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Commentaries

COVID-19: The Shift From Clinical to Public Health Ethics

DeBruin, Debra PhD; Leider, Jonathon P. PhD

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Journal of Public Health Management and Practice: July/August 2020 - Volume 26 - Issue 4 - p 306-309
doi: 10.1097/PHH.0000000000001204
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The Impact of COVID-19 on Health Care and Public Health

The terrorist attacks on September 11, 2001, and the bioterror campaign involving anthrax delivered via the US Postal Service shortly thereafter, revealed a significant need to prepare for public health emergencies, including emerging pathogens with potential to become worldwide pandemics.1,2 Significant intellectual and financial capital was initially invested in developing systems to contain and mitigate these kinds of disasters. However, what followed was a lack of sustained investment despite the disease transmission risks inherent to a complex and interconnected world economy,3 one that has made pandemics not “probable” but certain. The wildfire-like expansion of COVID-19, the disease caused by the SARS-CoV-2 coronavirus, across the United States in the early months of 2020 demonstrates that the world is still not ready for such a pandemic and that very challenging decisions will be necessary in the months and years to come.4 Some of these decisions involve fundamental departures from conventional standards of care and expectations about government intervention in one's life.5–9

In the United States, as of late April when this commentary was written, the situation on the ground is changing rapidly. The vast majority of Americans remain under a shelter in place or stay-at-home order, and hospitals across the country are preparing for critical care needs to exceed capacity, perhaps dramatically. Neither PCR tests for active infection nor serological tests for immunity are widely available.10 We expect tens of thousands of deaths at best.11 What has become clear is that health departments and hospitals alike must consider how norms change in a crisis.6,9 We offer this commentary as a means of highlighting some of these challenges and offering some foundational ethics guidance.

How Crises Necessitate a Shift in Norms

Ethical issues pervade planning and response for public health crises, especially when health needs exceed available resources.7,12 Under normal circumstances, clinical ethics focuses directly on the needs and wishes of the individual patient; resources are to be allocated to patients largely based on commitments to promote patient well-being and respect patient autonomy. In reality, of course, these norms tend to guide care for more privileged patients. Many individuals lack adequate insurance coverage or resources to pay for care out of pocket or face geographic barriers to access. Thus, even when resources are plentiful, fundamental principles such as beneficence (promoting good) and respect for autonomy may fail to guide care for disadvantaged individuals.13

In public health crises involving significant shortages of resources, public health and health care systems become overwhelmed and the norms guiding care must shift to focus on community benefit rather than individual well-being or autonomy.14 From a moral point of view, such a shift is profound and can leave public health and health care professionals facing tremendous uncertainty about how to meet overwhelming need while maintaining their fundamental professional values.14 It can also undermine public trust in professionals, health systems, and governmental agencies.14–16 As governments and health care systems plan for or respond to disasters, ethical guidance can—and should—provide the “bedrock” upon which crisis response plans are built.17

The response to COVID-19 in the United States has already revealed a number of ethical issues that require attention. These include questions about the imposition of liberty-limiting interventions such as stay-at-home orders, the challenges of communicating appropriately with the public and engaging communities in decision making, the use of unproven therapies, and allocating scarce resources. This commentary focuses on this latter question about rationing.

Ethical Frameworks for Resource Allocation

Ethical frameworks should guide allocation of resources. There is general agreement that saving lives across the population takes precedence over individual wishes, desires, or even needs to access scarce health care resources during a public health crisis.14 However, the ethical pursuit of that population health objective is a complex matter.6–8,12,14–16

During response to a pandemic, it is helpful to parse resource allocation decision making into clinical and population-based settings. In the clinical context, rationing will be required if the demand for resources, such as intensive care unit beds or ventilators, exceeds capacity. The depth of scarcity will drive the level of rationing; until need exceeds supply, conventional standards of care should not give way to crisis standards of care (CSC).14,17 But when they do, changes may be profound and will include consideration of reallocating lifesaving resources such as ventilators from some patients to provide them to others more likely to benefit, even when patients and families oppose such an outcome.

Resource allocation plans tend to call for a mixed principles-based approach, meaning that several goals are balanced in the creation and implementation of the CSC plan. In our home state of Minnesota, guidance balances saving most lives with respecting rights and ensuring fairness.15,16,18 Minnesota's guidance implements those objectives by prohibiting decision making on ethically problematic grounds such as race, ethnicity, or first-come first-served (which favors those whose privilege allows them to more readily access care) and prioritizing access to scarce resources based on clinical prognosis, duration of need, and other relevant factors. When patients need the same resource, and all else is equal, random assignment is the fair approach. Of course, it can be difficult to determine when all else is equal—that is, when patients have similar prognoses and likely length of need for the resource. How similar is similar enough, given limitations of clinical scoring systems and only emerging evidence about clinical outcomes at this point in the pandemic? And are other factors relevant? For example, key workers—who take on risk to provide critical service to society—are owed duties of protection in return. Moreover, protecting such workers promotes protection for all of us. Thus, those working on the front lines of the response—for example, health care workers serving in settings with an increased risk of exposure to the virus—are owed personal protective equipment (PPE). As of this writing, shortages of PPE significantly undermine the fulfillment of this duty.19 Pandemic ethics guidance also tends to offer some priority in access to scarce resources to such workers.5–8,15,16,18 But what level of priority, and to which resources (eg, ventilators in addition to vaccines?) are controversial questions, given that duties to these workers must be balanced against obligations we have to those with grave needs in the general public. Age as a criterion itself (apart from the role age plays in clinical prognostication) is a similarly controversial topic, one for which moral consensus does not appear likely.7,8,12,15,16,18,20 Where differing perspectives among individuals or cultures render the establishment of a community standard on this issue unlikely, ethical frameworks best limit consideration of age to its prognostic role.18 This coheres with legal guidance on the issue as well,21 although there remains some disagreement on this point.22

Ethical commitments should also guide the processes used to implement allocation guidance.15 Bedside clinicians should not have responsibility for deciding whether or not their patients receive potentially lifesaving resources; their fiduciary duties to patients remain.14 Establishing separate triage teams honors these obligations and helps address moral distress among clinical staff. Oversight of triage decision making must also be implemented. A streamlined process of real-time review can help ensure that errors and bias do not drive decisions, although in times of critical scarcity, even accelerated review processes may become impossible to manage.12,18 Throughout the pandemic, retrospective reviews of triage decision making will provide critical information to ensure that no groups are being disproportionately impacted in a way that leads to systematic disadvantage.

Even in this dramatically altered environment, some things should not change. For example, patients must be provided the best care possible, including palliation, mental health, and spiritual care supports.18 They retain rights to refuse treatment and to transparent and compassionate communication about their care.

On the public health level, much of the focus in a pandemic is on implications of government limiting liberty to protect population health.4 However, significant decisions must routinely be made about allocating scarce resources as well. State health departments must determine how to best distribute resources such as PPE from state and federal stockpiles, and who should receive prioritized access to vaccine once it becomes available. In situations where community distribution centers or public points of dispensing will be set up, public health must coordinate with other governmental entities to decide how, where, and when such a site will be established.

There must also be recognition of the locus of decision making for resource allocation, namely, that local health departments (LHDs) rarely have the ability to affirmatively choose who gets which resources—this is often dictated by the state or federal government.3 At the same time, LHDs and state health agencies are the “boots on the ground” and the practical and scientific leaders in these crises. Public health leaders should have access to ethics support to inform decision making, especially since no ethical framework can specify every contingency that may arise in the enormously complex context of emergency response.15,18

Guarding Against Inequities

One of the most morally troubling aspects of public health crises is their disproportionate impact on groups that are socially disadvantaged. We must recognize that socially disadvantaged groups are more vulnerable to illness than relatively privileged populations, given health disparities, less able to protect themselves through preventive strategies such as social distancing, and more burdened by public health response interventions that pose risks to job security or access to nutritional support programs. Barriers to access to health care hamper intervention when members of these groups fall ill.13,23,24 Structural inequalities underlie all of these factors. In both clinical and population-based decision making, special attention is owed to these groups, not as a form of reparation or remediation for societal injustice but in order to satisfy the core tenets of ethical disaster response. Exactly because these groups will be hit hardest by disaster, they must be paid special attention.23 In clinical contexts, processes must be implemented to prevent bias from affecting individual treatment decisions and to ensure that systematic deprioritization of these groups does not occur.5,18 In public health decision making, health and social service support should target vulnerable communities, keeping in mind that access to transportation and employer-sponsored health care insurance may be limited. Social supports such as sick pay, expanded unemployment insurance, and protections against utilities shutoffs and evictions will also help address inequities.

Conclusion

While moral norms shift in complex crises such as the COVID-19 pandemic, crisis response must be grounded on fundamental values that persist as society moves from routine circumstances to crisis. For both clinical and public health contexts, crisis response must be transparent with clear mechanisms of accountability and must respond to needs respectfully, fairly, effectively, and efficiently.16,18 The stakes in this pandemic are profound, which magnifies the need to develop and implement a robust ethical framework for response and to communicate that ethical grounding to the public. Only then will pandemic response be worthy of trust and promote the solidarity and mutual responsibility needed to succeed.

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