Ethical considerations during the COVID-19 pandemic

CLINICAL ETHICS DURING A PANDEMIC

Challenging ethical issues in healthcare are common because central to our role as caregivers is the relief of human suffering. Reviewed on a global scale, ethical issues surrounding pandemics are not unique to our healthcare systems, neither are the ethical issues surrounding scarce resource allocation. The concept of scarce resource allocation has value-incorporation, as shown during World War II when the US production of penicillin was not enough to meet all the need, with 90% being used for soldiers. This demonstrates the promotion of instrumental value (saves the most lives because soldiers were most valuable at that time) in allocation.¹

As part of an anticipated response to the effects of the COVID-19 pandemic, the importance of having an ethically sound framework to inform our clinical decisions cannot be emphasized enough. During this time, healthcare leaders are asked to engage in proac tive planning where addressing worst-case scenarios is the first step to reducing morbidity, mortality, and other undesirable effects of an emerging public health emergency.²

POPULATION HEALTH VS INDIVIDUAL RIGHTS

A public health emergency, such as a surplus of people seeking healthcare as well as critically ill patients with COVID-19 or another severe respiratory illness requiring admission to the intensive care unit (ICU), disrupts normal processes for supporting ethically sound patient care due to the steeply rising supply demand gap for treatment or supportive measures.³ The ethical framework in a public health crisis shifts to promoting the health of the population by using resources responsibly to maximize the total number of lives saved. Understanding the guiding principles surrounding public health ethics may help promote trust and alleviate moral distress and burn-out in bedside providers under austere circumstances.⁴ The focus of public health ethics, can require limitations on individual rights and preferences due to need for prudent use of resources and strategies.³ These limitations must be consistently and equitably applied, be proportional, necessary, and relevant.⁵

PRIORITIES OF HEALTHCARE PROVIDERS

During pandemics, the priorities of healthcare providers change. Shifts in these priorities create competing obligations for providers who are naturally geared towards focusing on their individual patients. Policy planners are asked to consider the two competing ethical obligations that must be held in balance (for the sake of brevity we only consider the two primary obligations listed here but concede that other ethical obligations exist):

• Duty to care—relief of suffering and respect for the rights and preferences of patients, which is a focus of ethics consultation services.

• Duty to promote equity and moral equality— fairness relative to need in the distribution of risks and benefits of care provision in society, which is the focus of public health ethics.³

Ethical reasoning thus requires caregivers to consider what should be ethically optimal and feasible for the patient. This is known as the crisis standard of care—a recognition of limitations during times of scarcity.⁶ In addition to duty to care and fairness, this ethical guidance is also based on duty to steward resources, transparency, consistency, proportionality, and accountability.² As an ethical concept, it offers concrete guidance for a system-wide response to a disaster, addressing allocation.

ETHICAL PRINCIPLES GUIDING PATIENT MANAGEMENT IN A PANDEMIC

The severe acute respiratory syndrome (SARS) outbreak in 2003 exposed the healthcare systems’ vulnerabilities, revealing the need for coordinated and cooperative responses across national borders. As such, the Pandemic Influenza Working Group at the University of Toronto Joint Centre for Bioethics was formed. They created a document that provides a framework for values at risk during a pandemic.⁵ This is being used as a framework for ethical decision-making during the COVID-19 pandemic (Table 1).

ETHICAL PRINCIPLES REGARDING SCARCE RESOURCE ALLOCATION

A majorly anticipated ethical dilemma is the allocation of finite resources, defined as measures, rationale, or means by which resources or access to care is obtained by individuals to exclude others in a time of crisis.⁶ Estimates indicate that a moderate pandemic would infect 64 million Americans and necessitate hospitalization of 800,000 (1.25%) with 160,000 (0.25%) needing space in the intensive care unit (ICU).⁷ With dwindling resources as hospitals approach surge capacity, it is likely that an increased need will cause competition for resources such as testing, personal protective equipment (PPE), ventilators, vaccines, and ICU beds. Ethical principles that guide resource allocation are well-described in the literature (Table 2).^8–11 Ultimately, we stress that no single value stands alone in determining which patients should receive scarce resources.

APPLYING ETHICAL PRINCIPLES TO RESOURCE ALLOCATION

It is important to remember that context will determine the crisis standard of care in order to apply ethical frameworks to our decisions. Thus, it is important to stress how pandemic-associated priority shifts will lead to the selection of ethical principles guiding institutional- and clinician-driven patient-level decisions. The current overarching goal is to “privilege the greater chance to successfully overcome critical illness with a greater probability of maintaining a good quality of life.”¹³

Redefining our approach to individual patient care while adhering to the principles of clinical appropriateness and proportionality of care happens as we move between the three operational stages in a pandemic: Conventional, contingency, and crisis.¹⁴ Like Italy, we must contextualize and account for the current disease severity, comorbidity, and the presence and reversibility of organ failures when allocating crucial resources.

RESPONSIBILITY TO FAMILIES

Communicating the definition of crisis standards of care to patients and families at admission is crucial to fulfil our commitment to transparency. Complimentary services (eg, ethics service, palliative care teams) should be involved early to potentially decrease distress for the patient and family. This applies to all patients being cared for during the COVID-19 pandemic, regardless of COVID-19 status.

ACCESS TO DIAGNOSTICS TESTING

COVID-19 testing is currently available in Ohio; however, nationally, testing may become scarce, requiring it to be allocated according to the same principles noted previously. We initially prioritize testing based on supply and demand and operating level of the institution (conventional, contingency, crisis). Therefore at the onset, we reserved testing for the patients with the greatest disease burden. As we enter a more conventional level in which normal operations in institutions resume, patients who are not suspected to be COVID-19 positive may require testing to be allocated in order to safely allocate healthcare resources and minimize exposure (eg, being tested for COVID-19 prior to accessing healthcare settings for services such as chemotherapy infusions, invasive procedures, or surgery).

RESPONSIBILITIES TO HEALTHCARE WORKERS: PPE, EXPOSURE RISK, PSYCHOLOGICAL AND MENTAL BURDEN

Pandemics challenge our duty to provide care to patients versus the moral obligation to ourselves and our families, among other tensions. The risk of occupation-related infectious exposures reveal vulnerabilities for both patient and caregiver populations during a public health emergency. Such populations include older individuals, those with underlying health conditions, and existence of pre-existing barriers to health care owing to insurance or immigration status. Thus, healthcare workers are prioritized when distributing PPE because their specialized training lends instrumental valve in pandemic response, which in turn increases their perceived duty to provide care.^5,9 If providers are sick, their smaller numbers will impair the crisis response, further diminishing our ability to maximize benefits for patients. Furthermore, the risk of quarantine and loss of income, transmission of the disease, and, possibly, death prove that the risk to front-line medical providers is both physical and psychological—both aspects of which should be considered.

SUMMARY

The care of patients during the COVID-19 pandemic has multiple layers of complexity. A shift in the perspectives of both patients and caregivers is necessary. If we are to be prepared to face the many challenges this pandemic will bring, we must prioritize the ethical demands of this disease as much as we do treatment and management concerns. Our Cleveland Clinic approach to resource allocation is summarized in Table 3. It aligns with guidelines from the Ohio Hospital association.¹⁶