The diverse backgrounds of clinical ethicists have strengthened COVID-19 responses at many hospitals. Patients and family, clinicians, and administrators are turning to ethics for help.
“One of the major early lessons in shepherding the ethical response to COVID-19 as a large institution is having a team with a deep bench,” says Andrew G. Shuman, MD, FACS, co-chief of the clinical ethics service at University of Michigan Medical School Center for Bioethics and Social Sciences in Medicine (CBSSM).
At Michigan Medicine, ethicists’ expertise encompasses scarce resource allocation, palliative care, neonatology, public policy, surgical ethics, research ethics, and learning health systems. Ethics has been an integral part of organizationwide disaster preparedness for the past decade.
“Our ethics team has contributed to local, state, and national discourse around disaster preparedness ethics, and how to allocate scare resources in times just like these,” says Christian Vercler, MD, co-chief of the CBSSM’s clinical ethics service. When dealing with a global pandemic, “a shift from the status quo must occur,” Vercler stresses. Scarcity of resources is no longer an abstract or hypothetical issue that can be debated without a deadline. This is an acute, tangible problem that limits individuals from getting whatever they want.
“That requires thinking much more seriously about public health ethics than the individual-centered, autonomy-focused ethic that pervades Western medical practice,” Vercler offers.
For patients and families who are denied certain treatments, it means emotional upheaval. It also is hard on physicians who are not used to saying no. “This is why we have developed a strategy for times like this,” Vercler notes.
On the clinical side, the team that decides on allocation of scarce resources is completely separate from the clinical care team. Ethics uses the same approach.
“We have separated the clinical ethics consultation team from the ethicists who are members of the review committee that makes rationing decisions,” Vercler explains. In some ways, it is business as usual for ethics. Regular consults are happening at the rate of about 10 per week.
“The process for requesting a consult, involving stakeholders, and addressing the ethical question remains much the same,” says Janice Firn, PhD, MSW, a clinical assistant professor of learning health sciences at the University of Michigan.
The main difference is that consults are handled remotely now. Also, many consults are affected in some way by COVID-19, even if indirectly. There are a few ways the pandemic has affected the work of ethics:
• Ethicists are closely involved in preparations for a surge of patients. Policies are needed urgently for when the hospital is filled to capacity with COVID-19 patients.
“We are actively involved in development of those policies, and ensuring that they are applied fairly across our different healthcare settings,” Firn reports.
• Clinicians are expediting the release of those who can be discharged safely to make room for anticipated COVID-19 patients. This affects ethics because the group of patients who remain hospitalized are more complex, both in terms of medical care and psychosocial care. Those patients are more likely to have more complex ethics needs, too.
“Continued hospital admission, treatment, and discharge planning have become more complicated,” Firn observes. “The proportionality of risks and benefits have changed in light of COVID.”
• Medical teams struggle to make clear recommendations because of known and unknown COVID-19 risks. “Patients and families are struggling with the burden of decision-making,” Firn says.
Before COVID-19, discharge to a skilled care facility was viewed as a safer and less risky option for many patients. Therefore, the clinical team was confident about such a recommendation. “This is no longer the case,” Firn says. Many patients and families are choosing home over another setting because they are worried about contracting COVID-19.
For the clinical team, the goal is the same. They facilitate informed decisions about the various options available. Once a decision has been made, they mitigate risk wherever possible. “However, the calculation of risk is challenging with so little COVID-related data available,” Firn adds.
• Ethicists and clinicians are suffering from physical and emotional exhaustion. “Cases can, understandably, start to run together,” Firn acknowledges. “It becomes more difficult to address the novel features of an individual case.”
• Ethicists help medical teams apply the skills they have built over years of caring for patients while also considering whether COVID-19 issues are a factor. Is COVID-19 really something entirely different than ethicists have ever faced before? “It is, and it isn’t,” Firn says. In the midst of so much uncertainty, it seems as though ethical decision-making is covering entirely new territory. This mindset is not particularly helpful.
“To overexceptionalize COVID can paralyze medical teams, patients, and families from using pre-COVID decision-making skills that are transferable to this situation,” Firn explains.
In important ways, the work of ethics really has not changed at all. “Ethics consult work these days includes elucidating any unique features of the case within an ethically sound triage process, creating space for reflection and creative thinking, and attending to the emotional well-being of the stakeholders involved,” Firn says.
There was not always a single best medical option, and decisions could not always be made based solely on patients’ values, even before COVID-19. “This reality remains true today,” Firn adds.