The COVID-19 pandemic is raising profound ethical questions, including whether different socioeconomic groups and rural facilities are receiving equitable care and resources as their better-positioned counterparts.
Providing guidance in this area is the Hasting Center, a bioethics institute in Garrison, NY. The ethics think tank has issued some recommendations calling for healthcare facilities in the same region to work together to ensure ethical care.
“Ethical challenges arise when there is uncertainty about how to ‘do the right thing’ when duties or values conflict,” the authors of the recommendation note. “These challenges affect the healthcare workforce, healthcare operations, and a healthcare institution’s communication with the public. Planning to meet the needs of patients with severe COVID-19 illness includes explicit attention to critical care, palliative care, and institutional ethics services and resources.”
“Healthcare leaders have a duty to guide healthcare workers experiencing demanding work conditions, ethical uncertainty, and moral distress during a public health emergency,” the guidelines state. “The devastating nature of severe COVID-19 illness and the operational demands of caring for large numbers of COVID-19 patients add tremendous stress to clinical work.”
No healthcare system is an island in such times, since ethical duties apply across healthcare institutions regionally as well as within institutions.
“Regional collaboration can support the duty to plan by clari-fying regional challenges, sharing resources, identifying consensus, and reducing duplication and unilateral approaches in the development of policies and processes, including triage protocols,” the authors note. “Regional collaboration can support the duty to safeguard workers and vulnerable populations by facilitating personal protective equipment (PPE) allocation across institutions and care settings.”
Hospitals serving the same region should confer with each other concerning policies, processes, and practices to come to some agreement on the following issues:
- coordinated efforts to promote equity in PPE allocation across COVID-19 care settings, e.g., inpatient and outpatient clinical settings, residential care facilities, hospice programs, and home health agencies, including non-COVID-19 hospital settings where healthcare workers and hospitalized patients are at risk of COVID-19 exposure;
- creation of a resource allocation system for hospital and intensive care beds that can be activated when one healthcare system within the region is nearing capacity;
- communications with patients, families, and the public about care limitations during a public health emergency and about foreseeable medical decisions arising for critically ill COVID-19 patients;
- agreement concerning whether healthcare settings responding to COVID-19 should adopt the do-not-resuscitate (DNR) code status for critically ill patients in view of benefits to patients/survivability, risks to workers, resource constraints, and equity across institutions.
Hospital Infection Control & Prevention (HIC) sought more information on this regional approach to ethics in the following interview with lead author Nancy Berlinger, PhD, a research scholar at the Hastings Center.
HIC: Is one of the key ideas that hospitals and healthcare facilities in a region can elevate the ethical response to this pandemic by working together?
Berlinger: Exactly. When you think about healthcare ethics, it usually — but not always — has to do with treatment decisions made in a hospital context. I live in New York City. Fortunately, we are past our peak, but the focus has been very much on hospitals and the first responders. Now, looking at different parts of the country, which will experience different surges at different times, we need to be thinking of the broader community. We have more data now on who is most vulnerable to COVID-19 — older people, those with preexisting conditions, and people who are exposed via work. There are a lot of different people on the front lines who keep our society going and need to be protected.
Now, we ponder the long recovery from this terrible crisis, [knowing] there isn’t going to be a vaccine for quite some time. As we are thinking about whether it is safe to open certain parts of society, we have to remember that some people get this as a life-threatening illness, and hospitals can be overwhelmed. We have to start to think about the whole community.
HIC: What kind of discussions led up to these guidelines?
Berlinger: Some of the things that healthcare ethicists have been talking about throughout the country are where there are the cases and situations where protecting people from COVID-19 infection goes beyond my institution. Where should we be having conversations? One of the issues is who is a healthcare worker and who needs PPE. If we think of this only as the employees of a hospital or frontline workers, we are overlooking a lot of people who could potentially be at risk of infection, could be vectors of transmission between people. We have to think beyond the hospital to nursing homes, homecare, hospice programs, and outpatient clinics. All of the places where people are cared for within a community. But these groups are not all part of the same organizations — they have different professional ties and may even be competitors with each other. This is a time when we need to emphasize this is a community-wide challenge. We don’t want a situation where one facility got to a supplier faster and says, ‘Well, I’m OK.’ The community is not OK if only one institution is OK. We have to learn to think more broadly, and I think infection control and PPE is a clear-cut example of that.
HIC: There has been a lot of controversy about PPE or the lack thereof. When does a lack of PPE become unethical? Is that a question that can be answered?
Berlinger: That is such an important question. I think that this goes directly to when we think about what we owe to the public and what we owe to the workforce. It really goes down to the fact in terms of, in public health and ethics, this is a disease that travels between people. There is a social connection. We have to be thinking about harms that can occur between people. What are all of the ways that we need to protect each other? It is not sufficient to say I’m going to protect myself. If I am wearing a mask, and that is mandatory in my city, it is not to protect me. It is to protect another person from me. The other [masked] person is protecting me. In ethics, it is called reciprocity. So, when we imagine that safety is only available to the highest bidder, we are not acting in an ethical way. If we say, if you don’t have the means or political muscle to get something you are out of luck in terms of your health — that is not fair. You can also see that in terms of a richer medical academic center and a poor community hospital, a rural hospital, or a homecare agency. In public health ethics, we are always thinking about benefits and risks being distributed fairly. The concept of equity — that’s what it means. We are treating people as morally equal to one another.
HIC: Why is it important that a regional collaboration of facilities agrees on the approaches to, for example, DNR orders?
Berlinger: One of the things that comes up in formal and informal discussions is that it is desirable to not work in isolation from each other, nor to have slightly different approaches at various places that are very close together. And also, certainly not to have wildly different approaches. It would be strange, for example, if hospitals have very different policies about DNR. It is better to have a shared position and that may provide strength in numbers — if you can say everyone in the region has reached consensus, that this will be done in the same way. We can explain why we are undertaking this effort and [emphasize] that we are going to continue studying this. The same approach, rather than having differences that might be confusing to the public, who may think you “have a better chance” at one place or another. If you can reach agreement, it is better to say that all of the hospitals in the area have [a given policy].”