The COVID-19 pandemic is posing unfamiliar challenges for front-line physicians while also casting new light on longstanding health equity issues. An episode of the “AMA COVID-19 Update” explores several underlying ethical questions. Among these: How much risk is too much for physicians? Which patients should get priority access to scarce resources? And how do socioeconomic factors affect quality of care in an emergency?
In a conversation with the AMA’s chief experience officer, Todd Unger, three experts from the AMA delved into relevant ethical guidance.
The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 global pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical Ethics, JAMA Network™, AMA Journal of Ethics®, and consult the AMA’s physician guide to COVID-19.
Managing risk, responsibility
Physicians and other health professionals treating patients with COVID-19 may face higher risks of infection amid shortages of personal protective equipment (PPE), but how much risk is acceptable?
“There is no numeric answer to that question,” said Audiey Kao, MD, PhD, vice president of ethics standards at the AMA and editor-in-chief of AMA Journal of Ethics.
Noting that the lack of sufficient PPE is “a serious matter,” Dr. Kao added that physicians who have chronic medical conditions may want to avoid being placed in positions where there is insufficient PPE.
“But I think it’s important … that physicians and all front-line clinicians recognize that they have to show up for work, even in the face of personal danger,” he said.
Read about the history of the physician’s duty during deadly outbreaks, and consult the AMA Code of Medical Ethics’ advice on physicians’ responsibilities in disaster response and preparedness.
Also, learn more with the AMA about the plea to the nation from doctors fighting COVID-19: #GetMePPE.
Fairness is foremost
With shortages of ventilators and other equipment, hospitals and health systems are sometimes having to ration care, which requires a well-defined decision-making process.
“We want to look at medical need first, as the primary criterion—not social worth, not any of those other possible considerations,” said Elliott Crigger, PhD, director of ethics policy at the AMA. “Is this individual likely to benefit? For example: Can we avoid a premature death?”
If there’s no material difference between patients’ medical needs, "then we want to go a very fair and objective system for choosing among them,” in part so that individual treating physicians are not making rationing decisions ad hoc, Crigger added.
In fact, for several reasons, such decision-making should be done by a separate triage officer or triage team with relevant expertise, Dr. Kao said. One reason is that this allows for more objective and consistent application of allocation decisions, especially when time may be tight.
It also “reduces the moral distress and emotional burden on the treating clinicians who should be zealous advocates for their patients,” Dr. Kao said, noting that most hospitals have a process by which patients and physicians can appeal triage decisions.
Read the Code’s opinion on allocating limited health care resources, and learn more about other ethical advice that is highly relevant in the context of the COVID-19 pandemic.
Accounting for inequity
Of course, competition for scarce resources won’t only affect patients with COVID-19 during the pandemic. Patients with lower health literacy or less familiarity with the health care system could be disadvantaged when their physicians are pressed for time.
“We're seeing that a lot of people presenting for care in hospitals—especially those that are disproportionate share hospitals—are limited-English proficient and having a hard time describing their overall symptomology,” said Mia Keeys, MA, the AMA’s director of health equity policy and advocacy.
So while objectivity is a priority, some patients will benefit from a more subjective approach.
“It's important to keep the more upstream considerations in mind,” Keeys added. “Where are people coming from? What encourages them to present for care in the first place? How does that differ from their past experiences?”
Learn more about why racial and ethnic data on COVID-19’s impact is badly needed.
