Ethics in the Time of COVID-19
Student Author: Sienna Li  Contact: [email protected] Student Reviewers: Priya Shah , Allison Fialkowski , Margaret Irwin  Faculty Reviewers: Dr. Louise King  , Dr. Ned Palmer    Harvard Medical School,  Brigham and Women's Hospital,  Boston Children’s Hospital
Ethics are the moral principles that govern a person’s, a community’s, or an organization’s behavior. As a field of study, ethics is a branch of philosophy that examines questions and tries to find logic-based solutions grounded in moral arguments. The COVID-19 pandemic has exposed some important medical, social, and legal issues. While there may be a legal “answer” to these issues, it is important to go above and beyond that to consider what an ethical solution might be–one that takes into account all perspectives and that ensures, to the extent possible, equal and moral treatment of all parties.
This pandemic is not the first time in our history when ethical questions have arisen as a result of unprecedented global events. For example, in response to the atrocities committed by the Nazis in World War II, ethical guidelines regarding the treatment of prisoners and human research subjects were reconsidered and a set of principles written and agreed upon by multiple countries. This is known as the Geneva Convention. The HIV/AIDS pandemic in the 1980s brought up questions about whether or not medical professionals should be able to refuse caring for infectious patients out of fear of becoming sick themselves. While ethical analysis dates back to the philosopher Aristotle, our conception of ethics has been under constant revision ever since, resulting in a fluid and rapidly-changing field of study.
We’re going to work our way through some important questions that are currently being discussed all over the world. Keep in mind that these are difficult and controversial topics, and they often do not have a clear answer.
Medical professionals take many risks as a part of their day-to-day job. These risks include, but are not limited to:
- Contracting infectious diseases from patients
- Pricking their skin with an infected needle
- Threats from patients
However, because of the unprecedented and high risk of infection associated with treating COVID-19 patients, many people have asked the question: can doctors refuse to treat a patient solely due to the increased risk to themselves? Importantly, certain groups of people are at higher risk of having serious complications as a result of COVID-19. This includes:
- 1.Pregnant women
- 2.Elderly (over 60 years old)
- 3.Those with an underlying chronic health condition (such as heart failure or diabetes)
- 4.The immunocompromised (immune system is not working as well as a healthy individual due to a disease or a side effect of a drug, as in cancer treatment)
- 5.Those with a history of smoking or lung disease (including asthma or exposure to air pollution)
In general, many consider it the medical professional’s ethical duty to provide care to COVID-19 patients. By choosing medicine as a career, medical professionals assume and accept the responsibilities of caring for patients, including the risk of contracting an infection. However, it is important to consider situations in which:
- 1.Adequate personal protective equipment (PPE) is not available. Unfortunately, due to scarcity of resources, this was the situation at nearly every hospital in the United States. Thus, while issues of inadequate PPE need to be addressed, they do not absolve medical providers of their duty to provide care as safely as possible. We will talk more about resource allocation later on.
- 2.The provider is in one of the high-risk categories mentioned above. In these cases, medical professionals should use their judgment to assess their individual risk for contracting COVID-19. Stopping or reducing in-person clinical practice may be appropriate, if the risk to an individual’s health is significantly greater than the general population. That being said, medical professionals also have a duty to provide their patients with continuous care, to the best of their ability. A medical provider is required–both legally and ethically–to find an alternative provider to take over their clinical responsibilities before discontinuing care of a patient for any reason.
It is within one’s legal and ethical right to resign from a job. However, in most circumstances, medical providers cannot simply refuse to do their job, even for reasons of personal safety. Importantly, doctors are not the only people being asked to risk their health during this pandemic. Nurses and other essential employees (housekeeping, maintenance, dietary staff etc.) are paid much less and often must keep working to support their family or keep their insurance.
When a person is diagnosed with COVID-19, it becomes extremely important to identify any people whom they have been in close contact with and to notify the contact that they might be at risk. The national organization Centers for Disease Control and Prevention (CDC) defines a close contact as someone who:
- 1.Was within 6 feet of someone who has COVID-19 for a total of 15 minutes or more
- 2.Provided care at home to someone who has COVID-19
- 3.Had direct physical contact with a COVID-19 patient, including shared eating or drinking utensils
- 4.Came into contact with respiratory droplets from a COVID-19 patient (from sneezing, coughing, etc.)
In addition, the CDC recommends that people who may have been exposed to COVID-19 stay home and monitor their health for 14 days. Quarantining can impose significant burdens–financially, mentally, and socially–on people, but this public health measure is an important and effective method to slow the rapid spread of the virus.
While doctors have an ethical duty to maintain patient confidentiality and not disclose a diagnosis without consent, they also have a duty to protect other people who may be at risk of exposure. Medical professionals are legally and ethically required to report transmissible disease. Public agencies, like the CDC, provide standards for when to make these disclosures of confidential patient information by law.
Given how deadly and contagious COVID-19 has proven to be, it is in the people’s best interest to keep hospitals and public agencies informed of any COVID-positive patients. This notification will not only help contain spread and reduce the risk of transmission to close contacts but could also help inform which areas we need to dedicate the most resources.
Unfortunately, because of the global scale of the current pandemic, necessary resources–such as masks, ventilators, and available hospital beds–have become scarce, and in many communities not everyone has access to them. Even in the U.S., one of the richest countries in the world, hospitals are severely ill-equipped to handle the volume of COVID-19 cases inundating their emergency departments. Additionally, resources have not been distributed equally, with low-income and underserved communities receiving far less than wealthier areas and healthcare systems. This has led to dramatic socioeconomic and racial disparities in incidence and outcomes of COVID-19. Unfortunately, doctors everywhere have been forced to make difficult decisions about which patients get life-saving medical resources and attention.
There have been many allocation principles used in the past to distribute resources, including:
- 1.Lottery system
- 2.First-come, first-served
- 3.Sickest first
- 4.Youngest first
- 5.Save the most lives
- 6.Save the most life-years (prognosis)
- 7.Reward future social usefulness
- 8.Reward past usefulness (reciprocity)
The field of organ transplantation, which involves replacing a missing or damaged organ with one from another person, is one example of when these principles have been combined. There are many more people waiting for an organ transplant then there are healthy, viable organs from donors. Thus, the medical community has had to come up with guidelines for how to decide which patients get organs first. In general, these decisions are made to optimize the survival of the organ recipient, and thus the organ itself. The organ allocation system combines three of the above principles–sickest first, first-come, first served, and prognosis–to rank patients waiting for an organ transplant. Ideally, the patient’s perceived social status or life accomplishments are not taken into account. However, factors such as lack of medical insurance, absence of social support networks, and substance abuse can be disqualifying. While this allocation system has advantages, it is inherently flawed as it is vulnerable to bias and manipulation and discriminates against low-income, disabled and persons of color.
A similar framework has been applied to distributing resources during this pandemic. At the beginning of the pandemic, when less was known about the virus, some hospitals began “scoring” COVID-19 patients based on their:
- 2.Health status
- 3.Other health complications
Theoretically, the patients that score the highest are the most in need of resources and medical attention and have the highest chance of surviving if given them. While this may appear to be a relatively unbiased method for ranking patients based on need, there is a critical problem. Patterns of structural and environmental racism and economic injustice throughout our country’s history have led to higher rates of health conditions (such as diabetes, asthma, and heart disease) that could significantly impact long-term survival with COVID-19. Thus, using the scoring criteria above, low-income persons and people of color are statistically less likely to receive life-saving resources. It is important to take into account political and social determinants of health in order to assure equitable allocation of resources.
You might ask: what then, is a fair and equitable way to allocate scarce resources? There is a controversial question and does not have a clearly accepted answer. One paper suggests a “complete lives system” that prioritizes younger people who have not yet led a complete life, but have a good chance of living one if given resources. This system creates a priority curve on which individuals aged between ~15-40 years are given the most substantial chance, whereas the very young and very old get slightly reduced chances. This is by no means a perfect system, but it prioritizes morally relevant values, resists corruption, and treats life-years as equally valuable to all.
Another paper recommends using clinical “survivability” scores, instead of broad exclusions by demographic category, to determine the patients who are most likely to die without resources but and most likely to survive with them. This system allows for near-term survivability to be determined independently from disability and does not treat a year lived with a disability as inherently less valuable than a year lived without one.