Almost one year ago, the universal rollout of COVID-19 vaccines began in the United States. 

While some initial hesitancy was expected, it was widely assumed the public would embrace a safe, effective, free vaccine once readily available. That a significant percentage of the eligible population would reject such vaccines — too often at the cost of death to themselves or family members — seemed unfathomable. And yet that is precisely what has occurred. 

Paradoxically, of the hundreds of unvaccinated patients treated in my hospital over the course of this pandemic, I have yet to see one refuse therapies such as monoclonal antibodies, all of which carry many more side effects than the vaccines they have declined.  

Though mandates have boosted the vaccine numbers among certain groups, incentives, outreach and appeals continue to meet stiff resistance. There is little reason to believe that will change. Having survived the winter 2021 COVID surge, health care systems experienced a relative lull for an extended period. In my own hospital, the number of COVID patients declined from a high of over 700 during the first wave to single-digit numbers in the spring and summer of 2021. The delta wave that arrived this fall, followed rapidly by omicron, has swelled the number of cases dramatically with rising admissions by the day. 

Waning immunities from the initial vaccines — requiring booster shots — has compounded the problem. It must also be noted that current vaccines and boosters were engineered against a virus that no longer exists. While further boosters will inevitably be required (most diseases require chronic therapies), the current vaccine/booster regimen offers the best protection now available. But we are still vulnerable. 

Breakthrough cases routinely occur among the vaccinated and boosted. Twenty-five percent of our current COVID hospitalizations have been in vaccinated patients, with a small percent having been boosted as well. These numbers will surely grow in the coming months as vaccine immunities continue to wane. While their prognosis will be better than their unvaccinated counterparts, vaccinated patients will still be hospitalized, suffer and potentially die, particularly if they are afflicted with comorbidities.    

As COVID cases surge, there is a corresponding increase in the demand for treatments. 

Current therapies such as Sotrovimab, a monoclonal antibody with activity against omicron, and the oral agents, Paxlovid, and Molnupiavir, exist in very short supply. Already the demand has far outstripped our capacities raising the specter of rationing and a host of medical, social and ethical issues.  

The use and administration of these therapies – funded by the federal government without cost to the end-user – are governed by the Centers for Disease Control and Prevention and state prioritizations. Although immunosuppressed patients are appropriately atop the list, most unvaccinated patients will be granted the next highest level of priority.  

For example, a 35-year-old unvaccinated former smoker with asthma gains priority over a 66-year-old vaccinated cancer patient. Similarly, an unvaccinated 25-year-old smoker with depression takes precedence over a 64-year-old vaccinated patient with chronic pulmonary disease. Indeed, the highest priority on the CDC list does not include a single profile of vaccinated patients other than the immunosuppressed, regardless of other comorbidities. Based on current supplies, unvaccinated patients will receive most of these lifesaving medications.  

Beyond its inherent unfairness, the decision to prioritize unvaccinated patients for scarce therapies is based on assumptions regarding risk factors, and the data regarding which risk factors contribute to a poor prognosis is weak at best. It is this very paucity of evidence that explains the lack of clear prioritizations in the initial vaccine rollout. 

Health systems and society are benefiting greatly from a renewed focus on health equities. Underpinning it all is the question of fairness. The decision to refuse vaccination is a matter of personal choice, but with choice comes consequence. To date, the adverse consequences of such rejections have shifted from the individual to the community.  

The financial cost of caring for sick and hospitalized unvaccinated patients is being borne largely by the taxpayer. The additional cost of the unvaccinated spreading the virus, even to those who are vaccinated and boosted, tears at our social fabric. Personal freedom to refuse a vaccine takes away freedom from nearby susceptible individuals. It deprives them of safe social contact with others. Without personal consequences, refusing vaccination becomes an easier decision. Denying the unvaccinated priority to remedial treatments and therapies needs to be reevaluated.   

Summoning consensus over divisive issues, especially in times of crisis, will always pose a great challenge to a free society. Self-determination and choice are fundamental to our way of life, but so too are the principles of personal responsibility and fairness.    

Bruce Farber, MD, is chief of Public Health and Epidemiology at Northwell Health, and the chief of Infectious Diseases at North Shore University Hospital and LIJ Medical Center. Farber is a fellow of the Infectious Disease Society of America.