With 15 colleagues in my Harvard Medical School Media and Medicine intensive (made longer by the coronavirus, and more intensive too) co-signing and editing, I wrote an Op Ed for USA Today on the coming scarcity of ventilators and critical care resources, including clinicians themselves. The National Academy of Medicine calls our approach a “crisis standard of care,” which they define as the “optimal level of care that can be delivered during a catastrophic event, requiring substantial change in usual health care operation.”
That’s a mouth full, but here’s the short story: clinicians have already stepped up in Italy, the UK, China and South Korea to deliver care to patients, putting themselves in danger. Angela Merkel is in quarantine at this moment, because her doctor tested positive. Many older clinicians remember not just H1N1 but the HIV/AIDS epidemic, and the same feeling of—geez, what is devastating our patients in the most horrible, unseen way? I remember, 30 years ago, comforting a bleeding young man with an unknown terrible pneumonia, sores and Kaposi’s sarcoma over his lower limbs, weight loss and cachexia obvious, who was alone and fighting for his life. He didn’t make it.
Clinicians’ duties are to their patients, and when we can’t cure, we can explain, we can comfort, we can listen, we can stay the course, and in the room. It’s harder than it looks, but it comes naturally to most people I’ve seen who have a passion for healing. It’s natural, when it’s just you and your patient, and the problem you’re looking at together, whether it’s painful arthritis or a weight loss diet, or treatment for breast cancer or rehabilitation from injury.
But that was last month. This month, dying patients in the hospital are separated from their loved ones, who are quarantined off, never to enter a negative pressure hospital room until the moment has passed. Someone in many hospitals in America are going to have to decide about resource allocation when two patients need one ventilator. The burst of creativity about creating more, from 3D models on 3D printers, to repurposing Tesla auto lines, to using one ventilator for four people, to reimaging sleep apnea machines is astounding and truly American.
As we’ve seen in Italy especially, however, military triage and casualty medicine devastates clinicians forced to make decisions, even with reasonably good ethics guidance from authorities. And many bioethicists prefer not to guide these decisions: they prefer to prevent the need for them in this pandemic. I hope they have that chance, but every indication is that they may not get what they prefer. What we all prefer. That’s the clinical difference: by the bedside, there needs to be a decision for this patient, not patients in abstract.
I hope that harm is preventable, that all patients are considered equally irrespective of their societal position, and that the most vulnerable are not victimized or abandoned. A scene from last year’s Emmy award winning The Morning Show has correspondent Bradley Jackson (Reese Witherspoon) interviewing a fireman, hired privately to fight the fires on a wealthy Malibu estate owner’s property. Ms Jackson asks (I’m paraphrasing) if he thinks what he is doing is fair to others, with much smaller houses and less property nearby. The fireman replies “This is America…I wish everyone had some extra money so they could have us help them too.”
We live in an individualistic society, and it will be hard to look at community as a priority, and not to discriminate against the most vulnerable, including the half million homeless people in the U.S. Yet, fairness requires it, and we want to live fairly. If only we had been prepared (with a full complement of pandemic preparation on the federal level); failing that, the UK Nuffield Bioethics group is actually prepared for pandemics: this writer smartly writes about why being unprepared for Covid-19 is unethical. So what else is new?
One thing we can rely on in the pursuit of fairness: self-interest: the better and longer we accomplish social distancing, and the more Zoom parties and Netflix collabsshould be apparent that it is in the interest of the public’s health to ensure that COVID-19 does not spread rapidly through these populations.
For more on making tough ethical decisions in medicine, with many cases and a how-to, practical approach, see our now 26 year old guide, Ethics Consultation: A Practical Guide widely used as a text in clinical ethics and bioethics programs. And for more on the ethical issues raised by the pandemic, see Larry Gostin et al’s excellent essay.