A Pandemic Ethical Conundrum: Must Health Care Workers Risk Their Lives to Treat

A Pandemic Ethical Conundrum: Must Health Care Workers Risk Their Lives to Treat COVID-19 Patients? Alan Kadish, M.D. John Loike, Ph.D.

Photo Credit: Go Nakamura/Getty Images

The sweep of COVID-19 across the globe has raised a fundamental question about medical ethics: Do physicians, nurses, EMTs, and other health care workers have moral and legal obligations to risk their health and lives to treat patients during a pandemic?

It’s an important question, given the toll that COVID-19 is taking on medical professionals. As we write this, more than 100,000 health care workers have been infected in the United States alone and nearly 550 have died from COVID-19. The Centers for Disease Control and Prevention estimates that health care workers accounted for 11% to 16% of COVID-19 infections during the first wave.

To answer this fundamental question, we first need to define the ethical and legal duties of physicians during a pandemic or a war or a bioterrorist attack — and these aren’t necessarily clear. It is quite revealing that when students graduate from medical school, they all take various oaths modeled on the World Medical Association’s Declaration of Geneva. None of these include any statement that physicians must risk their lives in caring for patients.

There are conflicting perspectives on defining the responsibilities of medical professionals during an epidemic. Some have taken the position that medical professionals who refuse to work in hospitals during this pandemic should lose their jobs or even their licenses. This perspective is based on the idea that medicine is a humanitarian profession that requires health care workers to care for the sick under all conditions. By freely entering into this profession, so the thinking goes, physicians and other health care professionals have implicitly agreed to accept all dangers and risks.

This view is consistent with that of the General Medical Council in the United Kingdom, which asserts that physicians have an obligation to provide urgent medical care during disasters, even when there is a significant The American Medical Association takes a different position. Its 2020 update of Opinion 8.3 sets out physicians’ obligations in this pandemic to “provide urgent medical care during disasters … even in the face of greater than usual risk to physicians’ own safety, health or life.” Opinion 8.3 also recognizes that if the risks of providing care to individual patients are too dangerous, then physicians can refrain from treating COVID-19 patients because doing so may hinder their ability to provide care in the future.

The American Nurses Association offers similar advice, stating that during pandemics, nurses must decide how much care they can provide while also taking care of themselves. Nurses may refrain from working when they feel physically unsafe due to a lack of personal protective equipment or inadequate testing for infections.

Many ethicists believe that physicians and health care professionals may, at times, refuse to care for patients when their service conflicts with their own moral views. For example, physicians do not have to comply with a patient’s wish to terminate a pregnancy, or assist in euthanasia, if that conflicts with their moral framework. These ethicists recognize that emotions and motivations are integral parts of any moral decisionmaking process. There are no rigid rules. Choices must be adapted to the particulars of each given situation. For example, the moral duty not to harm or kill another person includes self-care for the clinician who is providing care to these highly infectious patients. It is akin to not requiring paramedics to enter a building on the verge of collapse to aid someone inside.

A health care professional’s specialty may also influence his or her moral obligation to treat a patient or refuse to do so. One who specializes in infectious diseases may not have the moral autonomy to refuse to treat COVID-19 patients, while one whose specialty is ophthalmology, cosmetic surgery, or dermatology can reasonably maintain a moral obligation to serve as a medical consultant or serve in some other capacity in the hospital, but not take on the risks of treating COVID-19 patients.

Physicians and other health care professionals must also balance their obligations as professionals with their duties as husbands, wives, parents, and children. The risk to personal health from the coronavirus is alarming enough, but the risk of infecting family members, especially those with a higher risk of infection, may be ethically and morally unacceptable. Health care professionals’ refusal to work in a state of emergency may be justified if their health or well-being is endangered because of medical susceptibilities such as heart problems, diabetes, pregnancy, and the like that place them at a high risk of contracting and dying

from the virus, or if they reasonably believe that their work environment creates an unacceptable hazard by not providing them with essential personal protective equipment.

Historical lessons offer insight into this ethical conundrum. For example, the history of secular medical ethics reveals that the medical community has never come to a consensus on the nature and scope of its responsibilities during an epidemic. The lack of consensus may be due in part to the fact that medical ethics are embedded in various broader social and cultural fabrics.

Jewish law supports the view that a person is obligated to save another, though there are situations in which the dangers or risks are so high that these moral obligations are not mandatory. Rabbinical scholars have concluded that physicians have an extra obligation to heal the sick and are expected to accept a greater degree of risk than nonphysicians, due to their training and nature of their work. Yet they must also be prudent in their obligation to protect their families. Interestingly, rabbinical scholars maintain that treating COVID-19 patients is not mandatory but is considered to be a great act of compassionate professionalism and is highly praiseworthy.

We believe that the question of whether health care workers must risk their lives to treat COVID-19 patients does not have one uniform answer. We do believe that health care workers who specialize in infectious disease or respiratory medicine have a greater responsibility to treat COVID-19 patients than health care workers in other subspecialties of medicine. Moreover, most, but not all, health care workers have a professional obligation to provide some medical service during this pandemic. Society, however, should be understanding of those health care workers who may defer their medical responsibilities because of their own personal health risks or extenuating family responsibilities.

While it is important for physicians and other health care workers to explore and come to terms with their moral and legal obligations to care for patients with COVID-19, this will not be our last pandemic. That is why it is essential to incorporate these issues into the medical and health science educational curricula and get students thinking about them early. Professional education should help students — and practicing health care workers — learn how to balance their health risks with the immediate benefits to individual patients and the capacity to care for patients in the future.

The moral obligation, the courage, the compassion, and even the heroism of millions of clinicians on the front lines are what professionalism is all about.

As appeared in STAT on July 24, 2020.

Saving Ourselves From the Groundhog Day Effect Ira J. Bedzow, Ph.D.

In the weeks since “sheltering at home” began, we seem to be living in an eternal present. Because our most recent memories of anything different – or “out of the new ordinary” – are weeks old, we have a funny sensation that early March was only a moment ago. There are no experiential memories to track time mentally. Each day feels the same as the previous one to the point where it is difficult to remember if a new day has even begun or not. It is almost as if we have adopted the mindset of Ben Zoma, the young but expert scholar in the Talmud, who sees “all the days of your life” simply as one long day rather than as an expression of a life trajectory over time.

This is a dangerous mindset to maintain, and it can cause us to fall into obsessive thinking and feelings of helplessness. It can shrink our perceived range of possibilities as well as our ability to connect with others. In the end, this type of obsessive thinking played a role in Ben Zoma’s mental decline. We should find ways to protect ourselves from allowing the COVID-19 pandemic to similarly take over all of our mental energy.

Here are two suggestions to create a break from the repetitive cycle of daily stresses that are brought on by our current situation. Of course, each person should take the details below the suggestions simply as my ideas so that the suggestions themselves speak to you personally, but I will give you my process and experience with them, simply to show how these suggestions could work.

Tip #1 – Take a moment every day to reflect on something bigger than the current moment.

In order to break the daily repetition, force yourself schedule time to think about something different. Don’t just take this time haphazardly; if you do, you will never actually do it. Establish a moment or two every day that is set aside without distractions.

In this time, I ask myself if I still want to become the person I thought I did and whether my actions (both small and large) in this moment demonstrate that desire. Have my values changed, and, if not, am I still acting on them? Am I making room in my life for the people and beliefs that I cherish or am I closing myself off by allowing new – and bad habits – to form? What small thing can I do today to make my life, and the lives of those around me, a bit different? Can I add some fun into the day?

Many of us are living with spouses and children, so this may seem impossible, but it is not. My time is early in the morning before everyone in the house wakes up. This works for me for two important reasons. First, it forces me to go to bed at a reasonable hour so that I don’t waste time at night with distractions and waste time during the day because I am overtired. Second, the scheduled time serves as a way to start my day thoughtfully and with purpose. It makes the upcoming frenzy that I must ultimately face secondary to the main goals and purposes to which I want to dedicate my life. (Truth be told; I actually take a second scheduled time after the work day as a reward for finishing the day, like spraying Febreze after cleaning a room. This time allows me to reset my priorities and my mood before having dinner and spending time with my family.)

Whatever time works for you and whatever questions you ask yourself, the important thing is that we expand the ever-narrowing worldview we risk acquiring when our movements and options become limited. The bigger you make the life around you, the less the pandemic’s social and psychological consequences will bear on you.

Tip #2 – Take a day each week and make it wholly different from the rest.

Days turn into weeks very quickly when there is nothing that marks a beginning and an end. In order to impose a structure on your weeks, as well as give you respite from the daily anxiety onslaught of the current situation, take a day and make it different. We all have heard about taking a “mental health day” which is specifically meant to relieve stress and prevent burnout. In normal times, 40% of workers in the U.S. say they find their jobs stressful; just imagine what the percentage is today. Mental health days are not simply days off. They are meant to help clear and heal a person’s mind so that he or she can return to work more relaxed and productive.

In order to use a day to reset your perspective, you need to change what you do, how you talk, and even what you think about on that day. The importance of making a day separate and distinct is proclaimed by the prophet Isaiah, who emphasizes that one “restrain from your normal goings for the sake of the Sabbath, from pursuing your affairs on My holy day; and call the Sabbath a delight, the Lord’s holy day honored,” by not continuing our usual daily activities or even speaking in our usual ways. While the prophet demands that the Jewish people engage in distinguishing the Sabbath day for the sake of honoring God, there is no doubt that making such distinctions benefits the Sabbath observer as well. As Achad Ha’am famously said: “More than Jews have kept the Sabbath, the Sabbath has kept the Jews.”

Both of these suggestions share the same idea. We need to find ways to hold onto the bigger picture before losing sight of it due to the overload of the everyday. Happiness is elusive even in times of relative calm, and when you aim for it directly you always miss the mark. “It is the very pursuit of happiness that thwarts happiness,” says Viktor Frankl. However, if you search for meaning and purpose, and take steps every day to reinforce your values, happiness may just come along for the ride.

As appeared in The Times of Israel on May 2, 2020.

When the Current Crisis Passes, Will We All Still be Created Equal?

Ira J. Bedzow, Ph.D. Stacy Gallin, D.M.H.

The arc of our country’s moral universe, bending toward justice, has steadily sought to broaden the practical application of the words of our Declaration of Independence, “that all men are created equal.”

Yet discussions regarding triage and allocation of scarce resources in the wake of the COVID-19 pandemic risk changing our national cry to something that is reminiscent of the conclusion of George Orwell’s book, “Animal Farm”: “All animals are equal, but some animals are more equal than others.”

As hospitals are writing policies on how to treat what they see as an overwhelming deluge of incoming patients, many are looking to other countries for guidance in how we should allocate scarce resources. Utilizing established best practices is extremely important for crisis management, but we must also make sure that humankind creates guidelines and protocols that are based on our moral arc. Decisions like these, and medical decisions in general, cannot be made on science alone. Treatment and care decisions will always entail applying science and medical facts to the goals and purpose of medicine — healing others.

In Italy, the Society of Anesthesia, Analgesia, Intensive Care and Therapy published the paper, “Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments, in Exceptional Resource-Limited Circumstances,” a 15-point document intended to “offer authoritative professional and scientific support to those who are forced by daily events to make sometimes difficult and painful decisions.”

The Society guidelines clearly prioritize greater life expectancy as the criteria for access to intensive care and life-sustaining treatment, but they also state that if the situation demands, it may become necessary to set an age limit for ICU admissions and allocation of scarce medical resources. Though the recommendations certainly did not intend for this to be the case, age quickly became a lightning rod because of COVID-19’s Looking at age or disabilities — when those factors do not relate to the direct cause of a patient’s prognosis or probability of survival — as a reason for not providing care out of deference to a general guideline is troubling. It embeds an inherent social bias that the elderly or those with disabilities are less equal than others for consideration of medical treatment. Even comorbidities can become reasons for prejudice if not considered in light of their effects on survivability and prognosis. For example, African Americans are 60% more likely to be diagnosed with diabetes than non-Hispanic whites in the United States. People with diabetes face a higher probability of experiencing serious complications from COVID-19. Yet, if a person’s diabetes is well managed, the risk of severe complications from COVID-19 is currently perceived as being the same as the general population. Diabetes, and other comorbidities, however, require long-term care and management, something to which not all members of the population have equal access.

Creating these types of clear guidelines that are easy to follow comes at the expense of acting contrary to the professional goal of medicine — serving as healers to the vulnerable.

Hospitals must be thinking about creating guidelines to help medical professionals make decisions in the moment. There are a lot of medical factors to consider and, in normal times, it takes a lot for people to weigh the various factors to determine the right course of action. In a pandemic, these decisions must be made quickly with very high stakes.

Yet guidelines should not take the place of doctors’ or ethics committees’ roles in making decisions. Individual cases should not be answered simply by deferring to general — and hypothetical — examples. In times of high stress, however, we run the risk of guidelines doing more than they are meant to do. They can end

up becoming definitive rules for making decisions rather than serving as aids to the real decision-makers. Because of this, hospitals must be even more careful to create guidelines that cannot be used to justify bias, prejudice, or priorities in people based on “social usefulness.”

We already have examples from other health care crises in history when Do-Not-Resuscitate orders served to declare that a person was not worth saving, regardless of medical prognosis. In the article, “The Deadly Choices at Memorial,” about what happened during Hurricane Katrina, we can read how hospital leadership interpreted DNR orders to mean that those with them had the “least to lose” compared with other patients if calamity struck and these patients would not wish their lives to be saved at the expense of others.

It is extremely important to make sure health professionals’ efforts go for the sake of saving lives — as many as they can. And they should recognize when their efforts may be illusory. But saving lives by discounting others right off the bat is not in line with our medical or social ethics, even if it might be utilitarian.

Times of disaster do not call upon us to throw out our everyday values and adopt a different form of disaster ethics. Think of the analogy between a regular season game and the Super Bowl. The rules are the same, but the stakes are higher, and the players are more skilled to face the challenge. Similarly, this moment calls on us to rise to the challenge of applying our ethics and making moral decisions when we need to most. Otherwise, after the COVID-19 crisis has passed, we may find ourselves facing an even bigger threat to society — and our humanity.

As appeared in The Citizens’ Voice on April 11, 2020.

What Happens When We Run Out of Ventilators? Jewish Law and State Guidelines May Have Different Answers

Ira J. Bedzow, Ph.D.

Photo Credit: Getty Images

The COVID-19 pandemic facing this city will test our country’s most deeply cherished values: respect for multiculturalism and religious freedom on the one side and the state’s responsibility to promote the common good on the other. This inherent tension is quite literally an issue of life and death.

In New York City and elsewhere, hospitals are close to experiencing a shortage of personal protective equipment and ventilators, which will greatly tax the hospital system’s ability to provide care. To be clear, as of now the city’s hospitals have not run out of ventilators. Yet given the rise in the number of patients coming to the hospital each day, preparation is warranted.

As hospitals develop triage protocols to prepare themselves for the time when they will need to treat too many patients with not enough medical resources, rabbis and public religious figures are grappling with the halachic answers to those same questions. And the protocols that New York City hospitals will ultimately adopt are going to clash with the position held by most, if not all, Orthodox rabbinic authorities.

If two patients show up at the hospital at the same time in need of the only ventilator, both hospital guidelines and rabbis assert that physicians should use clinical judgment to determine which patient has a better chance of survival.

The problem arises once a patient is already put on a ventilator. Many hospitals look to the 2015 Ventilator Allocation Guidelines, written by the New York State Task Force on Life and the Law, to help them figure out how to ration ventilators.

In a crisis, hospitals continually assess patients to determine whether they should stay on a ventilator or should be removed so that someone else can have a chance to live. The 2015 guidelines recommend that after being placed on a ventilator, patients must

be reassessed after 120 hours, and every 48 hours thereafter, to see if there has been an improvement in their overall health. If there hasn’t been, the patient should be removed from the ventilator so it can be given to another person with a better chance of survival.

The details of the guidelines’ recommendations would not apply in the case of COVID-19, since patients typically must be on ventilators for a week or two before they show signs of improvement. Therefore, any new guidelines that emerge will necessarily have longer timelines before recommending reassessment. But the overall idea of periodically seeing if a patient should continue on a ventilator or be removed for the sake of saving another person will be adopted in the new guidelines.

The normative Orthodox position in such a situation is far different: Once placed on a ventilator, a patient cannot be taken off unless the condition improves or the patient passes away — even if someone else with a higher chance of survival will be deprived of a ventilator as a result.

This position is grounded in the idea that “one life should not be pushed aside for another.” In the Mishneh Torah, Maimonides writes that in a situation where a group of Jewish people is being accosted by idolaters who threaten them by saying, “Give us one of you and we will kill him. If you don’t, we will kill all of you,” they should all be killed rather than hand over a Jewish life. In essence, halachically, it is better to allow many to die than to actively participate in killing a single person.

The majority of contemporary American Orthodox rabbis rely on the rulings of Rabbi Moshe Feinstein to provide practical guidance in the case of triage. When Feinstein was asked about triage in the early 1980s, he wrote (Igrot Moshe, Hoshen Mishpat 2:7375) that if a patient is already being treated, even if physicians incorrectly judged his or her survivability and mistakenly allocated resources to his care, another person with higher chances of survival does not take precedence and resources should not be re-allocated.

Feinstein’s reasoning is as follows: There is no obligation for one patient to surrender his life for the sake of another. Therefore, when the patient was allocated medical resources, the resources in effect became the patient’s for as long as the individual maintained life. It is not the case that medical resources are given to the patient contingently by the hospital until the hospital decides to take them away for the sake of another person. Rather, the resources have been committed to the patient as long as they are keeping him alive, without contingency. This is the case even if the second person is in a life-threatening As you can see, the difference is clear — hospitals will re-evaluate and reallocate resources in hopes of maximizing the number of people they can save. The Orthodox position places a primary value on stopping any type of active killing. The religious mandate is to endeavor to save lives, not to think that we have ultimate power to decide who lives and who doesn’t.

As New York City hospitals have not yet reached capacity, this clash of values has stayed in the realm of the theoretical. However, we already are beginning to see how even the idea that hospitals will not follow Jewish law is causing great worry in the Jewish community.

Maimonides Medical Center, located in the heavily Jewish Borough Park section of Brooklyn, is following the concerns of the Orthodox community: The hospital has committed to intubate patients and work with local religious leaders to provide patients the care they need based on their religious beliefs for as long as they can. However, Gov. Andrew Cuomo has pushed to have all of the city’s hospitals work as one system, which will include a set of common guidelines when there may not be enough medical resources to go around.

If, God forbid, we get to a point where triage protocols must be followed, the state will choose the common good over respect for religious freedom. This calculation is embedded in the Western concept of liberty from the outset, as expressed by John Stuart Mill in his essay “On Liberty.”

“The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others,” Mill wrote.

This would not even be the first case in New York in the past 12 months where public health trumped religious freedom. Last April, Mayor Bill de Blasio signed an executive order compelling residents to receive the MMR vaccine due to a measles outbreak.

Though this may not be the first case where the state is faced with choosing the common good over the rights of individuals, it certainly is the most devastating. It’s tragic not only because hospitals may not have enough resources to care for its patient population, but also because our country must push aside the values of tolerance and religious freedom for another set of priorities.

As appeared in the Jewish Telegraphic Agency on April 2, 2020.

The Ethical Minefield of Prioritizing Health Care for Some with COVID-19

Ira J. Bedzow, Ph.D. Lila Kagedan, M.Ed.

“We are at war with a virus that threatens to tear us apart,” the World Health Organization Director-General, Tedros Adhanom Ghebreyesus, told world leaders in a virtual summit on the coronavirus pandemic Thursday.

Such dramatic phrasing as “the war against Covid-19” and “physicians are on the front lines of battle” is heard everywhere today -- in the media, and from politicians and health care workers around the globe.

As US hospitals grapple with the influx of infected patients, this war analogy is creating a morally problematic way of thinking about how to allocate resources to the critically ill. In a war, we want to treat and return the strongest and fiercest soldiers to the battlefield to kill the enemy. In a pandemic that is straining medical resources and health care systems, we want something different: to save civilians’ lives in a way that maintains our own humanity.

Ethicists use the term “triage” to explain how onthe-ground decisions about health care are decided in a medical emergency. While “triage” has become an accepted medical term, its roots in wartime practice has the potential to influence who should get treatment for Covid-19 based on factors that are not strictly clinical.

This influence does not apply when there are resources -- even if limited -- to be had, but rather when critical capacity is overwhelmed and decisions must be made about how to treat too many people with too few resources.

We do not fight a disease in the same way that we fight an enemy during wartime. We should therefore be making decisions based on concerns that are clinically relevant to survival. And we should not be making utilitarian decisions that make assumptions about who would remain, and compose the best society, after the pandemic is over. Hospital ethics committees around the country are looking for guidance to a few recent policy models, advanced in medical journals and in public discussions, regarding the allocation of resources during the pandemic.

However, many of these example policies rely on two dubious assumptions.

First, they make a distinction between public health ethics and clinical ethics and frame these decisions in terms of public health. This distinction is meant to focus on the welfare of the general population rather than those individual patients toward whom physicians have a fiduciary responsibility. This then justifies making decisions based on “the greatest good for the greatest number” even if certain individuals may suffer from it.

The mistake of this type of thinking is that it frames these triage decisions incorrectly: as matters of public health. Medical professionals in the hospital serve a clinical role and should be making clinical decisions. Public health policies are about prevention of disease and utilize overarching community strategies such as “shelter at home.” They are not meant to deal with individual treatment decisions -- even if there are many -- that need to be made in the moment.

Moreover, even if one were to apply public health ethics here, the fundamental values of clinical ethics would still apply -- just on a larger scale. As such, we cannot simply throw out values, such as equity and social justice, because they are harder to maintain in a triage environment.

Second, not only are these ethicists’ example policies for resource allocation utilitarian in the sense of saving the most lives, they would also create policies that prioritize saving the most “life-years.” Saving the most “life-years” does not mean that those with the highest chance of survival from Covid-19 would get treated first.

It means that, between two people with somewhat equal chances of survival, those perceived to have the most years left to live would get greater consideration. The moral justification for this prioritization is that it gives younger people the opportunity to live through life stages that they have yet to reach.

While some ethicists try to explain that this choice does not consider intrinsic worth or social utility, it is very hard not to see this as a way of saying “Well, older people, you have had a good run. Let’s let the younger people have a chance to get old now as well.”

There are other ways to respond to the challenge of choosing between cases of equal mortality, such as “first come, first served” or lottery selection. Of course, in the case of Covid-19, age is often clinically relevant,

since with age comes other physiological factors or conditions that will affect chances for survival. But we should be fully aware of when we are considering a clinical factor and when we are submitting a patient to social bias.

We understand the motivation to be utilitarian and to want to maximize “life-years” -- it makes the rules clear and it is easy to feel that “life is good, so more life is better.” But clarity alone does not make for good morality.

Prioritizing “life-years” solely for the sake of giving the youth a chance to get old is as much a non-clinical social decision as any other that we should try to avoid.

Potential quantity should not be deemed actual. We may assume a younger person will live longer, but one can never be sure that this will be so.

We should not be utilitarian based on assumptions that are outside the clinically relevant. Ethics committees and medical professionals have no moral authority to presume the value of “life-years” or who will give a greater contribution to society when the pandemic is over.

Guidelines for ethical allocation of resources should stick to considerations of chances for overall survival from Covid-19. Indirect factors, such as age, disability, and comorbidity (existing physiological conditions that make a patient more vulnerable), should only be considered as they relate to prognosis and survivability.

It will seldom if ever be the case that all considerations for resource allocation for two Covid-19 patients will be exactly equal. And if there is a case where it is close, we shouldn’t simply defer to general guidelines that turn decision makers into soldiers on the front lines.

As appeared in CNN on April 1, 2020.