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Refusing to wear a mask triggers anger from many people worldwide. In an extreme case recently, eight people in East Java, Indonesia who refused to wear face masks in public were punished by being ordered to dig graves for others who died of COVID-19.
The town’s district leader assigned two people to each grave — one to dig the grave and the other to lay wooden boards inside the hole to support the corpse. “Hopefully this can create a deterrent effect against violations,” the town leader said.
Obviously, these draconian measures would never happen in the US. Still, mask wearing has become a controversial issue, with multiple viewpoints and value systems converging upon one small square of fabric. Wearing a mask is recommended by the CDC to minimize the spread of COVID-19, but many people, including some healthcare providers, disagree with these recommendations.
A recent Medscape commentary by Arthur L. Caplan, PhD, director of the Division of Medical Ethics, NYU Grossman School of Medicine, New York City, tackled one such issue, suggesting that people who refuse to engage in social distancing or wear masks should be willing to “go to the end of the line, in terms of getting healthcare resources.”
His commentary, spurred by watching demonstrations featuring people who were not social distancing, wearing masks, or using hand sanitizer, proposed that, in “rationing circumstances,” people who become ill by not following these basic precautions should “have the moral fortitude to say, ‘I understand the consequences and I’m willing to accept them.'”
The commentary generated considerable debate among Medscape readers, with some questioning whether Dr Caplan’s proposal was serious or whether, as one reader put it, it was “tongue-in-cheek.”
Other clinicians simply considered it to be “theoretical” and unrealistic.
“Who will maintain the database of ‘last-in-line’ cards? The CDC? The DMV? The FBI?” queried one reader. Another added that the suggestion is theoretical because, “when a sick patient with COVID-19 infection presents, we don’t ask if they have flouted public health recommendations by refusing to wear a mask or social distance.”
Who Gets Priority?
Many readers bristled at the apparent implication that a patient should be “denied” treatment as a result of personal choices — even risky ones; one reader called it “medical punishment.”
“Do we deny surgery to a convicted murderer with a ruptured appendix? Of course not, because regardless of what our personal feelings may be about that person, our responsibility as healthcare providers is to treat and care for all patients as equals, without discrimination for any reason,” argued another reader.
Several commentators clarified Caplan’s suggestion. One physician stated that many readers “completely misunderstood,” since Caplan suggested specifically that non-mask-wearers voluntarily choose to go to the “end of the line,” not that healthcare providers should deny them care.
Moreover, added another clinician, “it seems like a lot of responders to this article are overlooking a key component of his scenario, which is that Caplan is talking about circumstances where rationing is required (ie, triage). And in those circumstances, we already do make such decisions — in choosing who gets a transplant, for instance. So he is not saying to not treat these people at all, but that they should opt to get in the back of the line, should rationing become necessary due to scarce resources.”
A pharmacist disagreed, stating that basing triage decisions on “a patient’s indiscretions is not an ethical dilemma, but an unethical exercise in subjective judgment.”
However, other readers pointed out that when triage is required, taking a person’s self-care into account is indeed part of the deliberation process. Some compared people who disregard public health recommendations, such as wearing masks, to people who continue to abuse alcohol but seek a liver transplant, or people who smoke but wish to have a lung transplant.
“Accountability is what’s needed,” a clinician emphasized.
Comparing Apples and Oranges
One reader called Caplan’s suggestion a “slippery slope,” potentially opening the door to denying treatment to anyone who takes risks with his or her health — a point of view shared by several others.
Said another clinician: “Most adults I see are in my office for choices they made: COPD because they smoked, hypertension because they made lifestyle choices that were not healthy, congestive heart failure after years of hypertension, renal failure after years of uncontrolled diabetes. The list goes on and on.”
A pharmacist offered other examples. “If a tattoo that someone receives becomes infected, do we not treat the infection? If someone intentionally pops a blister, should they not be provided care? If someone who knows they are allergic to peanuts eats one, do we not treat the reaction, or do we save the epinephrine for someone more responsible?”
The Opposite Point of View
However, as many readers pointed out, failing to wear a mask not only endangers the unmasked individual. A person who already has the virus — whether symptomatic or asymptomatic — and is not wearing a mask risks transmitting it to others, as does a person who contracts the virus by not wearing a mask and then is in contact with family members, especially elderly relatives.
A family medicine physician elaborated: “Readers want to compare this to not exercising or following your diet, but the vast majority of these comparisons are to other conditions, such as diabetes or hypertension, which do not potentially harm fellow humans. But not wearing a mask means the virus may be spread to another human and can potentially kill that human. Therefore, in my opinion, we are comparing apples and oranges.”
A pediatrician took it one step further. “A person with HIV who intentionally exposes others to HIV is criminally prosecuted. And HIV is much more treatable now than it has been and is not going to kill you as fast as COVID-19.”
“Give Me Liberty…”
Caplan noted that one of the central arguments offered for not wearing a mask or social distancing is that it impinges upon personal liberty.
“Ethically, I believe that liberty is great…but… liberty has responsibilities and it has limits,” he said, adding that people should be “free to choose…free to demonstrate…but…to take seriously the duties, responsibilities, and messaging that goes along with groups assembling in ways that are not safe.”
Many readers disagreed. One physician wrote, “The State cannot enforce responsibility. We all have a right to self-determination and autonomy.”
But the argument about violating “rights” cuts both ways, other readers noted. In the words of one clinician:
“The freedom to not wear masks and to flout COVID-19 precautions is dangerous, not only for the perpetrator, but for those of us who wear masks and socially distance. Therefore, they are violating my rights, not only by possibly exposing me, but also by keeping the virus level in the population high. Those of us at risk won’t be able to exercise our freedoms safely.”
Another reader said, “If people don’t feel safe to leave their homes to go to a medical appointment or grocery store because of the people who ‘don’t want their rights infringed upon,’ who is really being hurt? My 80-year-old neighbors are not getting their routine medical care because the world is not safe for them.”
Several readers recommended balancing individual freedom with responsibility to others. As one clinician summarized: “I do believe that everyone should take personal responsibility for their own health as well as social responsibility for doing what is morally correct in regard to protecting others from harm. All rights come with the responsibility to exercise them with care, consideration, and morally appropriate behavior.”
Do Masks Even Work?
Despite the CDC’s recommendations, some readers questioned whether the use of masks to reduce viral transmission is evidence-based.
“I want to know where the science is to demonstrate that that wearing a mask protects others from infection, while not wearing a mask leads to exposure,” wrote an endocrinologist. An emergency medicine physician called the notion that wearing masks prevents viral transmission “the largest anecdotal conclusion in history.”
Many readers took issue, with one noting that there actually is an emerging evidence base regarding the effectiveness of masks in reducing disease transmission. Another wanted to see evidence showing that masks are ineffective in cutting down on disease transmission.
With or without scientific studies supporting the use of masks, their effectiveness in reducing disease transmission is “just simple logic,” since the coronavirus is “spread by aerosol as well as fomites,” a clinician observed.
Additionally, there’s no “down side” to wearing a mask, according to some readers. “Think of the risk/benefit ratio of what we have to lose or gain. We have little to lose by wearing a mask and existence itself to lose for ourselves and those we might infect,” one stated.
Another pointed out that surgeons routinely wear masks, adding tartly, “Perhaps surgeons should practice freedom by not wearing masks during procedures, because there’s no proof that masks work, right?”
Hard Decisions in Desperate Circumstances
The demonstrations that Dr Caplan alluded to were those focusing on whether to reopen the country, given economic damage and unemployment resulting from stay-at-home restrictions.
Some readers highlighted this point, noting the importance of balancing public health risks with economic concerns.
“It’s easy to sit in the ivory tower and criticize those who won’t distance, but in some rural areas, the immediate financial risk far outweighs the risk of the virus. I won’t second-guess someone else’s need to make hard decisions in a desperate situation, even if I don’t agree with them,” one physician wrote.
Another physician noted the high rate of homelessness and the reduction of essential services as a result of “severe” lockdown restrictions. “Every job is essential if the individual needs to support himself or herself and others too. Let’s get back to work.”
Dr Caplan noted that, although he has “sympathy” for the push to reopen the country, the purpose of the demonstration does not obviate the need to take precautions against public health risk while demonstrating.
Who Pays for Individuals’ Choices?
Some readers suggested that individuals who don’t wear masks or engage in social distancing should face financial consequences.
One physician wrote that they should be “held accountable for COVID-related medical bills, should they become ill with it,” or perhaps “increase their health insurance premiums and/or copays, based on risky behavior.”
Another stated: “It seems fair to me that those who are likely to increase the spread of, and cost to care for, COVID should bear some (or all) of the financial burden that comes with the consequent increase in medical care. In any case, there should be consequences — not punishment — for those people who choose to put themselves and the rest of us at increased risk when they could do otherwise. As they say, freedom isn’t free.”
A clinician noted that the US healthcare system is “burdened” by people who are “not appropriately taking care of themselves.” People who disregard public health recommendations “should sign a waiver! If you refuse to social distance or wear mask in public, then insurance should deny payment to your COVID-19 medical bills.”
And a family medicine physician broadened the concept to include other scenarios in which one person’s choices endanger themselves or others, suggesting that motorcycle drivers who don’t wear helmets or drunk drivers who cause accidents should self-pay for their care as well.
Said another reader: “The information disseminated by much of the news media, not to mention social media or many political figures, is often inaccurate, politicized, sensational, or simply false. There are reasonable guidelines that can be communicated to the public and should be more widely discussed. What we have now, with factions of people turning on each other, is a result of distrust and too little real information.”
The reader continued, “Perhaps I am an idealist, but I believe if you treat people as if they are intelligent, by taking the time to consider and explain the multiple factors involved, they will be more likely to act intelligently.”