The COVID-19 pandemic has put a spotlight on the challenges people without homes face in getting the care they need. Their physicians face challenges too, especially in balancing the dual responsibilities of promoting the welfare and confidentiality of individual patients and protecting public safety.
Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) by primary care physician Katherine Diaz Vickery, MD, Amy Gordon, DNP, NP-C, nurse practitioner, and Naomi Windham, DNP, APRN, NP-C, with Hennepin County Health Care for the Homeless, in Minneapolis.
Using a hypothetical case of a 48-year-old woman with uncontrolled type 2 diabetes and a history of anxiety and depression who presents with a persistent cough, shortness of breath, fatigue and myalgia, the authors explored how primary care physicians should respond when patients decline COVID-19 testing and isolation.
As health professionals in a homeless health care program, “we frequently find that patient-centered health care for people who lack housing presents a series of imperfect, insufficient choices,” the authors wrote. “The COVID-19 pandemic made these choices common and complex.”
Case in point: redesigned walk-in models of care. Physicians now routinely screen patients and provide social and behavioral health services via telehealth.
“Yet, despite our training, experience and resources, we still struggle to navigate how best to express respect for patients’ autonomy while minimizing harm to public health,” they added.
As with previous public health crises in the U.S., the COVID-19 pandemic has funneled resources into numerous projects that fail to strengthen society or address long-standing inequities, the authors noted. Meanwhile, people living in poverty—who disproportionately come from historically marginalized racial and ethnic groups—continue dying at higher rates, leaving behind families who then struggle to afford housing, food and other essentials.
“Bioethical principles and international law could offer clinicians guidance on how to navigate this complex confluence of challenging circumstances,” they wrote. “Such guidance could detail how to balance the rights of individuals against those of the public and how to support public good."
For example, the Siracusa Principles, developed in 1985 by the International Covenant on Civil and Political Rights, emphasize that limiting rights cannot “involve discrimination solely on the ground of race, colour, sex, language, religion or social origin.”
“Given the social origin of homelessness, this guidance suggests that it would be inappropriate to impose any limitations” on the rights of people without homes solely due to their living circumstances, the authors wrote.
But this leaves little room for protecting public health, so physicians should also look to Matose and Lanphier’s “harm principle,” which requires prioritizing the prevention of harm, which could come not just from disease transmission but also the unintended consequences of social restrictions, such as lost employment and food insecurity.
This principle also supports providing supportive housing—instead of compelled housing, which infringes on patent autonomy—as a fundamental human right, although leadership on this issue has been lacking at the national level.
The authors recommended that physicians who care for people without homes maintain an ethical framework of person-centered care, respect for autonomy and respect for resilience. They should also continue to build relationships with the people they serve.
“Such relationship building—rooted in establishing trust, harm reduction, and trauma-informed care—aligns with expert opinion about dealing with difficult cases of COVID-19 among people experiencing homelessness,” the authors wrote. "We also know it’s currently our only hope.”
The November 2021 issue of AMA Journal of Ethics further explores health care and homelessness.