The responsibility to show up for patients—often called the duty to treat—is an ethical obligation in medicine. But amid a pandemic, it may be difficult to satisfy because of the added obligation to protect oneself and one’s patients from infection during shortages of personal protective equipment (PPE).
A webinar, “Ethics and Equity in Crisis Standards of Care,” produced by Project Firstline—the Centers for Disease Control and Prevention’s national training collaborative for infection prevention and control—featured a presentation by Matthew Wynia, MD, MPH, professor of medicine and public health and director of the Center for Bioethics and Humanities at the University of Colorado.
Dr. Wynia, an AMA member, placed the topic of infection control in the larger context of crisis standards of care and outlined the core ethical issues that should be top of mind for physicians during disaster response. The presentation was followed by a discussion of infection control guidance under crisis standards with a specific focus on staffing and PPE shortages.
Unless you do no clinical work, you almost certainly have operated under crisis standards of care at some point during the COVID-19 pandemic, Dr. Wynia noted. Early in the pandemic, for example, physicians had to adopt standards of care for PPE.
“Reusing N95 or surgical masks is clearly not normal care,” he said. “Prior to this pandemic, that would’ve been essentially unthinkable—and now we do it all the time.”
This points to four realities that underscore how complicated—and imperfect—medical ethics can be during disaster response:
Standards of care do not, in fact, change during periods of resource scarcity. The legal standard is that you cannot be held accountable for doing something that is not possible to do, an idea also captured in medical ethics. In other words, you’re not obligated to do something impossible.
Ethical principles won’t always provide answers about rationing. “We can’t just make decisions based on a utilitarian calculus,” Dr. Wynia said, noting that physicians are taught to look to ethical principlism for guidance.
Its four components are autonomy, beneficence, lack of maleficence and justice. The challenge is that ethical principlism rarely provides a clear-cut answer. The reason is that its principles often come into conflict with each other.
“This is why ethical dilemmas arise—because you have a circumstance in which you cannot optimize all of your key ethical principles,” Dr. Wynia said. “You have to pick some that are going to exceed the value of others.”
Equity is important—even when trying to maximize the number of lives saved. In the rollout of vaccines, public health authorities sometimes prioritized older populations over people who have been historically marginalized.
“The efficient, rapid rollout of vaccinations might warrant that, knowing that we are going to exacerbate inequity.” Dr. Wynia said. “But it’s going to be short term, and this is the easiest way to get vaccines into the arms of the highest risk individuals.”
Making local decisions requires processes, not just rules. “What we are trying to do here is really hard. We are drawing lines about who gets what in a very granular world,” Dr. Wynia said. “There are very few decisions we’ve made that we haven’t had to revisit.”
Project Firstline is a collaborative of dozens of national, state and local health care and public health organizations—including the AMA—that have come together to provide infection control training for millions of front-line U.S. health care workers and members of the public health workforce.
Its resources include educational videos, a training facilitator toolkit, web buttons and social media graphics, print materials and online events. There are also a number of partner resources, which include additional helpful videos, webinars and podcasts.