Medical Ethics Think Tank Provides Ethical Framework for Managing Coronavirus
The prominent medical ethics research institute, The Hastings Center, has released a document outlining an ethical framework for healthcare institutions to aid them in managing care in the wake of the coronavirus pandemic. I believe this discussion would benefit all healthcare professionals by outlining the ethical terrain that lies ahead.
The document — titled ‘Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic’ — discusses three points: ethical challenges healthcare providers may face, ethical duties of healthcare leaders, and examples of institutional policies. I will address the first two points.
The overarching ethical challenge for healthcare institutions posed by the outbreak is balancing normal patient-centered care with public health interests. Patient-centered care during normal circumstances stresses accommodating individual patient interests and values. However, due to the nature of a pandemic and the resulting scarcity of medical resources, healthcare professionals will need to shift toward an ethics driven by public interest. As the authors write, the public-centered approach “aims to promote the health of the population by minimizing morbidity and mortality through the prudent use of resources and strategies.” This requires curtailing the patient-centered approach to medical decision-making, especially regarding resource allocation.
Healthcare facilities would do well to protect the psychological well-being of its professionals, which is at risk due to potential moral injury.
The result is a “tension between the patient-centered approach of clinical care under normal circumstances and the public-centered approach of clinical care under emergency conditions.” This may require “prioritize[ing] the community above the individual in fairly allocating scarce resources.” If medical resources become highly scarce, for example, the normal first-come, first-served policy should be jettisoned in favor of prioritizing patients who would benefit the most from treatment.
The authors note that as a consequence of implementing new measures of resource allocation, providers will likely experience “significant moral distress.” Difficult decisions will have to be made regarding withholding life-sustaining treatment “over objections of patients or families”. This is an important and overlooked issue. Healthcare facilities would do well to protect the psychological well-being of its professionals, which is at risk due to potential moral injury.
Another overlooked issue the authors discuss is the decreasing quality of medical care as resources become increasingly scarce. Resources they examine include supplies (e.g. medicine, respirators), personnel, and space (e.g. beds). For example, as more healthcare workers are needed to treat infected patients, institutions will need to recruit staff from other areas of expertise and, perhaps eventually, lay volunteers.
Healthcare Leaders’ Duties
The authors outline three duties to guide healthcare leaders: to plan, to safeguard, to guide. The duty to plan requires managing uncertainty. This involves “the identification of potential triage decisions, tools, and processes.”
The duty to safeguard requires supporting workers and protecting vulnerable populations. Because healthcare workers are particularly at risk, strong measures must be taken to protect them. Vulnerable populations also include those that have an increased risk due to underlying conditions or age, those who lack health insurance, and undocumented persons.
The duty to guide requires establishing ethically sound protocols for resource allocation during increasing levels of scarcity. As the authors write, “ICU beds and staffing are scarce resources, and a surge of critically ill patients could quickly fill available beds. Shortages of many other types of staff, space, and supplies are also to be expected.” It is advised that clinical ethicists be consulted when staff “experience uncertainty and distress under normal conditions.”
The Hastings Center’s document does not make predictions. Rather, it offers ethical guidelines for various contingencies. Even if we are able to ‘flatten the curve’ many hospitals will experience scarcity. My hope is that this document will help better prepare healthcare professionals for the ethical terrain that lies ahead.