Utilitarian vs deontological ethics in medicine and dentistry

On August 9, 2021, Jay Inslee, governor of the state of Washington, proclaimed that any health care worker who has not been fully vaccinated against coronavirus disease 2019 (COVID-19) will be prohibited from working after October 18, 2021.¹ This decision was made after considerable discussion with over 60 medical groups including the American Medical Association, the American College of Physicians, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists, together with the Society for Maternal-Fetal Medicine.

His announcement has created an uproar in the dental community with the Washington State Dental Association (WSDA) asking for a modification to this rule adding the option to “vaccinate or test.” This would be in line with the states of California and Oregon allowing those who are not vaccinated to attest to their health and get regular COVID-19 testing. Most private dental offices (irrespective of specialty) are small health care facilities that do not have the same “luxury” as larger medical centers when there is staff depreciation. A loss of even 1 or 2 staff members can tip the balance from success to struggle. As it is, since the pandemic, there has been an extreme labor shortage in all working sectors not just medicine and dentistry.

The president of the WSDA wrote to the governor in response that “in failing to consider the differences among different health care settings, this mandate also fails to recognize how COVID-19 transmission varies among different settings. U.S. dentists continue to have a lower infection rate than other health professionals, such as nurses and physicians. … the cumulative infection rate for U.S. dentists is 2.6%.² … Comparatively, the cumulative COVID-19 prevalence rate for other U.S. health professionals ranged from 3.3% to 35.3%.” ^{3 , 4}

I have read and heard a slew of comments for and against the governor regarding his decision. Some of them, not surprisingly, are quite vitriolic. Most of these comments, emails, social media postings, news reports, etc. are generalizable to the country and globe. COVID-19 has brought us to our knees in more ways than one. This brings me to the crux of my editorial: What is the role of utilitarian vs deontological ethics in medicine and dentistry as related to COVID-19? The purpose of medical ethics is to deal with moral dilemmas that arise from conflicts in duty and obligation. Modern medical ethics is based on 4 fundamental principles: autonomy, beneficence, nonmaleficence, and justice. Take the following scenarios I made up with no one individual in mind:

• •As a health care worker, do you have the right to provide patient care and not be vaccinated, knowing you may place your patient at risk of infection?
• •As a patient, do you have the right to seek care from a health care worker and not be vaccinated, knowing you may place that worker and their staff at risk of infection?
• •Does a patient have the right to insist their health care worker be vaccinated?
• •As health care workers, do we have the right to refuse (elective) care to someone not vaccinated?
• •Is it right for a patient to seek medical care for COVID-19 after choosing not to be vaccinated?

At least one if not all of the above will bring an immediate visceral response from the vast majority of readers. But which one is right? Can they all be right? These arguments have been in place since the beginning of health care. Utilitarianism was developed by Jeremy Bentham (1748-1832). Its concept is that of the greatest amount of good (happiness) to the greatest number of people. Even if the good may be harmful to some, if the overall benefit to the majority is good, then utility prevails. We know there are side effects of the COVID-19 vaccines. However, at this stage in the pandemic with millions vaccinated in the U.S. and globally, the overall side effects are minimal.⁵ The data support this. So, should the greater good prevail? Utilitarianism will say yes and that it is acceptable to force, cajole, threaten, entice, and even pay people to vaccinate.

Deontological ethical theory is also known as Kantism, named after its founder Immanuel Kant (1724-1804). Its premise is that the morality of an action should depend on the nature of the action. It follows universal moral laws: “don't lie, don't steal, don't cheat.” Its basis is on whether the action itself is right or wrong, i.e., harm is unacceptable irrespective of its consequences. Deontological ethics is in keeping with scripture and natural moral law. To a deontologist, right takes priority over greater good. Even with demystification using evidence-based medicine, the vaccine remains as daunting and omnipotent as COVID-19 itself. “The vaccines are still not fully approved by the Food and Drug Administration,” “They only have emergency use authorization,” “They were created too quickly,” “Governments are trying to control us,” “I am healthy, and the chances of me becoming sick are small,” “There are chips in the vaccine to monitor us,” and “It causes infertility.” These are some of the arguments I have heard from my own staff who are not vaccinated and are facing the prospect of being jobless. And let's not forget that losing your job owing to this mandate will also mean you are not entitled to unemployment benefits. It is COVID-19 today, but what about other vaccines? — Measles, mumps, and rubella [MMR] (arguments for and against resurface every year), smallpox, tetanus, polio, etc.? What if everyone decides they do not want them? Is this refusal to vaccinate really deontological, or is this something else? I leave that to you to decide.

It is now nearly 2 years since the start of the pandemic. There are multiple variants, each one we are told is more deadly or infectious (pick your adjective) than the last. We have had varying levels of social isolation, masking mandates, and the restriction of travel and our liberty with the possibility of more to come as the latest spike takes hold — all in the name of the greater good.

Irrespective of which side of the fence you are on, the only winner here is COVID-19, and that is here to stay. History will tell us who was right.