In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.1
Why is a pandemic more ethically challenging than a snowstorm? As a nurse leader, I have worked in incident command centers to prepare for hurricanes, snowstorms, and even the Boston Marathon bombings, but the pandemic has heightened ethical challenges.
Pandemics, as with the other situations mentioned above, do share something that is unique to health care professionals. We do not have “contracts” with our patients; we have covenants. Unlike contracts, covenants are not inherently bidirectional. We do not provide care to our patients based on anything they will or will not do for us. We provide the care out of obligation. An obligation we interpret as the patients' right to receive care. Arguably, we do it for pay, but we do not think of the patient actually paying us. There is always a third party—the hospital as an employer or the insurance company. In fact, we get all worked up about patients having copays, which shows that the idea that the patient is our source of income is distant in our ethos.
Covenants secure a tremendous amount of good for society. But can a covenant do harm? We are facing that question right now. In a snowstorm, clarity about our obligations helps us get through the exhaustion and chaos. Often this concept is more reinforcing than harmful.
In a storm, the challenges are about how many staff can get into work safely and/or find daycare because schools are closed. For those who come to work, we must consider how to provide shelter and food until the roads open up again. Inside the walls of the hospital, we know we are safe. The hospital has generators more powerful than those at our homes, so we know we will have light and heat. The greatest problem experienced is fatigue, as we get more tired than usual because of the challenges of staffing at our “necessary levels” to continue to provide the same level of care. We are challenged ethically only in as much as we are not sure longer hours and even fewer staff are the right thing to do, but because it is necessary for this day or two, we proceed relatively unscathed ethically.
In the extreme situation of the Boston Marathon bombings, there was an eerie feeling inside the hospital, even with the presence of law enforcement, including snipers on our roof—we were a community that felt safe with each other. In addition, mercifully, although a very long week, it had a known ending. The week ended with a 1-day shelter in place effort by the city of Boston, the second terrorist bomber was captured. Once the city was secured, we knew that we could resume our normal operations. Most importantly, we made a difference. We saved lives and limbs that week. We delivered our societal good, and that meant we kept our covenant.
Now, we face an invisible enemy. This enemy could be delivered to us in the person of that colleague we are used to turning to for a hug during stressful times. Our message and action say, “Do not TOUCH!” We wear a mask and stay 6 ft away as much as possible. On March 27, 2020, as protective equipment becomes a precious and widely consumed commodity, Jay Baruch, an emergency room physician, asks, “Why does the lack of PPE alter the science of PPE we have all been taught?”2 That is just one example of the cognitive dissonance we are feeling as scientists and humans. We are inundated with questions—What is good? What is harm?
Health providers are asking why our norms are shifting, just because we cannot achieve them. Worst of all, we are not sure we have a deliverable response to offer as the science is unfolding in real time. What stops this virus from spreading, from killing? Unlike the snowstorm, our colleagues and we are less safe at work than home. What implications does this one covenant have for our other covenantal bonds, specifically the ones with our family? Am I putting them in harm's way without delivering the same societal good I use to justify my extreme commitments? Is it okay to choose the patient over my family even if I am willing to put myself in harm's way?
Moreover, what are our standards of care? As a nurse, I know that humans heal better with light and nature. Unfortunately, flower shops are not essential businesses. We cannot even send flowers to a patient. I consistently preach the importance of self-care to nurses reminding them that “You cannot pour from an empty cup.” However, there is not an easy way to prioritize traditional modes of caring and self-care.
As a nurse for more than 3 decades, I have fought vociferously to have family members with patients in all, even taboo, circumstances. I do not believe in visiting hours, keeping families out of codes, or that age should limit access to see a patient. In truth, I was okay with having pets come visit long before we labeled pets as therapy. I have always told my loved ones never to go to a medical consult alone—when it is about your body even the most educated and assertive among us loses ground and cannot hear what is being said. Now, because every person is a potential hazard, I am banning loved ones from visiting or accompanying people to physician appointments. To say I feel that conflict at my core is an understatement. I am providing less good than usual. In truth, I fear that I am doing harm. Nursing's social policy statement articulates our holistic view. Our worldview sees patients in the context of their loved ones and communities. My definitions of beneficence and maleficence in this clinical context are stretched now beyond my comfort.
There are few good choices. This is a near-constant state of moral distress. Worse yet, it is a communal state of moral distress. You know the right thing to do, but you cannot do it. Everyone should wear an N95, but because the supply is low, you have to use them judiciously. Masks for a day and conservation of resources in unique ways become the new norm. Resource allocation drives complex care decisions. Do you start chemotherapy knowing a patient will need blood and the future supply is questionable? Do you delay care knowing time matters? Do you split use of vents for two people when you really cannot imagine that is anything but a desperate idea? How do you make time-based decisions when you do not know when the timing will be better?
How much autonomy can I strip away from the patient and still feel good? John Stuart Mill said, “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”3 Here we are limiting liberty. To the patient we say, “Even if you are nauseous you have to wear a mask because it is not for your safety, it's so you do not contaminate anyone else.” That includes the staff. Because if too many staff get infected, there will be nobody to take care of anyone. When do we stop treating cancer and redeploy everyone to the pandemic? All new questions, unimaginable in the United States, but here we are, and we are forced to shift ethical paradigms.
We are not in beneficence, autonomy frame right now. We are utilitarians—the greatest good for the greatest many. It is hard. It is ethically challenging. It is not where our covenant usually takes us.
To my nurse and other colleagues out there, I want to say thank you and offer these thoughts. We will not understand this until we are on the other side of the pandemic. I do not know when this will end, but I do know each day we are one day closer to its end. My grandmother often said, “It's an ill wind that does not blow some good.” As women and men of science and compassion, we will learn much, and those lessons will become our next societal good to deliver. My hope is that when this pandemic has ended, it will have served to strengthen, not break, nursing's social covenant with society.
Love is still in full force even if you feel our other deliverables have been compromised beyond recognition. Let the demonstrations of a grateful society seep into your souls so that our covenantal bond stays healthy for us all. As we face these difficult times, take solace in the words of Theodore Roosevelt, “In any moment of decision, the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing.”
Be proud we are doing something. We always do. Our seemingly heroic efforts now deliver our societal good to our patients and maintain our covenant with society.