As the COVID-19 pandemic increases the numbers of critically ill patients flowing into hospitals, doctors in many areas are facing an increased shortage in vital equipment and supplies.
In some cases, this can present ethical dilemmas to physicians who must choose between patients or choose between their own safety or providing care.
Medical Economics spoke with Jeremy A. Lazarus, MD, a member of the AMA Council on Ethical and Judicial Affairs and former AMA president about what physicians are facing and how they should handle these difficult situations.
Medical Economics: During this pandemic, what kinds of ethical dilemmas have physicians been facing, and what dilemmas do you expect them to face as the crisis deepens?
Jeremy Lazarus: The most pressing dilemmas that have emerged to this point are raised by shortages of essential resources, especially personal protective equipment (PPEs) for frontline clinicians and the looming prospect of having to make extremely difficult decisions about which patients will, or won’t, have priority claim on our limited supply of ventilators. Physicians are facing very difficult choices under conditions of great uncertainty—we just don’t have good data yet.
Most of us, in the U.S. certainly, have never been in situations where what is widely seen as optimal care simply may not be feasible. We can’t practice the way we’ve been used to and that’s very unsettling. But that’s exactly what we have to do in a pandemic when the demand suddenly becomes so much greater than our capacity.
ME: How should physicians approach each of these decisions?
JL: Physicians shouldn’t be left to make these decisions individually. They need guidance—from their institutions, their states, or national bodies. Having the institution make the call, in a systematic way, about who gets a ventilator and who doesn’t is far preferable from an ethics perspective, than leaving that to the patient’s caregiver. Having a designated committee or institutional officer make the call based on objective guidelines helps ensure that decisions are fair and takes the burden off physicians and other clinicians who are providing care for the individual patients affected.
We know that many institutions and states have policies that they’re updating in light of what we know currently about COVID-19; others are developing them. The AMA is gathering triage guidelines from many sources with the goal of posting examples.
ME: How can physicians deal with the mental stress of making life-or-death decisions caused by equipment shortages?
JL: Institutional protocols for making the life-and-death decisions that we’re going to face is one of the most effective ways to help physicians cope with the uncertainty and the psychological toll of the pandemic. But we’re also seeing virtual professional communities emerge with physicians sharing information, concerns, ideas on Twitter for example. Not just with clinicians in their local institution or community, but across state lines and even internationally. Having the support of colleagues who are facing the same dilemmas can be enormously helpful.
This started out as ad hoc communication, but institutions and communities are beginning to create virtual activities more systematically. Things like virtual town halls can connect physicians to one another and bring the public into the conversation in ways that support everyone. The state medical society in Colorado, where I live, has been holding these virtual town halls bringing in state public health experts to update us on the situation in Colorado and responding to questions from practicing and retired physicians.
ME: With a shortage of PPE, what ethical dilemmas do physicians face when it comes to caring for patients who may be infected with COVID-19 but the doctors lack the proper equipment to safely treat the patient?
JL: One of the commitments physicians make on entering the profession is to accept greater than usual personal risk in times of urgent need, such as an outbreak of pandemic disease. In the best of all possible worlds, of course we’d provide them with top-of-the-line personal protective equipment, because we also need to protect the physician workforce to meet ongoing chronic health needs. When there’s a shortage of PPEs, physicians may have to be willing to accept suboptimal, but safe protection—at least until supplies can be replenished.
Decisions to allocate PPEs are similar to those to allocate ventilators or other supplies for patient care, and like other allocation decisions the institution should have a protocol for how to make them. Thinking about which personnel have the most urgent need for PPEs because they are exposed to the greatest risk caring for seriously ill COVID-19 patients have a strong claim to available protection. There may be other options for protecting physicians who are personally at high risk because of an underlying medical condition, if they can be assigned to provide care to non-COVID-19 patients, for example.
The institution should also explore options for increasing the supply of PPEs or determining whether PPEs can be adequately sterilized and safely reused until supplies of new equipment are available, or find other creative ways to meet the need.
ME: Many physicians have young children or elderly parents at home. Is it ethical for them to not show up for shifts at a hospital where COVID-19 is prevalent? How should physicians keep their families safe while still meeting their ethical obligations as a doctor?
JL: I don’t think we know just how many physicians have family or household members who are at high risk, but we do know they’re out there. Balancing the professional commitment to provide urgently needed care in a pandemic with responsibility to one’s family is tough. Physicians need to think carefully about what a decision not to show up for work will mean, what burdens it will place on their patients, and the colleagues who will have to pick up the slack. Following strict infection control measures at home should be a first choice. The risk to the physician would have to be very compelling to justify a decision not to go to work.
But again, this isn’t a decision that an individual physician should make, or be asked to make, on their own. Health care institutions have a responsibility to provide guidance for their staff.
ME: What are the ethics around not allowing end-of-life visits by family members, leaving someone to die alone?
The prospect of patients dying alone because protecting the well-being of the community means that family members won’t be allowed to see their loved ones is appalling. No one wants that to happen. But that’s the reality of a pandemic, when public health needs have to take precedence.
It can help to remember that we do it to protect the living, including family members. Making sure families understand why they can’t see their loved one doesn’t make it easier, but does help them accept it.
We must meet our obligation to ensure that every patient receives appropriate palliative and supportive care at the end of life.
ME: If this crisis ends up being worst-case scenario, do you think there are ethical dilemmas coming that no one has even thought about yet?
JL: I don’t know that we’ll see new ethical issues, but I do think the pandemic sharpens our focus on questions we’ve been debating for a long time now without resolving them. For example, in the face of pressing needs for access to medical care, we’re being challenged to think very concretely about how we organize care, have health care coverage and — how can we get more people into care, in a timelier way?
We can think about leveraging technologies like telemedicine to screen patients for coronavirus, or to provide routine primary care services.
We can think about how we might tap the wisdom and skills of retired physicians. Not in providing direct patient care in high-risk settings, but in in providing care in other areas to free physicians to care for COVID-19 patients. It would be terrific to have local or regional clearinghouses where retired physicians in the community could sign up to volunteer in different roles. Right now, we don’t really know who’s out there willing and able to help. And in parts of the country that haven’t been hit hard yet, we still have time to plan for how they might contribute to the overall effort.
ME: Are there ethical resources doctors should know about?
JL: The American Medical Association is developing short-use cases that apply guidance from the AMA Code of Medical Ethics to issues as they are emerging in the pandemic that are posted to the AMA's COVID-19 Resource Center as they become available. The full Code is available online at https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-overvie