyle is a personal choice and getting or not getting the vaccine should be as well. Even if the choice does not seem to be an act of solidarity. That is the personal responsibility of the individual. It is not up to health care providers to have a moral opinion when treating patients. Health care practitioners are not in the position to morally judge the personal choices of their patients. This is something I have consistently taught my students over the years.
When health care practitioners, who are supposed to be advocates of an equal treatment for everyone, without making a selection between individuals, start saying that they are finding it difficult to treat unvaccinated people, I see it as a sign that discrimination and social pressure from the present moral values have broken through into health care. The same health care system that used to be neutral, no matter what, even in times of war. Discrimination and exclusion have no place in health care, and neither do health care providers who discriminate. Doctors and nurses have to treat everyone. Everyone. The vaccinated and the unvaccinated, without making a distinction. Non-discrimination is an essential basic principle of our profession.
When health care providers appear in public and say that they have objections against treating unvaccinated patients, they are collaborating with the immoral polarization and discrimination that is presently ongoing in our communities. As an ethicist, and as a fellow human being, it is frightening to witness this. Especially when I keep in mind our history of exclusion, dehumanization and condemnation. The health care system and our hospitals should always be a safe haven for everyone. No matter who knocks on the door for help. Always. Even in times of a crisis, a pandemic or during a war. Please, never renounce to these essential human values. They exist for a reason and are of tremendous importance.
Thanks to Rudy de Kort, JetCompanion, Canada for the translation