Professional Ethics & obligations

By Mike Baker and Sheri Fink

The New York Times, March 31, 2020

I chose this article because it’s a good reminder that scarce resource allocation preoccupies the public as much as it does healthcare workers, and because Sheri Fink has written extensively about crisis medicine, most famously in the book “Five Days at Memorial”, recounting events at a New Orleans hospital after Hurricane Katrina. The perspective offered in this article is pretty standard, reminding us that these decisions are made at the institutional, or at best state level – there is no national strategy for this. This paper gets into the details about common resource allocation guidelines, and the limitations of scoring systems used in many resource allocation algorithms. It’s a good synopsis for the uninitiated (a good reference to send to your non-medical friends and family who have questions about this topic). -Naomi Laventhal, MD

Key points:

- This paper accurately predicted a worrisome issue that’s emerged in this public health crisis – striking health disparities, with disproportionately high mortality in African-American patients with COVID-19 infection; scoring systems that take into account underlying chronic health conditions will not mitigate the effect of long-standing health disparities. I expect we’ll be talking about this much more in the coming days. For me, start here: https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true

- As we practice in “crisis standards of care”, transparency is essential, but has consequences. Namely, when we (rightfully) make these documents public, the public has questions.]

- Historically vulnerable groups are watching this very closely. Although most scoring systems are based entirely on estimated likelihood of long-term survival, it’s hard to quell anxieties about rationing on the basis of disability, age, and functional status.

By Joel Frader and Lainie Friedman Ross (both are well-known pediatric ethicists).

The Hastings Center Bioethics Forum Essay, November 7, 2014.

Summary by Naomi Laventhal, MD

“What is the obligation of health care professionals to assume personal risk?” – they offer a pretty tidy answer:

Professionals acquire specialized knowledge and skills that others do not and cannot have. Having these skills creates a presumptive obligation to use them. However, such an obligation is tempered by the likelihood that intervention will actually benefit patients by either curing them or relieving pain and suffering. The extent of professionals’ duty to assume risk must take into account the rights of the providers to receive appropriate training and resources to protect themselves.

“Is it ethical to adopt policies that systematically exclude or include classes of professionals from participating in especially risky care?”

Should the relative inexperience of students include them from care, and how is this similar or different from redeployment of clinicians who are fully trained but lack expertise to care for patients with the pandemic infection? And is exclusion of either group a fair way to mitigate risk of infection among healthcare workers, or should we all bear this burden more equitably in a public health crisis?

One aspect of this that I hadn’t previously considered, in regard to excluding trainees and students:

“Such a stance seems particularly problematic when advanced physicians-in-training have exemptions but can look forward to substantially greater future income and social status than their colleagues in nursing and the allied health professions. This disparity, it has been argued, affirms “how ethical issues embedded in power and systemic politics go unrecognized within bioethical principlism.”

For more on the topic of professional duty see also:

Feudtner C, Wadleigh J. Should I stay or should I go? The physician in time of crisis. Virtual Mentor. 2006;8(4):208–213. Published 2006 Apr 1. doi:10.1001/virtualmentor.2006.8.4.ccas3-0604 Open Access: https://journalofethics.ama-assn.org/article/should-i-stay-or-should-i-go-physician-time-crisis-commentary-1/2006-04

Huber SJ, Wynia MK. When pestilence prevails...physician responsibilities in epidemics. Am J Bioeth. 2004;4(1):W5–W11. doi:10.1162/152651604773067497. PDF attached or With level 1 password: https://www-tandfonline-com.proxy.lib.umich.edu/doi/pdf/10.1162/152651604773067497?needAccess=true&

Adam Gopnik. The Coronavirus and the Importance of Giving Science the Time It Needs. The New Yorker, March 25, 2020.

https://www.newyorker.com/news/daily-comment/the-coronavirus-and-the-importance-of-giving-science-the-time-it-needs

In this piece for the New Yorker, Adam Gopnik writes about what he describes as “the brutal but essential logic of plague science.” It’s an easy read, and it draws in some interesting historical literary references. Gopnik starts by discussing some of the dialogue surrounding possible therapies for the novel coronavirus, and some of the understandable public confusion about why it’s better to perform expedited but careful high-quality research rather than simply trying any and every possible medication indiscriminately. Gopnik then goes on to talk about a novel called “Arrowsmith” by Sinclair Lewis in 1925, about a young American doctor who develops a new treatment for bubonic plague and travels to fictitious West Indian island experiencing an outbreak of plague. There, he attempts to perform a controlled experiment to test this cure - but things go awry. Gopnik concludes with some tough questions about how we ought to proceed: “How long is the longer term? How compassionate should a compassionate trial be? How desperate must a sufferer be before she gets experimental drugs?” – Phoebe Danziger, MD