The Moral Dilemma of COVID-19
Special Issue: May/June 2020
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
Certainly, there is only one issue which is dominating all thoughts, prayers, and efforts on our planet right now and it is COVID-19. Hopefully where you are, your life and practice will only be incredibly inconvenienced and that your family, your community, and your hospital will be spared the worst of this pandemic. Many areas may be relatively spared by early social distancing and the shutdown of many aspects of daily life which until last month we took for granted. This crisis has brought to the forefront many ethical and moral dilemmas which our society and world need to face with open eyes and minds. Our medical capabilities in our modern prosperous society are currently been taxed past the breaking point in the hotspots of the COVID-19 pandemic. We need as a profession and as a society to consider the correct response to the complex and difficult decisions which physicians on the frontlines are now making or may eventually be facing where conditions are worse. Even if we manage to make it through this pandemic without running out of ventilators and do not lose too many talented and selfless healthcare professionals there may be a next time.
Sadly, I work in one of the initial hotspots of New Orleans. The citywide healthcare system became inundated within days. The whole medical community has come together to try and work through the new complex daily challenges which we are required to meet each and every day. The process, which we worked out the day before, can be quickly scrapped or modified as we learn or try new things. The idea that a new disease can come out of seemingly nowhere and challenge every treatment concept we have is a humbling experience. When you realize that we truly are wandering in the desert when it comes to what is the best course of action for the dying patient is front of you, it is terrifying but also enlightening. How far are we really removed from the “plaque doctor” of old?
Many of us have quickly been through the protocols of early intubation, late intubation, prone ventilation, CPAP, BiPAP, non-rebreather masks, no non-rebreather masks, viral filters, or whatever in an attempt to figure a path forward. Just walk through an ICU of any COVID filled hospital and you quickly see the reality of this pandemic and the current limitations of the available treatments. The prospect of throwing away much of what we thought we knew in regards to treating critically ill patients can make one question much of what we thought were sound and scientifically based principles. Listening to the various experts proposing yet another way to do things differently for this novel disease is fascinating as the medical community having to throw out, at least partially, our “evidence-based” mindset.
Consider the ethical dilemma of trying a novel ARDS protocol or giving a medicine normally used for malaria or lupus with known serious side effects on only anecdotal evidence. Certainly, the intention of using these techniques or medications by physicians in the trenches seeing their ICU and emergency departments filled with patients struggling to breath and dying all around them is noble and in the finest traditions of medicine. The usual treatments and protocols which we have all learned to use are not working and in an act of desperation a dedicated and caring physician who is putting their very own life on the line is attempting to save the patient in front of them. However, there will always be critics and naysayers who will demand to see the evidence and the trial, which shows the safety and efficacy of what is proposed. Many of these ideas will fail and patients will continue to die. I fear the personal consequences for these innovative physicians down the road when the tired old pundits and plaintiff attorneys come out to denounce the medical experimentation, which went on while they were safely home in self isolation. I certainly think that sovereign immunity should be granted to all physicians in this crisis to allay any fears of later recrimination after the dust settles. AAEM has sent letters to all of the governors of our states asking for relief from the fear of medical malpractice liability during this crisis. Will it be fair to pass judgment on the actions of these same doctors who literally placed themselves in danger to treat these patients knowing that our treatments were untested and were driven by their professionalism and compassion to try novel treatment options, which may or not work?
I certainly know what I believe, but more and more I feel like I am a plaque doctor of old. Dealing with a novel disease which is cutting a swathe thorough my community is humbling to say the least. Our emergency department early in the pandemic tried new methods to try and depressurize the department and hospital. Trying to keep a COVID-free area became almost impossible as despite a patient’s chief complaint, in the end everything became COVID. We started seeing patients via Zoom while they were in triage to help start workups and triage to see who needed the next available bed while preserving our limited personal protection equipment supplies and to try and limit exposure to the providers. The fire marshal allowed us to put army type cots along a long hallway outside of the waiting room to see patients when there was no other available space. The scene was surreal walking past six ambulance stretchers waiting on the wall to see people in pediatric area, which we had also cannibalized for sick adults. I never would have thought that I would order so many ferritin or LDH levels in my career.
The potential of the need to ration care when your department seems to be drowning in COVID can become a pressing thought. This is especially true when your local nursing homes become infested with the virus. At one point, we would have nursing homes calling and stating they were sending five patients at a time. Who to see first? Who would get the bed? Would we have enough ventilators? Who to put on hydroxychloroquine? The crucial question, sadly on the initial presentation on some of these patients, is quickly reviewing the code status and immediately trying to call families to discuss treatment options. On some days, it seemed that our number one consulting service was palliative care. Hopefully this time is past for my emergency department, but please think about these questions now before you are doing this in a time of crisis. Please consider beefing up your medical ethics committee. There was a good article in JAMA related to this issue of the potential liability of the rationing of care (https://jamanetwork.com/journals/jama/fullarticle/2764239).
The reality of the shortage of personal protective equipment (PPE) is another moral dilemma. Can you expect any worker in the hospital from an emergency physician to the poor housekeeper dutifully deep cleaning the COVID rooms to enter these contaminated rooms without proper safety equipment? Can we judge them if they are too scared to work? Should only staff less than sixty who do not have significant comorbidities be asked to see these patients? Should older staff members with these comorbidities be asked not to place themselves at risk? Should pregnant staff members be excused from direct patient care? The questions can be endless and I think the answers will also be drastically different depending on your hospital and your perspective. My hospital was spared the worst of this PPE shortage, except for the fact we were given one N95 mask and told we needed to use it for five days and to wipe off the gowns and reuse them. I am thinking of having my first N95 mask bronzed to have as a memento of this pandemic. Luckily, one of my partners “knew a guy” who owned a contracting company and gave us a small supply of nicer masks, which seemed to fit better. Our hospital system seemed to work miracles and we were able to obtain real respirator masks relatively quickly compared to the stories out of New York.
The other remarkable fact about these COVID profession is truly on the frontlines of a real pandemic and that our work entails real risk makes me feel two paradoxical emotions. One is pride that we are professionals who have taken an oath and are dedicated to trying to save the lives of at times an overwhelming number of critically ill patients with the realization that we are putting ourselves and our coworkers at a potential real personal risk. The conflicting emotion is a sense of humility and insignificance that in our advanced and modern medical system we can be seemingly vanquished by a tiny piece of RNA.
Please reflect on these issues even if you have not been required to face them, as the moral and ethical issues related to COVID are real and significant. Hopefully this pandemic is a generational one, but we can never be sure and should be prepared. I would ask you to consider sharing your thoughts on these or any other COVID issues. Working together as a profession can help us all deal with the stress and uncertainty of our new reality.