Prioritizing the rest of health care in a public health crisis


In the midst of a pandemic, attention shifts toward containing the spread of disease and treating those who become seriously ill and away from the health care needs of other patients. In the short term, it may be essential to restrict the delivery of "routine" care in the interest of reducing immediate risks to public health, but that strategy is not medically or ethically sustainable in the longer term. The health of the community ultimately requires that a broad range of care be available beyond crisis-driven patient needs.

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The AMA Code of Medical Ethics offers insight into thinking about what is ethically required to safely make this broader range of health care services available. The challenge is to prioritize among services and to identify conditions that should be in place to enable the delivery of care while minimizing the ongoing risk of exposure.

Principles VIII and IX of the AMA Principles of Medical Ethics set out physicians' commitments to individual patient welfare and to supporting access to care for all, respectively. Opinion 8.11, "Health promotion and preventive care," of the AMA Code of Medical Ethics defines the professional responsibility "to prevent disease and promote health and well-being for their patients and the community." Opinion 11.1.2, "Physician stewardship of health care resources," charges physicians to be "prudent stewards of the shared societal resources with which they are entrusted. Opinion 1.1.6, "Quality," meanwhile, delineates the "obligation to ensure that the care patients receive is safe, effective, patient centered, timely, efficient and equitable."

Finally, Opinion 11.1.3, "Allocating limited health care resources," suggests criteria for determining which services have the strongest claims to priority. Viz., services that address urgent medical needs, offer likelihood of benefit and promote change in quality of life, including services intended to prevent disease and promote health in keeping with Opinion 8.11, such as primary care or well-child visits or routine vaccinations.

Depending on the specific public health threat, some preventive services—for example, nonemergency dental care in the context of a severe respiratory infectious disease—may pose undue risk to both patients and health care professionals. Other services, such as those that reflect patient preferences rather than clinically defined need, have a lesser claim to priority. For all services, informed consent requires that patients be made aware of the "burdens, risks, and expected benefits of all options, including forgoing treatment," in keeping with Opinion 2.1.1, "Informed consent."

Taken as a whole, this guidance suggests further conditions under which it is ethically acceptable to offer noncritical health care services in the context of pandemic disease:

  • Ability to ensure a safe environment, including ability to quickly and reliably test all individuals who will be involved in patient care to ensure that they are free of disease or immune
  • Ability to provide care without making a claim on health care resources that are otherwise required to meet other patients' urgent medical needs, including medical equipment, personnel and laboratory or other services
  • Ability to provide appropriate follow up, including monitoring and testing to ensure the patient remains disease free, or to provide immediate access to appropriate care if infection is suspected

Additional ethics guidance in a pandemic

The AMA offers an overview of foundational guidance regarding medical ethics for health care professionals and institutions responding to the COVID-19 pandemic.