This country doesn’t like conversations about death. We created the term ‘death panels’ to avoid a much-needed national conversation about what our public health care programs should pay for. And, we would rather ration care indirectly by having a certain number of individuals without health insurance instead of thoughtful and transparent analysis in the context of utility, quality of life, and limited resources.

Yet, here we are today with hospitals in every corner of the country overwhelmed with patients with COVID-19 and with all the other conditions that necessitate hospitalization. Hospitals are at maximum capacity; they aren’t accepting new patients; patients are waiting hours, if not days, for treatment; and doctors and nurses are overwhelmed. But we’re still not having public discourse about who gets care when there isn’t enough for everyone who needs it.

Anger at those who choose not to get vaccinated against COVID-19, whether from laziness, paranoia, ignorance, or genuine questioning, is growing. There is no doubt that the Americans who didn’t get vaccinated in the spring are responsible for the increasing number of COVID-19 cases and hospitalizations as well as the delays in care being experienced by patients who need other types of care. But, how to hold them responsible? Do we deny them hospitalization and treatment because of their (in)action? And, who makes that decision? Do we want the frontline physicians and nurses making these decisions on an ad hoc basis, particularly when we know they are at their limits of exhaustion and frustration?

According to the Dallas Morning News, earlier this month, a coalition of physicians, the North Texas Mass Critical Care Guideline Task Force, prepared an internal document to alert doctors in North Texas to the imminent possibility that COVID-19 vaccination status can be considered in deciding who gets an ICU bed and who doesn’t. The intent of considering vaccination status isn’t to punish the unvaccinated or even hold them accountable. Rather, the rationale is that unvaccinated COVID-19 patients have less likelihood of survival than other seriously ill patients. Nonetheless, the private document, when leaked, immediately raised questions about fairness and perpetuating racial and economic injustices.

The chief author of the document quickly backpedaled, calling it a “homework assignment,” implying that it was a theoretical exercise rather than the articulation of ethical and clinical guidelines to equip physicians with actual tools to make fair decisions in impossible circumstances. And then he reversed course altogether saying that vaccination status shouldn’t be considered when rationing care.

He also told reporters, “We’re trying to decide how to explain this addition to the public.” Indeed. That is the challenge. How to explain care rationing to a country that historically has refused to accept any health care limits is an impossible task. But it is an absolutely essential one. What happened in North Texas is a missed opportunity for bioethicists to take charge of the conversation and bring these very difficult decisions out of the shadows and into the open. The waffling and backpedaling are precisely why we need more transparency from our hospitals about what it means operationally when they are out of beds and who is rationing care and using what criteria.  Any whiff of secrecy taints the entire process, threatening public trust at a time when trust in our basic government and scientific institutions is already unacceptably low.

Learning to communicate about death and dying in the midst of a pandemic is not ideal. But, we can’t avoid it any longer, and we need the bioethics community to start talking to the public.