Clinicians nationwide suddenly have multiple urgent concerns on hypothetical COVID-19 scenarios. They are turning to ethicists for answers.

At Columbia, MO-based University of Missouri Health Care (MU Health), clinicians’ concerns revolve around mostly these three scenarios, says Lea Brandt, PhD, OTD, MA, OTR/L:

  • Patients who are positive (or presumptive positive) for COVID-19, but want to leave the hospital against medical advice;
  • Moral distress stemming from limited visitation for patients on a comfort care pathway;
  • How to answer questions about critical care resource allocation policies that could become necessary.

“Our faculty and consultation service is focused on developing ethics-related policies surrounding the COVID-19 response,” says Brandt, director of the MU Center for Health Ethics.

Their efforts have targeted the exact same issues with which clinicians are struggling. Ethicists are working on policies regarding balancing the public good with patients’ right to leave against medical advice, critical care allocation, and modified visitation. Concurrently, they are determining the best way to make all these new policies available to the public once they are vetted and finalized. “We want to promote transparency around the preparedness process,” Brandt reports.

Institutions need to be fully prepared to make ethical decisions on allocations of scarce resources, although it may never reach that point. “It is important to note that many of the policies with which we are involved focus on preparing for worst-case scenarios,” Brandt notes. In terms of conveying information on the policies, it is a balancing act. Transparency is important. “We are also wanting to limit fears that will inevitably accompany policies that offer alternative standards of care based on different ethical guidelines than those typically applied in healthcare decision-making,” Brandt says.

The MU Center for Health Ethics is participating in a videoconferencing COVID-19 program, fielding questions from frontline providers. “Through this medium, we are able to communicate the ethical rationale behind various policies and recommended practices,” Brandt explains.

One question in particular keeps arising. Some providers question the ethical justification for social distancing. They posited that it would have been more ethical to isolate at-risk groups and allow a rapid spread to promote herd immunity, with the intent to restart the economy. “They are asking questions of benefit and burden. It is important that we don’t completely discount these questions, but rather engage in thoughtful dialogue,” Brandt says.

Ethicists explain why constraints on individual liberties are ethically justified. “The short answer is that in a pandemic, the ethical analysis shifts to focus on the public good over individual liberty,” Brandt says.

This approach differs markedly from the typical ethical reasoning that is employed in the United States. However, says Brandt, “if the approach of allowing the virus to spread uncontrolled is employed to rescue the economy, there would be a significant increase in lives lost. Thus, social distancing is the ethically supported course of action.”

Institutional policies related to the COVID-19 response drew in part on the organization’s own 2009 white paper, which focused on pandemic flu.1 “In short, we have communicated that in times of pandemic, ethical responses should focus on the goal of having an objective and fair allocation framework that maximizes benefit to populations of patients,” Brandt offers.

There is an immense amount of public support and appreciation for healthcare providers right now. “But in order for the public to continue trusting, we need to be transparent on the possibility of what might happen in the future,” says Trevor M. Bibler, PhD, assistant professor of medicine at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston.

Some hospitals are including COVID-19 pamphlets as part of the admission package, specifically addressing supply shortages. Some communication on this point is better than none, according to Bibler. “People are able to get some sense of what the institution is thinking at that moment,” he says.

If there are not enough ventilators for all the patients needing them, a policy response from the organization “is going to be crucial to maintain trust,” Bibler stresses. Concerns in this regard are entirely legitimate. “The public would be very right to say distribution can be unfair and unequal if it’s based on a clinical decision at the bedside rather than policy-level guidance,” Bibler says.

Lack of policy guidance “usually means a lack of equity in these decisions,” Bibler says. “That is where the public should fight back very hard to say, ‘I don’t trust you to make these sort of bedside, ad-hoc decisions.’”

The downside is that openness on policies to ration care risks needless panic. “Such documents are easy to misinterpret,” Bibler says. Information given to patients might cover these specific issues:

  • The ethical basis for allocation and triage decisions, and that these are necessary to improve the survival and long-term health for as many patients as possible;
  • Some patients may not receive the machines and medicines they would during non-pandemic times;
  • A promise to allocate resources as fairly as possible.

“The right of patients to receive interventions, not just say no to interventions, but to receive interventions, is kind of foundational in American medicine,” Bibler says.

It is only in this type of public health emergency where the shift from the individual to the community seems justified to people. “In other less-resourced communities and countries, that shift happens often,” Bibler notes. “It doesn’t take an emergency. It’s daily care.”

As if it was not enough of a challenge to create a policy in alignment with the current professional consensus — and to navigate public scrutiny — ethics also has to do so on short notice. That is different from how ethics usually operates. “The role of ethics is typically to slow down the process. A lot of that process is being short-circuited,” Bibler observes. “There’s going to be ethical nuances and complexity that’s lost.”

This could result in policies that are less helpful at the bedside than intended. “The policy should be specific enough that if you hand it to a healthcare professional, they could read it, understand it, and implement it,” Bibler says.

The policy also needs some wiggle room so it is not instantly outdated if some aspect of medical care changes. “What institutions are thinking right now is: It’s better to err on the side of having a policy that isn’t perfect, rather than having no policy guidance at all,” Bibler says.

REFERENCE

  1. Consortium of Missouri Health Ethics Organizations. Health ethics considerations: Planning for and responding to pandemic influenza in Missouri. Published 2009.