Clinical Scenario
You’re an otolaryngology faculty member at an academic medical center. You have clinical responsibilities for a range of patient care sites, you have teaching responsibilities for residents and medical students, and you are working to establish a credible research effort. All of your efforts have been going well, with a high level of personal and professional satisfaction. Then along came the novel coronavirus—COVID-19.
At first the incidence of infected persons in the population seemed low, and there was hope for a lesser impact in the U.S. than in China. As the numbers of infected persons rose, however, so did the number who required hospital admission, in particular to intensive care units. Having some understanding of public health, you knew that the number of counted infected persons lags behind the actual incidence in the population, especially with a virus that has a high transmission potential and varying levels of symptoms and signs.
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Now it’s clear that the virus is catching hold across the country through traveler and community spread. Following federal guidelines, your state has finally placed a moratorium on all surgeries and procedures that aren’t immediately medically necessary. Evidence that upper aerodigestive tract endoscopic procedures are among the highest risk for surgeons is emerging. There is information that healthcare personnel in your hospital system are increasingly turning up positive for COVID-19, with the concern that others may follow. You have been asked to continue to care for patients with urgent and emergent issues in both outpatient and inpatient settings, amid rumors that personal protective equipment (PPE) supplies are running short and should be conserved and/or reused. At this time, critical care specialists are providing the frontline care of seriously ill patients, and other physicians may be tasked to provide critical care as the demand increases. You have also heard that some community private practitioners continue to see patients, while others are significantly restricting their practices. You are quite concerned about the resident cadre and medical student exposure risk.
How can you navigate the ethical challenges and personal risks with your sworn obligations to patients?
Discussion
Note: This discussion was written during a specific point in time, and, most assuredly by press time, the clinical situation will have dramatically evolved, hopefully in a positive direction. The comments below are specific to challenges U.S. otolaryngologists face during the COVID-19 epidemic.
Most certainly, the challenges/pressures placed on practicing otolaryngologists by the COVID-19 pandemic are not really “everyday ethics.” Very few situations test our commitments to ethical principles more than a pandemic that requires so much from us for the greater social good.
However, it is during these times that we come to understand the importance of making clinical and personal decisions based on the four ethical principles that so firmly guide our “normal” practices—beneficence, non-maleficence, autonomy, and social justice. Several of these principles are frequently in conflict, but in the midst of COVID-19, these ethical conflicts may become even more challenging.
Most American otolaryngologists don’t have clinical experience with outbreaks or epidemics. Some older otolaryngologists (like me) do remember the polio epidemic in the late 1940s and early 1950s (as children and teens, not as physicians), but these memories are sufficiently strong to help us appreciate the dangers of the current COVID-19 epidemic. While polio was primarily an intestinal infection, saliva and respiratory droplets were a secondary transmission mode. COVID-19 has a high upper respiratory tract transmission mode, causing otolaryngologists to be among specialists with the highest clinical risk.
Infectious disease outbreaks, epidemics, and pandemics may well represent the most ethically challenging clinical responses for all physicians. In a general sense, our ethical challenges during this pandemic will fall into four categories: duty to patients and society; duty to the profession, including colleagues, trainees, and staff; duty to family and friends; and duty to law and order.
Duty to Patients and Society
Is there a difference between “answering the call of duty” and “above and beyond the call of duty?” Do we actually “swear an oath” to place ourselves as physicians at higher-than-usual risk? When is it too much for us to handle? These questions and many more are on our minds today as we as a profession, specialty, and American citizens respond to COVID-19.
Swearing to the Hippocratic Oath isn’t widely practiced today, although many medical schools subscribe to some type of professional oath for students under which they agree to uphold certain ethical rules and expectations as a physician. These oaths are much like the ethics codes of our profession—in particular the AMA Code of Ethics, which prescribes certain duties, behaviors, guidelines, societal expectations, and conduct.
The AMA Code of Medical Ethics Opinion 9.067 addresses guidelines for an individual physician’s duty to “provide urgent medical care during disasters,” including epidemics, and notes that “this ethical obligation holds even in the face of greater than usual risks to their own safety, health, or life.” (Virtual Mentor. 2010;12:717-718) However, the Opinion also advises physicians to balance their duty to individual patients with their ability to care for patients in the future. This leaves the decision up to ethical judgment.
Many otolaryngologists will have the opportunity to participate in the early development of protocols to protect patients and healthcare workers in departments and institutions. Safety measures should consider vulnerable persons, pertinent patient (and healthcare worker) screening, and rapid disposition of suspected exposures for testing, isolation, or home quarantine. We have an ethical duty to raise concerns if safety measures are incorrect, incomplete, or risky.
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We also have an important obligation to educate our patients for their own protection, and to reassure them with respect to their fears and concerns. AMA Code of Ethics Opinion 2.25 sets forth an expectation that physicians will support isolation and quarantine public health protocols and educate patients on their importance (Virtual Mentor. 2010;12:717-718). Additionally, calling to check on patients with chronic or subacute conditions, returning calls, updating them on laboratory and radiographic results, refilling prescriptions, and speaking calmly can help alleviate some of their isolation and disconnection. During these critical periods, however, patient health information confidentiality must still be protected, and consent obtained for telemedicine consultations. (Eur Respir J. 2009;34:303-309;DOI:10.1183/09031936.00041609; BMC Med Ethics. 2006;7:E5).
One of the harshest ethical dilemmas during epidemics is whether it will, at some point, be necessary to consider imposing limits on the continued care of critically ill patients who aren’t expected to survive. Many COVID-19 patients are critically ill for weeks, requiring intensive care and ventilator support. If there aren’t enough critical care facilities, medical equipment, and healthcare personnel resources available, discussions among bioethicists have turned to considering a triage care system based on chance for survival versus futility of care. Care triage has been a mainstay of combat casualty care for at least a century. Whether U.S. care limitations will be suggested during the COVID-19 pandemic is currently unknown, but it’s possible if critical patient demand is significantly greater than medical resources. Ethically, this falls under the guidance of the principle of the greatest good for the greatest number, but it will be a moral and an ethical challenge for physicians who have to make decisions to withhold/withdraw care.
Duty to Profession
Physicians and other healthcare providers must look out for each other, especially supporting those who are placing themselves at greater risk. Otolaryngologists, in dealing with upper aerodigestive tract disorders, will undoubtedly face high-risk patient care scenarios, perhaps without sufficient PPE.
One of the harshest ethical dilemmas during epidemics is whether it will, at some point, be necessary to consider imposing limits on the continued care of critically ill patients who aren’t expected to survive.
Among our most vulnerable resources are medical students, resident physicians, and fellows, who are often on the front line. These young physicians and physicians-to-be are our profession’s most valuable future resources, and we have an ethical responsibility to protect them as much as possible. Using specific trainee and student protocols, ensuring adequate and sufficient PPE, and placing decisions for urgent or emergency endoscopic procedures with faculty members are a few ethically solid measures. Resident-faculty teams (junior resident, senior resident, faculty member) allow for thoughtful and safe patient care discussion and decision making.
Additionally, we have a professional/ethical responsibility to adopt clinic and hospital protocols that protect the staff with whom we work and for whom we may be primarily responsible. Not only are staff valuable members of the team, but they also have family and friends who should not be unnecessarily exposed to greater risk.
As the pandemic progresses, would non-critical care physicians and specialists playing a role in critical care units be considered an ethical patient care standard? With the recent relaxation of some clinical practice restrictions, it isn’t too far-fetched. Transferrable skills and experience may be required in the future, and otolaryngologists individually should consider how that might be possible with their knowledge and capabilities.
The American Academy of Otolaryngology-Head and Neck Surgery in its March 19 OTO News email presented an opportunity from the Society of Critical Care Medicine for a complimentary online training for healthcare professionals entitled “Critical Care for the Non-ICU Healthcare Professional.” These training modules are comprehensive and provide a basic knowledge foundation for how to be of assistance in critical care units if needed.
How we prioritize duty and responsibility to patients versus family and friends is a very personal decision and should be respected as such.
In addition to clinical support and oversight, there’s also the matter of emotional support. Surgeons tend to be characteristically self-reliant, but in times of sustained clinical care of seriously or critically ill patients, performed under a cloud of heightened risk using stifling or inadequate PPE, everyone can use a friend. It’s entirely conceivable that otolaryngologists might lose colleagues, family members, friends, and patients to COVID-19. We must be cognizant of the effect such losses may have on ourselves or our colleagues and make emotional support part of our ethical duty.
Duty to Family and Friends
Otolaryngologists understand their ethical responsibilities to patients and profession, but they also have a moral obligation to their birth and extended families. We are not only responsible for protecting the patient from healthcare providers but also for protecting those individuals who mean the most to us in our lives. Elderly family members should be considered particularly vulnerable to COVID-19, but we must also protect children and pregnant women, as well as those whose comorbidities may make them more susceptible. How we prioritize duty and responsibility to patients versus family and friends is a very personal decision and should be respected as such.
Duty to Law and Order
This is a time of ongoing adjustment for everyone, including physicians—our profession and our society haven’t seen this level of extreme measures for isolation, quarantine, shelter at home, practice restrictions, moratoria on elective surgery, and other mandates during most of our lifetimes. Most states have at the current writing time postponed all surgeries and procedures that are not immediately medically necessary, and those guidelines continue to evolve.
Laws and ethics have much in common. In this very difficult time of temporary loss of individual rights for the greater good of society, physicians have many ethical duties, and among them is the duty to follow the law. The Texas Medical Board recently required any facility or individual with knowledge of violators of the governor’s non-urgent elective surgery and procedures order to promptly report said violators to the Medical Board. Penalties will be considered for the violator as well as for those who fail to report the violation. Violating a lawful order is committing both an ethical and a legal violation.
An otolaryngologist in this scenario who wishes to be ethically and professionally responsible realizes that caring for patients during an epidemic raises many ethical issues and dilemmas, some requiring ethical decision-making that is uniquely challenging. Ethical and moral conduct, along with compassion, empathy, and duty, will be her pathway.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.