Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


AMA Chief Experience Officer Todd Unger speaks with AMA Vice President, Ethics Standards, Audiey C. Kao, MD, PhD, Director, Ethics Policy, Elliott Crigger and Director, Health Equity Policy & Advocacy, Mia Keeys on updates regarding COVID-19 including ethical considerations during the COVID-19 pandemic, including the lack of PPE that puts physicians in a dangerous situation when they show up for work and equitable access to testing by underserved populations.

Learn more at the AMA COVID-19 resource center.

Transcript

Unger: Hello this is the American Medical Association's COVID-19 update.

Today we're going to talk about ethical considerations during the COVID-19 pandemic. I'm joined today by Dr. Audiey Kao, AMA's vice president of ethics standards in Chicago. Elliot Crigger, director of ethics policy in Chicago and Mia Keeys, health equity policy director in Washington, D.C. I'm Todd Unger, AMA's chief experience officer in Chicago. The COVID-19 pandemic opens up a lot of ethical questions, especially when a lack of PPE puts physicians in a dangerous situation. Audiey, do you want to start by commenting on that?

Dr. Kao: Yeah, thank you Todd. I think it's probably important to first recognize that this duty for doctors to show up for work even in the face of personal danger, as we're confronted now with the lack of PPE, wasn't always the case. It wasn't until, frankly, the mid-18th, 19th century where this duty to show up for work was actually codified in the AMA Code of Medical Ethics.

So, I think in a public health emergency of this type, doctors are placed in greater than usual risk when they do show up for work. And your question poses, well how much higher risk should physicians be placed? And I think there is no numeric answer to that question, to state the obvious. I think it's fair to say that not just physicians, but all front-line clinicians are at higher than usual risk in this pandemic.

And so, with the lack of sufficient PPE, that's a serious matter.

So unless we have that fixed, I think it's reasonable when physicians for example, are individuals that have high chronic morbidities, they themselves have chronic medical conditions, they may want to seriously consider being placed in a position where there is insufficient PPE. But I think it's important to note that physicians and all front-line clinicians recognize that they have to show up for work, even in the face of personal danger.

Unger: We're hearing more and more about choices about who gets care. I read something about EMTs having to make difficult decisions in New York City. What kind of factors do we need to consider when we talk about making decisions about who gets care and who doesn't?

Crigger: Let me jump in on that topic, this is Elliot. I think the first thing we have to think about are what are the clinical circumstances? We don't want to make random decisions, and we don't want to leave those decisions to individual physicians. We would want to have institutions or state governments or some other entities developing policies, and they are.

But we want to look at medical need first, as the primary criteria. Not social worth, not any of those other possible considerations. Is this individual likely to benefit? For example, can we avoid a premature death?

If there's no material difference medically, across the patients who are all pressing claims to things like ventilators, then we want to go to a very fair and objective system for choosing among them. And probably the best way is either a lottery or some other form of random choice, so that you're not pegging it to personal characteristics of physicians, and you're not leaving the burden on the physicians themselves to make those calls ad hoc.

Keeys: I want to pick up with what you're saying there, Elliot. You're making serious, important points. In a world where our health infrastructure is pristine and perfect, then objectivity is absolutely the way that our physicians need to go. It's the way that they're trained, it's the way that science runs.

But we also know in terms of social considerations—this is why the policy is important, to your point—in terms of social considerations, especially in high pressure times such as this pandemic COVID-19 is presenting. Our physicians are faced with really critical and hard decisions to make in short order, in short amount of time, even shorter than previously.

And so we are seeing and hearing anecdotally, because the data don't yet reflect what we need for it to, so we're hearing anecdotally our physicians saying, well, I had a patient presenting with stomach pain and abrasions from a car accident, and I had to make the decision, the swift decision in that period of time, to go and spend the short amount of time that I already have to attend to this other patient who has a severe presentation of COVID-19 symptoms.

And it becomes even harder when we start to layer that with social factors, and socially determinant factors such as race, especially, and such as language.

So we're seeing that a lot of people presenting for care in hospitals, especially those that are disproportionate share hospitals that are limited English proficient and having a hard time describing their overall symptomology to the admin and are potentially not only in danger themselves, because they can't explain what's going on, but the physicians aren't able to make those objective decisions, because there is this level of subjectivity that they have to navigate through, and dig through.

And it takes time. It takes effort, and it often takes resources, now, that are already stretched to have in terms of in-person interpretation and telephonic interpretation, and such like that.

Crigger: Yeah, and you make a really, really good point about how this is stressing a system that is already seriously flawed in many, many respects, and there's too many patients.

Keeys: Indeed.

Crigger: Very limited or inadequate access to care in the first place.

Dr. Kao: If I can just jump in, I think that's why many of the proposed triage or allocation policies separate the treating physician, or the treating healthcare team, from having to make those difficult choices, and putting that onto a triage team, or triage officer, that is comprised of people with relevant expertise, but they are not people who are actually treating the individual patients.

And I think that's important for many reasons. One is that I think it allows more objective and consistent application of treatment and allocation decisions from individual decisions by individual clinicians, potentially under a very rushed timetable, to a triage team. And it also, for very important reasons, reduces the moral distress and emotional burden on the treating clinicians who should be zealous advocates for their patients. And then more importantly I think most protocols have an appeals process. So that based on whatever triage decisions that are made, patients and/or possibly the treating clinicians can appeal that process.

So, I think that's a very important dimension in a very difficult circumstance for all frontline clinicians.

Unger: Mia, do you see any other health equity issues kind of fitting into this discussion around ethics?

Keeys: Yeah, for sure, so I really appreciate what you just contributed here, Audiey, with respect to differentiating between the treating physician and the triage team. That is a really notable difference.

The issue that we also should potentially think about here, or discuss here, is how does that algorithm then translate in issues outside of the treating facility.

In terms of testing, for instance, right? We're definitely seeing some disparate, well, potentially seeing some disparate access to testing for persons who suspect that they might be sick with the virus or are just fearful. And, of course, in that way the fear drives them to seek out care—potentially in ways where medically underserved communities have never sought care before. Whether it's because they feel institutions are not trust-worthy or they just don't have a practice of presenting for care or maybe they don't have a PCP or something like that.

So, I think it's important to also think about it in ways outside of the emergency setting. Think about access to testing. We certainly need to think about—Elliot, to the point that we both talked about—the fragility of the healthcare system or, really, the fragility of the institutions that bear on a person's ability to make healthy choices or choices are made for them that make them sick.

So, I think it's important to keep the more upstream considerations in mind: Where are people coming from? What encourages them to present for care in the first place? How does that differ from their past experiences? And especially with respect to testing, in addition to treatment, we need to be able to keep equity in mind as a strategy to build out those algorithms that you spoke of, Audiey.

Crigger: I think also one thing that's begun to bother me is this sense of if, for example, you're going to allocate whatever resources, whether it's testing, whether it's a ventilator, on the basis of medical need, well that medical need is already going to be stacked against persons who are from disadvantaged communities.

They are the people who are most likely to have the comorbidities that will put them lower on the list. They are the people who have the least knowledge of how to get into the system. And right now, we don't really have a good way to level that playing field. But we have to be acutely aware of the fact that the playing field isn't level to start with, when we start making these decisions, when we start developing these policies.

Unger: Well this has been an excellent discussion. There's clearly a lot more to talk about in regard to ethical considerations. The AMA is building out an extensive set of resources on the ethics front which you can find at our COVID-19 resources page.

I want to thank today's guests, Dr. Audiey Kao, Elliot Crigger and Mia Keeys for their contributions. We'll be back with another episode tomorrow, where we'll be talking with front-line physicians on their experience with the COVID-19 pandemic.

Thanks for joining us today.

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