David Misselbrook is a retired London GP. He is currently deputy editor of the BJGP. This article is his personal opinion and does not represent an official view of the BJGP or the RCGP.
To ethicists “the trolley problem” does not relate to the number of patients spilling out into hospital corridors, waiting to receive care. It relates to a 1960s thought experiment from a well known ethicist, Philippa Foot.
The trolley in question is the American word for a tram or railway carriage. Imagine an unmanned carriage is hurtling down a track towards five people stuck on the rails, unable to move. You notice that there is a set of points with a lever – if you pull the lever the carriage will be diverted onto a side track where there is one single person stuck on the rails. If you do nothing five people will die, but it will not be your fault. If you pull the lever only one person will die, but you will have killed them. Should you pull the lever?
In case you’re wondering, there isn’t a “right” answer. The trolley problem is a way into discussing how much value we put on normal rules and duties, or how far we are prepared to discount them to respond to a greater need. Once the number to be saved starts to climb above three most people say they would pull the lever. We ethicists are endlessly diverted by discussion of such distant problems in student seminars.
But now, suddenly, the trolley problem has wheels.
On the 2nd of December 2020 the UK Medicines and Healthcare Products Regulatory Agency (MHRA) granted emergency authorisation for use of the Pfizer Covid-19 vaccine.1 The nation cheered and formed an orderly queue. My own local vaccine centre announced that it would start vaccinating patients on 16th December, aiming to protect hundreds of patients daily.
But on the 10th of December the MHRA introduced the requirement that patients should wait, socially distanced, for 15 minutes following vaccination. If you plan to have a throughput of 120 patients an hour then space will not allow for this in most community healthcare facilities. So our local immunisations never started, along with much of the nation.
Actually, early experience was reassuring – most severe immediate reactions can be anticipated.
The reason for the change is that two patients had serious and potentially life threatening allergic reactions to the vaccine.2 Fortunately neither died. However this was predictable – both had strong histories of serious allergic reactions and both carried Adrenaline auto-injectors. Actually, early experience was reassuring – most severe immediate reactions can be anticipated. Special clinics could be run for those with such histories, leaving the rest of the population to get a first dose of vaccine quickly, for those who consent.
Locally we are hoping that full scale vaccination will restart on January the 15th. But as I write, 2,986 people in the UK died from Covid in the last week for which there are official figures.3 It is hard to know how much delay to Covid vaccination there has been across the UK due to the MHRA ruling. But with almost 3,000 people dying per week, any delay is pretty bad news.
So do we not care if the odd handful of people die from anaphylaxis after Covid vaccination? No, of course we do. However it seems perverse to care so much less about 3,000 people dying each week when their protection could have been expedited.
Of course, safety risks to Covid vaccination might increase the number of people refusing vaccination, delaying herd immunity. But this is balanced by the risk that delay in the vaccination program could mean a surge in cases that overwhelms the NHS’s ability to give effective care – our worst nightmare, where those who have the potential to be saved die in hospital corridors from lack of available care. The unthinkable trolley problem.
Surely any reasonable balance of risk would mean adding two extra screening questions to the original Covid vaccination arrangements; any history of serious allergy or any history of needing Adrenaline auto-injectors? If negative then go ahead with rapid throughput clinics with normal medical backup.
But deeper than this, why does the MHRA appear to put less value on the lives of those dying every day from vaccine delay, who may be in their hundreds, than the hypothetical possibility of a very small handful dying from anaphylaxis?
Perhaps the immediate reason is seen in the trolley problem itself. The MHRA will have been following its standard operating procedures. It is much easier to restrict one’s gaze to the normal duty, the highest level of individual safety. That is the MHRA’s job. The thousands who may well die will not be seen as the MHRA’s fault. And there are the lawyers circling each of us in our 21st century US-lite society. Who would want to pull the lever?
When “standard operating procedures” no longer serve the public good they are not fit for purpose.
But when “standard operating procedures” no longer serve the public good they are not fit for purpose.
What can be done? In a national emergency then any system no longer fit for purpose needs to be called out. We need leaders who are prepared to do this. We need open debate, but also leaders who are prepared to act. In this situation we need a DoH that will bypass or override one specific part of the MHRA recommendations for a definite and clearly argued exception to usual procedures.
The trolley problem is being played out for real. We have become a society and a profession that is being over-regulated and micromanaged to the exclusion of reason, common sense and the common good.
In this instance, insisting on the normal highest standard of safety is dangerous to us all.