RESPONSIBILITIES
These articles relate to moral and social responsibilities that may be especially important for various stakeholders in the COVID19 pandemic. As the pandemic unfolds, so does the content on this website. Please share and visit often.
COVID in NYC: What We Could Do Better
American Journal of Bioethics; May 28, 2020
This clinical ethics perspective by Tia Powell and Elizabeth Chuang is from NYC’s COVID “round one” experience. If you believe, as I do, that we’re just in the second round of this challenge, it is important to share lessons learned. I took two important and underreported lessons from this essay related to broadening the duty to plan, to focus on more than cure. The first is the need for better standards for CPR – indications and exclusions. And the second is that palliative care resources were vital but, without planning, rapidly became overwhelmed. In a Research Letter published in JAMA on June 5, 2020,(doi:10.1001/jamainternmed.2020.2713) Jihae Lee reported that virtual conversations with palliative care specialists in the ED at the time of a COVID admission for very elderly patients decreased the number wanting “full code” status from 83% to 18%. Goals-of-care conversations are only one of many specialty services palliative care offers in achieving goal-concordant care during a pandemic and beyond.
Recommended by Jean Abbott.
The Moral Determinants of Health
Journal of the American Medical Association; June 12, 2020.
Donald Berwick who started out as a pediatrician, founded Health Partners in Boston, served as director of CMS, became a leader in the Patient Safety movement, founded the Institute for Healthcare Improvement (IHI) and has done many other good works in his long career. In this JAMA article he refers to Immanuel Kant's concept of the "moral heart" and writes about the moral imperative for health care workers and institutions to adopt a broad vision of their responsibilities and opportunities for improving the health of society. He talks about the "subway stop" phenomenon, something Robin Johnson called our attention to recently, namely, the importance of neighborhood or zip code in determining health status and longevity. He refers to our present very expensive model of health care metaphorically in the mold of a car repair shop industry when there is so much potential for prevention which is sadly short changed. He lays out several possible interventions that could have profound effects on the health status of our fellow residents. I'm hoping to stimulate our collective concern about the social determinants of health.
Recommended by Don Parsons.
Sunshine is the Best Disinfectant, Especially During a Pandemic
New York State Bar Association; June 1, 2020.
When it comes to COVID-19, Arizona, Texas and Florida apparently learned nothing from New York City… or did they? This question is what makes this trenchant piece by Joseph Fins, MD, professor of medical ethics and chief of the Division of Medical Ethics at Weill Cornell Medical College, my pick for today even though it came out at the beginning of June. Fin writes, “Despite public declarations to the contrary, there was scarcity and resorting to crisis standards of care in New York City during the COVID-19 surge…History will show that there is absolutely no doubt usual standards of care became impossible during the crisis posed by the pandemic.” Yet New York never acknowledged that fact, and never provided sufficient guidance or protection for health care teams forced to make triage decisions. In Arizona however, the state Disaster Medical Advisory Committee unanimously recommended the declaration of crisis standards (providing guidance and legal protections for those forced into making triage decisions) on June 26th. The declaration now sits on the Governor’s desk. It’s an unspeakable tragedy that Arizona (and other states) couldn’t learn from New York how to avoid needing to resort to triage in the first place, but it’s not too late for Arizona to show they did learn that when triage is required, failing to acknowledge that fact doesn’t make it go away.
Recommended by Matthew Wynia.
Structural Stigma, Legal Epidemiology, and COVID-19: The Ethical Imperative to Act Upstream
Kennedy Institute of Ethics Journal; June 23, 2020.
This paper by Daniel Goldberg presents a clear and compelling description of “legal epidemiology.” The discussion of stigma is good (he’s always good on that) and the pieces on the history of plagues are terrific (he’s an historian, so what would you expect?). But I loved his brief description of laws and policies as social determinants of health, which “can fairly be regarded as epidemiologic exposures akin to any other (e.g., toxicants, tobacco and hazardous working conditions)” and which can and should be categorized, bundled for implementation, and tracked for health impacts.
Recommended by Matthew Wynia.
On Becoming a Plague Doctor
New England Journal of Medicine; May 20, 2020.
In this personal perspective piece, Mark Earnest, MD, PhD reflects on the loss of “the intimacy of patient care” during the COVID pandemic. He invokes images from the Middle Ages when plague doctors wore costumes that included protective suits and beaked masks to protect themselves. To Dr. Earnest, “the image represented the triumph of fear and superstition over the more noble impulses I hoped would drive me in a time of crisis.” When in March 2020, he found himself covered in personal protective equipment preparing to meet a patient, he “stood for the first time outside the door of a patient who I suspected had Covid-19. I was wearing two layers of gloves, a gown, an N95 mask, and goggles. While taking her history and examining her, I felt a wave of guilt and a sense that I was betraying something important.” In this thought-provoking essay, Dr. Earnest explores how these new barriers effect his experience as a health care worker and also describes how being present to care for patient is paramount.
Annotation: John Reilly.
UN Report on the Rights of Persons with Disabilities
Human Rights Council of the UN General Assembly; March 20, 2020.
A study on the impact of ableism in medical and scientific practice…The report contains recommendations to assist States to develop and implement legal and policy reforms oriented to embracing disability as part of human diversity, in line with the standards set forth in the Convention on the Rights of Persons with Disabilities. They include adopting measures to raise awareness, implementing rights-based prevention policies, respecting and protecting personal autonomy, the right to life and the right to personal integrity of persons with disabilities, and promoting their participation in decision-making, especially during the COVID-19 pandemic.
Annotation: from the Report Summary.
Respecting Disability Rights — Toward Improved Crisis Standards of Care
New England Journal of Medicine; May 19, 2020.
This NEJM perspective article underscores the ethical obligation of the healthcare system to honor commitments to equally and fairly value the lives of people with disabilities when planning for crisis standards of care and allotment of scarce resources. It explores problems with existing discriminatory codes in certain states such as Utah, Alabama, and Pennsylvania and how they have been challenged, revised and revoked in response to a need for clear and equitable triage guidelines around the COVID-19 pandemic, with a special emphasis on the ethical justification for including near term prognosis in triage scoring systems. It concludes with six practical guideposts that States and hospitals should consider when creating, reviewing or revising triage and crisis standards of care protocols.
Annotation: Meleah Himber.
Covid-19 Crisis Triage — Optimizing Health Outcomes and Disability Rights
New England Journal of Medicine; May 19, 2020.
This NEJM perspective article provides a timely analysis of the tension in crisis standards of care that seek to maximize lives saved and also protect the worth of all persons. The authors discuss the views of disability rights advocates who wish to challenge recently released critical care triage protocols. The authors provide an argument against the disabilities rights community's desire to have a first come, first served triage standard and offer ways to provide triage guidelines that do not unfairly discriminate against people with disabilities. The authors describe a fluid process that is transparent and open for community input and a requirement that research into the effects of the triage standards is essential. In addition to the value of saving the most lives and protecting the worth of all persons, the authors emphasize the importance of preserving integrity and trust and the ability of the community to heal in the wake of a once-in-a-century pandemic.
Annotation: Jackie Glover.
Responding to Covid-19 as a Regional Public Health Challenge: Preliminary Guidelines for Regional Collaboration Involving Hospitals
Hastings Center; April 29, 2020.
Useful document for regional collaboration safeguarding the health care workforce (such as equitable distribution of PPE to home care, nursing homes, hospice programs, etc.) and joint action to safeguard vulnerable populations in a region, as well as effective communications and patient care.
Annotation: Matthew Wynia.
UK Program for Bioethics Educational Resource on Pandemic Ethics
University of Kentucky Program for Bioethics & The UK Healthcare Ethics Committee; March 19, 2020.
The UK Program for Bioethics Educational Resource on Pandemic Ethics summarizes the history of pandemic ethics and ethical issues and principles in a pandemic. This comprehensive, evidence-based resource could be a useful tool for decision-making and planning in the COVID-19 pandemic. It includes links to pandemic ethics plans for resource allocation from Arizona, Maryland, Michigan, Tennessee, and Utah, as well as ethical framework for pandemic preparedness that public health practitioners, researchers, and students, ethics consultants, healthcare workers, and policy makers may find useful.
Annotation: Angela Lee-Winn.
Coronavirus Disease 2019 (COVID-19): Reducing Stigma
Centers for Disease Control; March, 2020.
This official CDC page on reducing stigma is embedded in the "Daily Life & Coping" heading and "Stress & Coping" subheading section on COVID-19.
The "Reducing Stigma" page introduces stigma in the context of public health emergencies and gives definitions for the terms "stigma", "mental health",
and "resilience" and identifies persons of Asian descent, people who have traveled, and emergency responders or healthcare professionals as those
who may be experiencing stigma as a result of COVID-19. Links to COVID-19 factsheets and mental health resources are provided, as well as a list of
things that can be done by communicators and public health officials to combat stigma.
This is a great resource to help guide public health professionals on best practices to counter stigma, but doesn't go far enough to characterize the
severity of the issue or address how being intentional about the language used to describe COVID-19 can have an impact on stigmatized groups.
Providing a link to a resource where reports can be filed could be useful as this page is currently geared towards those who aren't familiar with the issue,
rather than for those who are experiencing it and are looking for support.
Annotation: June Homdayjanakul
Ethical Framework for Health Care Institutions Responding to COVID-19. Guidelines for Institutional Ethics Services Responding to COVID-19. Managing Uncertainty, Safeguarding Communities, Guiding Practice
The Hastings Center; March 16, 2020.
This ethical framework and guidelines document represents the collaborative work of many ethicists who were brought together by the Hastings Center.
It includes an excellent summary of the ethical issues when public health ethics is in tension with bedside clinical ethics; a discussion of three ethical duties (to plan, safeguard and guide); examples of institutional policies and processes; and selected resources. It is a go-to resource for ethics committees and consult services to help them prepare for this Pandemic.
Annotation: Jackie Glover
Supporting the Health Care Workforce During the COVID-19 Global Pandemic
JAMA; March 12, 2020.
This JAMA Viewpoint article by two Emergency Medicine physicians outlines very practical ways to support the health care workforce during this
Pandemic. It reviews guidelines for advancing safety including the widespread use of barrier precautions; processes particular to Emergency Departments; and decontamination processes. The review of obligations to health care worker's families is particularly valuable, as is the discussion of
the obligation to support self-care efforts and transparent and thoughtful communication.
Annotation: Jackie Glover
Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic
JAMA; April 7, 2020.
This JAMA Viewpoint includes a timely review of the sources of anxiety for health care professionals working in the COVID-19 environment. But more importantly, it also includes timely suggestions for how to address these sources of anxiety. They are conveniently summarized in a table as Hear me / Protect me / Prepare me / Support me / Care for me. It is particularly relevant for hospital administrators.
Annotation: Jackie Glover
A Practical Approach to Running a Scarce Resource Allocation Team (SRAT)
LITFL-Australian Critical Care Physicians and Nurses; April 1, 2020.
A new invention of a triage-type team which has too many members and for which relationship with an institution's triage team is unclear and probably
redundant. An unneeded layer according to most Crisis Standard Guidelines.
Annotation: Jean Abbott
The Toughest Triage -- Allocating Ventilators in a Pandemic
NEJM; March 23, 2020.
A "perspectives" piece outlining the rationale for triage teams for allocation and re-allocation of ventilators and the justifications that do and do not work in
a pandemic. Includes a suggested process for decision-making and for withdrawal of vent support. As an essay, the evidence review is not exhaustive,
but it is a state-of-the-thinking compelling essay about an ethical approach.
Annotation: Jean Abbott
Too Many Patients: A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters
Chest: Contemporary Reviews in Critical Care Medicine; April, 2019.
Informed by public deliberative sessions and expert consultation, this article proposes a framework for the allocation of mechanical ventilation during
disasters, including infectious pandemics. The framework for ventilator priority is founded on two main criteria: short term survival (based upon validated scoring systems) and survival at 12 months (based upon assessment of comorbid conditions). The latter criterion is meant to mitigate equity concerns
that could arise regarding unfairly disadvantaging those who experience persistent health disparities, systematic disadvantage, and disability, among others. Additional exclusion criteria, adjustments for pregnancy, and "tie breaks" are also discussed. Unlike some systems, health care workers are not
prioritized. A proposed structure for triage teams and appeals is also described. Major strengths of this paper include its empirical basis with an informed public and its explicit recognition of equity concerns. Limitations include its single geographic site (Maryland), the high likelihood that the scoring system
will result in ties (a limitation the authors embrace), and because the deliberative sessions were held in 2012-2014, the possibility that public attitudes may have shifted.
Annotation: Matthew DeCamp
Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators During A Severe Influenza Pandemic or Other Health Emergency
CDC; July, 2011.
This document presents recommendations of the Advisory Committee to the Director of the US Centers for Disease Control and Prevention (CDC),
approved in 2011, that supplement a 2007 CDC document. The document describes several distinct domains, including the ethically-relevant distinction
between routine and emergency practice, the contrast between allocation of vaccines/antiviral medicines (where the ethically relevant principle is
preserving a functioning society) and allocation of ventilators (where the basic bioethics principles of respect for autonomy, beneficence and justice are
cornerstones). Aspects of procedural justice, including public engagement, transparency, and accountability, are highlighted. The document also includes
a comparison and contrast between the allocation goals of maximizing lives saved, maximizing years of life saved, social value, instrumental value, life
cycle principles, and fair chances. A strength of the document is its comprehensive treatment of various ethical principles and concepts, which can be
useful as a “primer” for those new to the field (or a “refresher” for others). A weakness of the document is that those looking for discrete guidance points
will not find them here; as the authors acknowledge, the document is not intended to provide such recommendations but instead an overall framework of
principles.
Annotation: Matthew DeCamp
Ethical dimensions of COVID-19 for front-line staff
Royal College of Physicians; March 31, 2020.
The Royal College of Physicians (UK) document refers to prior work under the auspices of NICE (National Institute for Health and Care Excellence)
where more specific guidelines are available, for examples, a Clinical Frailty Scoring Algorithm, and a Critical Care Index. It outlines principles and
practice guidelines for patient care, including withholding and withdrawing care, including all critical patients, not only COVID-19. Specifically, it also
addresses the issues of health care front line personnel safety and speaks directly to the issue of physicians practicing outside of their specialty.
This is an excellent resource but does not, by itself, establish triage scoring systems or the use of triage teams apart from the front line workers.
Annotation: Don Parsons
Beyond liberty: social values & public health ethics in responses to COVID-19
Nuffield Council of Bioethics; March 26, 2020.
This document is an opinion piece by a British lawyer who is hoping to convince colleagues in the Nuffield Council on Bioethics that individual liberty
(freedom from government interference) must yield to social or public health ethical and policy considerations in the face of this pandemic. The author
articulates the view that we all are part of a society struggling for collective survival and, therefore, must concede unfettered individual liberty to the good
of the whole in accepting some constraints, for example, lockdown. This is a useful resource to reinforce social ethics of collective action in contrast to each individual acting on personal behalf.
Annotation: Don Parsons
Rapid Policy Briefing: Ethical considerations in responding to the COVID-19 pandemic
Nuffield Council on Bioethics; March 17, 2020.
This Rapid Policy Briefing is dated 3.17.2020, which means it is not fully current on the significant changes in UK policy that the government initiated in
the ensuing weeks (including full stay-at-home orders). Nevertheless, it highlights values central to effective public health responses (trust and solidarity),
and focuses much more on public health interventions than questions of clinical care and triage ethics. The discussion on solidarity is especially
important and is developed more in this policy briefing than in many other ethics resources I have seen specifically focused on COVID19.
Annotation: Daniel Goldberg
Fair Allocation of Scarce Medical Resources in the Time of Covid-19
NEJM; March 23, 2020.
This commentary tackles some of the primary issues of scarcity and resource allocation during a public health emergency like COVID19. It focuses on
questions of triage ethics, including access to mechanical ventilators, and highlights the key ethical appeals supporting various options for triaging
access. It offers six specific recommendations for how a triage calculus should look, and considers several objections to those recommendations.
Annotation: Daniel Goldberg