Ep.45 The Stance Of Biomedical Ethics On Vaccination With Dr. Arthur Caplan

Updated: Nov 18

The debate on vaccinations and individual freedom has been hot given the pandemic's extended period of quarantine. However, what does biomedical ethics say about this? Joining Dr. Alaina Rajagopal today is Dr. Arthur Caplan, Professor and founding head of the Division of Medical Ethics at NYU Grossman School of Medicine. He is also the author or editor of 35 books and more than 800 papers in peer-reviewed journals. His most recent works focused on vaccination, ethics and policy, and good research integrity in biomedicine. Today, they dive into the discourse on vaccination and how medical professionals and patients should approach each case. Within that context, they also delve into which patients to prioritize, the doctor's right to decline or accept patients, and their thoughts on the rampant anti-vax protests. Tune in to this interesting and insightful conversation to learn more about the issue.


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The Stance Of Biomedical Ethics On Vaccination With Dr. Arthur Caplan

We're talking to Dr. Arthur Caplan. He is a Professor and Founding Head of the Division of Medical Ethics at NYU Grossman School of Medicine in New York City. Prior to coming to NYU, he was the Sidney D. Caplan Professor of Bioethics at the University of Pennsylvania, where he created the Center for Bioethics and the Department of Medical Ethics.

He has also taught at the University of Minnesota, the University of Pittsburgh and Columbia University. He received his PhD from Columbia University. He is the author or editor of 35 books and more than 800 papers in peer-reviewed journals. His most recent books are Vaccination Ethics and Policy and Getting to Good: Research Integrity in the Biomedical Sciences. With that welcome, Dr. Caplan.

Thanks very much. I have to laugh. I've added about 30 articles in the peer-reviewed journals due to COVID.

I can imagine there's no shortage of biomedical ethical questions. Let's start with the basics. What do you do as a biomedical ethicist?

I ran a division at NYU Grossman School of Medicine. I'm the Chief of the Division. We have a number of areas where we do work. We teach required courses to our med students. We have a Master's program in Bioethics that recruits doctors, lawyers and other people with other backgrounds. Some are on their way to medical school. Some are on their way to law school. Some are on their way to social work school. We have about twenty students at any given time there. We teach them. We have research projects.

We're a very busy research program in that we do surveys and analyses of opinion leaders. We try to see using Decision Theory, how doctors make decisions about things like Ivermectin. We have a study on that going on. We might do research using legal analysis or even history. Our projects are ongoing in vaccines which, by the way, I started at the University of Pennsylvania many years ago, long before COVID. It's positioned us to be knowledgeable about what goes on with vaccines.

We have projects on rationing, early approval of medicines and how you gain expanded access and compassionate use of drugs and vaccines. This came up again, ironically, with emergency use approval, reproductive technologies, big footprint in transplant ethics. We have many papers and reports. We sometimes get involved in issuing guidelines. Readers may be interested in that.

We started a project on boosters, trying to get some guidance about, “Are they really boosters? Are they third shots? Are you taking away from other people if you use a third shot for yourself?” We handle distribution and many other questions like that. Lastly, we do get involved in policy advice. The Department of Health for the City of New York will use us. The State of Connecticut will use us. That's been true, particularly in COVID for allocation, rationing, decisions, mandates and other decisions that policymakers have to face.

It's busy and very active. We occasionally do one more thing. We do case consults. If there is a battle in the hospitals that NYU has, and it's a huge system stretching from Long Island, through Brooklyn, into Bellevue, in the VA, in the Tisch Hospital in Manhattan and up into Westchester County. If a family is fighting about ending food and water for a particularly ill loved one, they can agree. That's the sort of thing we get called in to help mediate. We have a clinical presence and that can be lively sometimes.

I've been involved with a few of those cases. It's always a valuable asset to have a bioethicist involved and helping guide some of the ethics of those decisions. A lot of family members feel a lot of guilt about making those decisions and they don't want to “give up.” Discussing some of the ethics of, “Are we doing harm? Are we making this person's end of life more difficult than it needs to be?” Going through those discussions is very valuable.

Medicine should not be practiced like a restaurant. You don’t go in and have somebody order something and then say, “Okay, we’ll get you that.”

We've done some good being able to mediate some difficult cases and get them resolved. I will confess it doesn't always happen. The family still resists, has a path that they want to follow on religious grounds or cultural grounds or whatever it might be. I can't say we succeed all the time but many times, it can be helpful.

You founded several departments of medical ethics. What inspired you to study Biomedical Ethics?

There's a deep Freudian answer to that and a more practical answer. The deep Freudian one is when I was about six, I had polio. I was in the hospital for nine months at the Mass General. I'm from Framingham outside of Boston. I was in there paralyzed. My legs and neck were paralyzed. I did not have any complications with my diaphragm, muscles in the ribs or anything like that. I could breathe. I never was in an iron lung.

Many people around me were. Many of the kids died. It got me thinking even at that young age, they don't tell us the truth. They'd say, “Johnny went home.” You're like, “Johnny didn't go home. Johnny was dying next to me. I doubt very much he went home.” Even at six, you're like, “This doesn't square up.” I can tell you, my memories of that are almost photograph-type. I remember them well.

You couldn't see your parents, your family and you had limited visiting hours at that time. They didn't have people stay in the hospital, which we often do. I didn't think I saw my dog for a year, which drove me crazy. I got involved in rehab because, for reasons unknown to science, the virus was beginning to be killed in my body and I began to get function back. I'd been in bed for so long that I had a lot of muscle weakness. I had to learn to walk again. That was two years roughly more of PT.

I learned about rehab medicine. I probably am the only ethicist that writes about rehab medicine. It's not glamorous. It doesn't have a big technology. People forget about it but it's obviously very important in orthopedics, stroke and many areas where you have to be rehabbed. That got me interested. Not to take up the whole program with my biography but I went to college at Brandeis.

I was very interested in ethics because I took some philosophy courses. At the time, there were all kinds of issues breaking about the Vietnam War, feminism, gay rights or civil rights. Lots of issues on campus were being debated and I got engaged with all that. I decided to hit off to med school and I went to Columbia. When I was there in the first year, I began to see different issues happening in front of me.

For example, we did an early program to try and do in vitro fertilization but it was very controversial. The head of OB-GYN at the time did not want any in vitro fertilization experiments done. He went into the lab of one of the guys that were doing that work and flushed down the drain whatever was in those dishes. I wasn't there to see it but I certainly heard about it. I began to ask our medical school dean, “When do we talk about these ethics issues?” the dean said, “You ask your attendings.”

For those of you not familiar with medical hierarchy, the chance of a first-year student asking his attending about a medical ethics issue was somewhere between zero and a big minus number. That wasn't going to happen. I did what they said and that was about that. I decided to go down to Columbia and get a Philosophy degree, study the ethics issues and then try to bring it back to medicine. That was the more immediate road. It was probably more than you needed to hear but it's interesting.

Biomedical Ethics: Doctors should practice according to the standard of care, according to what they know is evidence-based, as the latest literature, and from talking to colleagues to get their opinions.

You bring up a good point. Biomedical ethics is incredibly under-taught in medical school. The only formal course that I took was when I was an undergraduate. I was required to take a Philosophy credit so I took Biomedical Ethics. That's all of the formal education that I have beyond the day-to-day education as you learn to become a physician. I'm very grateful you're doing what you're doing.

I will tell you, we have required courses in the first and second year and they're fine. We do more clinical discussions in the second year. The first year is a little didactic. My program has probably six professors, maybe eight postdocs and a variety of other med students and people hanging around. The biggest challenge is resonance. That's where the action is. They're scattered all over the place. Readers, again, may not realize we're using the NYU system.

We have 1,000 residents in a zillion departments scattered over geographic space. End-to-end, it's at least 200 miles. Getting in front of them, getting there when they have the cases and when they're responsible for decisions, is very tough. We do some but I don't think we do enough. That's the area I'm most challenged by and would like to see improved.

It's great to talk in the classroom and you'll remember this yourself. What you think in the first and second years about what's going on is interesting. It's what happens when you take care of patients that get interesting. The attending says, “Don't call me tonight unless you have the world's biggest crisis.” You got to make decisions and you're trying to figure out what to do.

It's very much a culture of learning on the fly in some cases. I feel fortunate that I took that course when I did because it gave me a framework as I went into medical school and residency to work from. There's been no shortage of topics in biomedical ethics, particularly related to COVID. Let's start at the beginning of the pandemic.

There was a lot of buzz around hydroxychloroquine as a cure for COVID or preventative medication for COVID, along with bleach and a bunch of other things. People were scared and desperate and prescribing medications inappropriately. Can you talk about the ethics surrounding the issue of prescribing medications for off-label use and how doctors should approach deciding whether to prescribe a medication off-label?

Let's even add into that mix Ivermectin, the deworming medicine that was developed for Guinea worm in Africa and used very successfully. Merck did it. Merck also realized if you could kill worms in people, you could kill worms in animals. They built a big division for veterinary medicine using Ivermectin and they didn't see a use anywhere else. The manufacturer has said, “Merck, this is for animals only.”

It's dosed for horses, sheep, and readers may not realize, dogs. It's the main ingredient of your deworming heartworm pill if you have a dog. I'm not sure it's used in cats. I don't have cats but I have dogs and it's used there for sure. There is a huge push. I'm not even sure who started it to use Ivermectin both prophylactically and therapeutically for COVID.

There was a paper that came out of France that said Ivermectin seems to help prophylactically. It has been withdrawn as completely incoherent. I don't even know how it got into a journal. It was challenged and it's been retracted, as they say. Therapeutically, we haven't seen any data or any substantiated claim that anybody who was dying from COVID got better and somebody gave them Ivermectin and they were either stabilized or got better.

I've seen nothing. They're anecdotes and people claiming something. Still, a lot of people ask for Ivermectin. My view is this. Legally, you can use anything that's out there off-label. You are free to prescribe it. We have a very generous legal backdrop. Once FDA approves a drug, you may use it off-label. It's important to remember that Ivermectin is not approved by FDA for human use, at least outside of a narrow indication for worms. It might be used for a tapeworm. I don't know.

If you're putting something into somebody's body, there should always be a discussion on when it's coming out. Starting things really demands some discussion on stopping things.

It's certainly not approved. There's no indication for it for any viral disease, including COVID. Second, science doesn't square up here. Why would Ivermectin, a deworming parasite medicine, kill the virus? That doesn't make any sense. Could you use it? Yes. You do have the discretion to prescribe but you are way outside the label indication.

Legally, your liability is if something goes wrong, you are responsible and you could be sued even if the patient requested it. It's not up to what the patient said. It's up to what you did. By the way, this is true for any off-label use of anything. You can do it but if harm happens, you are responsible. I can tell you I've testified, not a lot but a few times in malpractice suits for off-label use of a device or a drug. I'm going to say flat out. You will lose. There is no defense.

The person got injured, you're off-label and they turn around. Basically, it's how much are you going to pay to their insurance company? Some of them are self-insured so it's how much are you paying? Ethically, my view is whatever the off-label, you've got to resist it. I don't even care if there's a court order. I would not fill a prescription for a dangerous non-indicated drug that the manufacturer says don't use. That the WHO and AMA say don't use.

In other words, the standard of care says don't use it. I don't care what a judge says. If they want to come in, administer it, prescribe it, let them go to medical school and do it. I don't see it. I know it's risky to defy a court order and they have to be appealed but I would never fill an off-label request unless I believed, for whatever reason, that this might help.

It's common for patients to come into a physician or, in my case, an emergency department with an idea of what they want or what they think they need. Our job as clinicians is to guide them and say, “This is what the science supports.

This is what the literature supports. This is what my diagnosis is for whatever's going on. This is the appropriate treatment for that or there is no appropriate treatment for that.” Often, I've heard a lot of colleagues and I felt pressure from patients to cave into demands that I knew were inappropriate. It's always a good reminder to discuss these issues and remember that we should always be guided by science, not by any political or personal pressures

To put it simply, that was well said. Medicine should not be practiced like a restaurant. You don't go in, have somebody order something and then say, “Well I'll get you that.” Sometimes we do it. I see it. People come in and say, “The erectile dysfunction area is big for this. I want Viagra.” The doctor should be saying, “Do you have any other issues? Maybe I have to examine you for diabetes. Maybe you have high blood pressure. Maybe your relationship isn't so good. Before I prescribe this medicine that you want because you saw it on TV.”

We do have this, what I consider unfortunate direct-to-consumer advertising going on all the time of products. I have to work you up. I have to examine you. I have to see what the cause might be of your erectile dysfunction or whatever it is. When the patient comes in and says, “I saw on TV that I want this.” That's a starting point but that isn't the endpoint. Doctors should practice according to what the standard of care is. According to what they know is the evidence-based, the latest literature and talking to colleagues to get other opinions. The fact that the patient appears with their request is meaningless to me. It doesn't count.

Another interesting ethical issue surrounding patient requests would be the discussion of birth control. I've also had patients come to me and say, “So-and-so doctor refused to prescribe birth control for me. So-and-so doctor refused to remove my IUD when I asked.” That gets into discussions of patient autonomy and making sure that in those cases, we are following the standard of care and not refusing something based on a personal belief or a personal issue.

It reminds me of one other small but important point. If you're putting something into somebody's body, feeding tube, IUD, I don't care what it is, there should always be a discussion about when it's coming out. That can include, "Never or not until you die," or something. In addition to getting consent to start whatever it is you're going to do, a ventilator or intubation, somebody should have that discussion saying, “If you don't flourish or you don't respond, we're going to discontinue. If you decide you want a child, we're going to take it out. Here are the circumstances under which that can be done.” Starting things, demand some discussion of stopping things. That would get us out from under a lot of fights, misunderstandings and battles that break out.

Biomedical Ethics: If you're a healthcare professional, follow the principle, 'do no harm.' Every code of ethics in healthcare says patients first.

I do have patients ask if I'm admitting them to the hospital, “When am I getting out?” Often, that's an, “I don't know. I can't predict that,” kind of answer.

I'm all right with that.

As long as it's an honest answer.

I've seen a lot of situations, too many, where the first time somebody talks about the fact that you're not only not getting out, you're going to die when palliative care comes in. Too often, the oncologist or whoever it is, is pushing the next trial or the next something. They haven't said, “It's very unlikely you're going to benefit here. We want to prepare for a bad outcome. We want to prepare for your death.” Sometimes people aren't willing to go there. You've got to start that dialogue early so that you're not at the end of the road and people don't even understand that there's nothing more to do.

That sets up problematic expectations. When I was working in the ICU, in particular, you see all of these different specialists that come in and see patients. For example, there's a cancer patient. The oncologist is telling the patient, “There's this new study we can try.” The ICU doctors are coming in and saying, “You are going to be miserable if we continue to try these things. Here are some palliative measures we can do to make you more comfortable so you can enjoy as much as possible and have some freedom for the remainder of your life.” Other specialists are also coming in and saying other things.

I had a case where an individual had severe heart disease, multiple stents, diabetes, had some form of lung cancer going on at an early stage, was detected to have pancreatic cancer and underwent a Whipple. This guy isn't going to live a week anyway. Pounding on that person, I thought, was almost malpractice. It was like, “What are we doing here?”

People do feel an obligation, come in and either say, “I could treat that disease or I can offer you something. We have to try something.” At the same time, from the patient's point of view, there is a place of autonomy. They may say, “If that's what you got and I'm going to be sick or in the case of the surgery, laid up for my final two weeks, I'll forego that and I'd rather feel better.”

It's difficult for families to navigate that information sometimes. As a physician, it's difficult for me to navigate the medical system as a patient. I can only imagine how difficult it can be for families without any medical training. Let's talk about vaccines because this is another ethical question. There's been a huge amount of debate around personal freedoms. This applies to masks as well. It's somebody's personal freedom versus having some personal inconvenience to protect the population as a whole. How would you encourage our readers to think about this problem and approach this problem?

The first issue about autonomy with respect to vaccines or masks is, “What's my personal situation? Am I a nursing aid in a nursing home where I deal with very vulnerable people who we know have died in high numbers because of COVID being brought into the institution? Am I working at home with someone that doesn't also leave the house and works from home? I have minimal contact unless I go to the supermarket or the store with others.”

They're not quite in the same zone of risk, if you will, either to get sick or to make others sick.

The other one is very likely to expose people, given the high contact. The nurse's aid frequently shifts from place to place. They can become almost Typhoid Mary-like in some of the spread that they can do. Another person is home and not getting exposed and not exposing others very much. Where you are on the scale of risk to yourself and where you are in the scale of risk to others matters.

Where you are on the scale of risk to yourself and the scale of risk to other matters.

Secondly, vaccines. They're exceedingly safe and work very well. I see people sometimes say, “What about heart problems or heart inflammation?” The rate of heart inflammation from COVID is about 10 to 20 times what is alleged to come from vaccines. I'm not even sure it does come from vaccines. The people who have heart inflammation weren't tested for COVID before they detected the heart inflammation post-vaccination.

I don't know but it's very safe. Don't believe misinformation. A mask is not going to cause your child to have a lack of oxygen and brain damage. I keep seeing that stuff up on the internet. If you're a doctor, it's important to know what people are afraid of. Look at social media. Be ready to answer questions. I might even probe a bit, “Are you worried about vaccines because you think they have chips in them? Are you worried about vaccines because you think they contain fetal cells?”

Know what they're fearful about and that will help get compliance. Having said all that, I'm a big proponent of the following principle. Don't kill your neighbor. That's the Donald Trump Principle. That's the one that triumphs over my body or my control. You should not do things that harm others. It's freedom only to the point where you're not causing harm to others.

I can't pick which side of the road I want to drive on. I should put my child in a car seat. I cannot appear, let's say, to want to drive drunk or to speed at any rate I want. There are many walks of life, in other words, where we limit freedom. Limiting freedom and saying, “You can't kill everybody. You can't kill people you come in contact with. You can't put nursing home residents at grave risk.”

You can see where I'm going. I favor mandatory vaccination. I favor mandatory masking. Neither of which are dangerous. Neither of which are undue burdens. I don't like wearing a mask myself but it's not the worst thing that happens to me in a day. What I prefer is improved traffic flow in the New York area. There is a morally strong case to say, particularly for those in high contact, teachers, nurse's aides, doctors, EMTs, the state police, people who work at big-box stores and people trying to staff restaurants and groceries.

By the time you get done with it, it may be a tiny handful of people who can make the case that they're staying home, they're not going anywhere and their food is delivered. Maybe I can say, “You could waive out of a mask or a vaccine requirement. My bottom line is they're safe. They're easy. I got my third shot. I got my flu shot at the same time. I'm here. I'm talking to you. I was not turned into an alien being or anything. They work. Don't whine about them. Follow the principle, “Care for your neighbor.” If you're a healthcare professional, follow the principle, “Do no harm.”

Every code of ethics in healthcare says patients first. It doesn't say I get to do what I want. I was talking with a cop, a state policeman here in Connecticut, who wasn't sure about vaccinations. He said, “I have the right to do what I want.” I turned around. I looked at his police car and what does it say on the door? “Protect and serve.” It doesn't say, “I'm a policeman. I'm going to do what I want.” Let's use our heroic, altruistic motives, help others, protect others and serve others. Those are the principles I want to hear about.

I appreciate the freedom and autonomy that we have living in the United States. We also need to still consider our neighbors and make sure that we aren't doing harm to others because of our need for our own personal freedoms. That's where the line, for me, is drawn.

The classic philosopher John Stuart Mill out of England back in the 19th century said, I'm roughly paraphrasing, “You're free to do what you want but your freedom to swing your arm ends at the tip of the next guy's nose. If you punch him then you're not free to do it.”

Biomedical Ethics: The places that vaccinate have probably 20% fewer death rates compared to what's going on where people aren't vaccinating, and the numbers tell you the story.

If someone has a family member or a patient who is questioning masks and vaccines, what do you think is the best way to approach them given the plethora of vaccine misinformation that's out there?

The best way to approach them is to stay six feet away and put on a mask. That's how we approach but I know what you mean. Talk with them. We have to say, “Here are the facts about vaccine safety. Here's the real truth about vaccine efficacy.” These vaccines, I'll give credit, particularly Pfizer and Moderna, are extraordinarily effective. They're hitting rates like 90% efficacy even though we've seen breakthrough cases.

You don't die, you don't get as sick and you are less infectious. They work very well. They're better than the measles and flu vaccine. These are good. Their safety profiles are amazingly good. The newer technology reduces allergic reactions. Don't worry about the long-term effects. The agents that are in there to trigger the creation of a spike protein to intercept viruses, the body eventually clears them out after a year or two. That's why we have to talk about boosters or further vaccination.

There aren't any long-term side effects. This is not going to stay in your body. Figure out what they're worried about. Address the safety. Try to get rid of the misconceptions they picked up from the neighbors or the internet or wherever. I would even say familiarize yourself with what those false messages might be. It helps the conversation to know what they might be embarrassed to tell you that they're thinking about.

They're worried that there's a chip in the vaccine, they're going to be tracked and that kind of fear. The other thing I do is I start to say, “Here's the data. Do you want to look at the places that vaccinate? There are probably 20% death rates compared to what's going on where people aren't vaccinating. The numbers tell you the story. If you want to protect yourself and your family members, look at the data. It's pretty clear.”

Thinking about vaccination in general, you're an example of what a difference the polio vaccine has made. You may be the first person I've met who had polio. That's evidence of how fantastic vaccines can be in getting rid of some of these terrible diseases.

I have something mean to say, though, in that regard. Many groups are saying we must vaccinate the world. We do need to vaccinate the world, not just the neighbor or people in our county. We owe it to them to save their lives. As long as there are big populations out there unvaccinated, there's always the possibility of increasing more dangerous mutations. We've seen COVID strains here that are easier to catch. Hopefully, we won't get one that's more virulent, nasty or more lethal to us. The way to control that is to tamp down the ability of the virus to mutate by being in fewer people to incubate it. All that said, there's been a campaign to eradicate polio around the world. Do you know when it started?

“Don’t kill your neighbor” triumphs over “my body, my control.” You should not do things that harm others. Freedom is only to the point where you’re not causing harm to others.

It's been 60, 50, 70 years?

Fifty years. It's probably the biggest push. I'll give them credit. 1998. You could say 25 years to drive it. It's been led by the Gates Foundation. Rotary International adopted it as a class. WHO is on there. UNICEF is on there. For those who don't know, the polio vaccine is relatively easy because it's oral. You don't have to go around with needles, adjutants and heavy-duty refrigerators.

It's pretty easy to move it to a village, give it to the kids and line them up. The campaign was done. You'll like this. There's no informed consent. There is nobody declining when they hit a village. It's line up the kids and off we go. There's no risk discussion or, “Maybe this would give you polio with this.” For some of them, there's a teeny risk.

My point is to vaccinate the world and eliminate polio, which we're pretty close, not there. It's taken, if you want to be generous, 25 years. We're not going to vaccinate against COVID around the world in a year. Even if we made a ton of vaccines, you got to distribute them, they need the infrastructure and you got to teach people to deliver them. It's rigmarole on a big scale. You have to remember, polio is easier, in my view, to get around the world to remote areas, remote villages and places that don't have roads. It's quite a task

I've read a little bit about the issues with the polio vaccination and the reason that it's not been eradicated yet. There's still a lot of that mistrust where people have associated that vaccine with causing infertility incorrectly. A lot of that potentially has to do with the lack of informed consent and not having that risks and benefits discussion. That breeds mistrust.

By the way, that's 25 years of not doing consent and not tolerating refusals. That is not the world now. The world reads the same internet we do. If you go out there now with COVID vaccines, you're going to get more resistance. You're going to encounter more hesitancy. It's not the same world as it was back then. I'm not saying don't vaccinate the world. I'm saying you got to be realistic here. COVID's going to be with us for a while, for years. It's not going away because we vaccinated the world in a year.

My suspicion is that we're going to end up with annual mutations and probably annual booster shots. Maybe we'll get it under control eventually and figure out how to get rid of it on a more permanent basis but I highly doubt that.

Biomedical Ethics: The first principle of a pandemic is to prevent harm, prevent death, prevent vulnerable individuals, in particular, from dying, from whatever the pandemic might be.

I think it's going to drop down to flu levels. Maybe we'll come up with a pill like we have for HIV that could treat the infected and they won't die at the same rates. I want readers to understand you've got a nasty little virus that is easy to transmit. It's highly contagious relative to other things that are out there that we worry about a lot. It is not going to be gone. It's going to have to be controlled. It's going to have to be something we can live with.

I've heard about cases of individuals with non-COVID illness who have not been able to get good medical care because of the overload of unvaccinated COVID patients in hospitals. As a physician, to me, this is a pretty big ethical quandary. I want to help everyone but at the same time I question, “Is it right?” If a person is in a hospital because of an intentional choice that they made not to be vaccinated, is ill and takes a bed from another person who has a non-COVID illness that couldn't have been prevented. How do you approach this from an ethical viewpoint?

This is an entire course. There are different settings. Let me start you with one setting that I worked in. Remember, I mentioned we do transplant ethics a lot and study it. Here's a question. Do you have to be vaccinated to be on the transplant waitlist?