There may be some ethicists asking, “What can ethics do to capitalize on this moment?”
“Every single ethics committee needs to be asking that question right now,” says Melissa M. Bottrell, MPH, PhD, chief executive officer of Berkeley, CA-based Ethics Quality Consulting.
Hospitals are continuing to face complex ethical questions stemming from the coronavirus response. “It’s an opportunity to double down on infusing the concept of ethics throughout the organization’s culture,” Bottrell says.
The pandemic “made ethics committees players of central importance,” says Lydia Dugdale, MD, MAR (ethics), associate director of clinical ethics at NewYork-Presbyterian. Ethicists were called to craft policy for allocation of scarce resources and initiation of CPR in COVID-19-positive patients.
“Ethicists will need to continue to assert their voices even after the crisis ends,” says Dugdale, who also serves as director of the Columbia Center for Clinical Medical Ethics.
When COVID-19 first hit, hospital-based ethicists fell into two distinct groups, Bottrell observes. Some ethicists received calls from hospital leaders asking for their immediate help. “During policy and practice discussions, ethicists were a trusted advisor at the table,” Bottrell notes. Now, this group is focused on what they can do next for the organization.
Other ethicists were left out of the decision-making process for coronavirus issues. Members of this group are asking themselves why they were not consulted. “There are definitely places that didn’t get the call. They now have some soul-searching to do,” Bottrell explains.
Possibly, hospital leaders saw ethics as narrowly focused on bedside consults. “Some may have thought that ethics’ regular time frame for response was too long for the speed of decision-making that was happening,” Bottrell offers.
Certain ethicists already were part of pandemic flu preparedness committees. If ethicists were already planning that way, it clearly signaled their expertise was relevant. If not, says Bottrell, “maybe it wasn’t clear that it was in the ethics committee scope.”
Leaders also considered how well-connected ethicists were outside their own institutions. Right away, some jumped into exchanging model critical care triage policies with ethics colleagues near and far. “If they were tied into what was happening in the region or state, then ethics could be a conduit of information in this fast-moving story,” Bottrell says.
Typically, ethicists consult on cases involving one patient, their family members, and a small group of treating clinicians. “In normal times, we are doing things such as ethics education and ethics consults to help make decisions in the setting of individual patients,” says Mary Devereaux, PhD, chief of bioethics at Rady Children’s Hospital-San Diego.
Those same ethicists contributed to organizationwide, statewide, or regional issues. “We’ve scaled up to a completely different level. We are talking about how to save the most lives in the nation or the state or a particular community,” says Devereaux, who also serves as assistant director of the research ethics program at the University of California, San Diego.
At many institutions, clinical ethics expertise is not fully appreciated until a challenging case appears. “COVID has certainly been a tough case, but on a much larger scale, and with much higher stakes,” says David A. Fleming, MD, MA, MACP, professor emeritus of medicine and senior scholar at the University of Missouri Center for Health Ethics.
Caught off guard, healthcare systems suddenly faced many urgent, complex ethical questions. “The value of ethics expertise has certainly been realized in this pandemic,” Fleming notes.
Hospital leaders found themselves grappling with the reality of the COVID-19 surge with inadequate supplies. “It brought attention to the ethics question: How do you allocate resources fairly?” Devereaux says.
Ethicists asked leaders what the organization was doing, and soon found themselves crafting a triage policy. “In other cases, hospitals implemented their command center for disaster preparedness and ethics was part of that, but they didn’t have to initiate their involvement,” Devereaux observes.
Some ethicists helped with statewide or regional policies. “At all of those levels, people have been asking for medical ethicists to be involved,” Devereaux says.
Even if ethicists lacked strong ties with hospital leaders, they forged them out of necessity. “The pandemic has certainly raised the profile nationally of public health and epidemiology. It’s also true of bioethics,” Devereaux explains.
This is a special opportunity for clinical ethicists to nurture their newly expanded role. “I would hope leadership would see that there’s a unique kind of expertise that people trained in ethics bring to the table,” Devereaux says.
If hospitals want to create an institutional ethical culture that addresses fair access to healthcare, community trust, and physician and staff well-being, they are going to need ethicists’ help. “It’s easy to make decisions on a budgetary basis or economic basis without thinking of ethical issues,” says Devereaux, noting ethicists also are needed for future planning. “Once our current situation resolves, hospitals are going to need to review what we’ve learned. We will need to prepare for not just the next pandemic, but other public health disasters.”
Ethics can begin by examining larger issues behind recurrent consult requests. “The way you move into organizational thinking is to respond to these questions systematically,” Bottrell suggests.
If a life-sustaining treatment withdrawal policy lacks clarity, ethicists need to revise it or provide education. “That pushes you into conversations with leadership over specific topics,” Bottrell says. “You demonstrate that you can solve a problem for them — not as a one-off, but long-term.”
For instance, furloughs and layoffs happening at many hospitals require transparency. “Ethics can help with how to fairly distribute the economic belt-tightening, and assure good stewardship of resources,” Bottrell explains.
To accomplish this, ethics needs a presence during high-level discussions on resource allocation, protecting vulnerable patients, and caring for staff. “In the midst of this angst, as healthcare adapts to the ‘new normal,’ both old and new moral questions will arise,” says Fleming. “Clinical ethicists still have a lot of work to do.”
There are a few examples of hospital initiatives with which ethics can be involved:
• Hospitals will be restarting elective surgeries and returning to regular appointment schedules. More than just finances is at stake when such decisions are made.
“Having a voice at the table that offers a balanced and measured response as to mission and ethical implications will be important for the integrity of any healthcare institution,” Fleming stresses.
• A variety of new policies will be needed. Hospitals are expanding services to underserved areas, making resource allocation decisions for highly vulnerable patients, and setting standards for telehealth.
When institutions are crafting all these policies, says Fleming, “ethics should do the heavy lifting.”
• Hospitals need to respond to public concerns about transparency. For example, triage policies must be available for public viewing and engagement.
“It fosters trust that decisions will be objective and fair when the time comes for them to be made,” Fleming notes.
• Hospitals need approaches to respond to the emotional and physical welfare of healthcare teams. “This should, and hopefully will, be a high priority for healthcare systems and government in the foreseeable future,” Fleming says.
• Research ethics questions are arising regarding clinical trials for both treatments and vaccines. “This is increasingly important, especially in recruiting subjects from vulnerable and underrepresented populations,” Fleming says.
• Critical care triage protocols may need to be revised. Changes might be needed depending on the clinical experience in hard-hit areas, or input from public engagement.
“Further refinement of triage protocols should ensure that they are just, usable, and transparent,” Fleming adds.