In a call with the local health department on panemic control, I asked , what was being done to provide isolation for infected farm workers, prisoners, and the homeless. A member of the department replied, “We have that covered.” When I asked about the steps being taken, he said, “Are you implying that we are not doing our job?”. To another group, also COVID-related, I offered my services as an epidemiologist and ethicist to help identify ethical issues. The group leader enthusiastically folded me in, made a point of asking my opinion during discussions, and immediately acted on my recommendations.
I have served as an ethicist on committees at my university, a few states, the Centers for Disease Control and Prevention, and the World Health Organization (WHO). I studied ethics during a sabbatical year from the Department of Epidemiology at the University of North Carolina. Although my training in ethics was a patchwork, my perspective on the intersection of public health and ethics was in demand a few years later when the world was preparing for an anticipated pandemic of influenza. With COVID-19, this expertise has been called into action again.
Sometimes I provide input one-on-one, sometimes I am part of a group that is tasked with addressing ethical issues, and sometimes I am folded into a decision-making group that wants some ethical input. When I am one of a group of ethicists that is charged with providing guidance, I am with colleagues who speak my language and a group that shares a common goal. The intellectual challenges are both stimulating and confounding.
Thinking through issues before a crisis is important and valuable. There is time to gather a group and to consider all the options. The guidelines, once established, are one less thing to think about when the crisis arrives, allowing the response to be quick. However, many ethical conundrums in a public health emergency cannot be anticipated. New issues arise daily, but decision times shrink, and the mental capacities of the responders are stretched to the limit by 24/7 urgency.
In this situation, it is helpful to have a designated ethicist. A standing ethics committee responds to ethical questions presented to it, but it is typically only an individual who is asked to listen for ethical concerns in non-ethics meetings.
When listening for ethical concerns in such a meeting, I rely heavily on the American Public Health Code of Ethics. The Code reminds me of time-tested values and principles within public health. For example, I was alert to the risks not isolating infected farm workers because the Code states: (1) Improve access to community-based public health services and outreach to underserved populations and those most affected by health disparities; and (2) Recognize and act upon the fact that the ethical obligation to provide access to health care is not limited to persons with citizen status only. Other resources I draw upon are the WHO’s Guidance on Ethical Issues in Pandemic Influenza Planning, the CDC’s Ethical Guidelines in Pandemic Influenza, and my own state’s Stockpiling Solutions: North Carolina’s Ethical Guidelines for Pandemic Influenza.
Even with these guidelines, however, the answers are seldom obvious. Contextual factors complicate decisions. One ethical issue may be more urgent, requiring that others be put on hold. The available information is never enough. And with all the available information, there is seldom only one viable ethical answer.
I can’t think of an instance in a discussion when an ethicist identified an issue and immediately recommended an action agreed to by all. In my example about farmworker risks, someone else in the group typically would have further complicated the question with more information such as “There are no thermometers in migrant camps to determine whether a person might be infected.” An ethical question often leads to more questions before the group can narrow in on potential answers.
I have never found that I am the only ethics-minded person in the group. Moreover, others inevitably identify issues I did not see, often because they know details I didn’t know. And because I am first of all an epidemiologist, my input to discussions often draws upon my non-ethics expertise. I have found this can earn the trust of the group, by demonstrating that I understand the complexities of what they are wrestling with.
Our ethical responses to COVID-19 are evolving with the pandemic. Each day brings new information, new considerations to factor in. Each morning I spend an hour reading up on the new developments so I can be fully current in the response team discussions. Even so, decisions made on one day might need to be rethought or adjusted with new information that is learned the next day. We may still miss some ethical issues altogether. But the likelihood of overlooking an issue in the frenzy and exhaustion of racing against a pandemic is less likely by giving at least one person the responsibility and authority to listen in on decision-making discussions with an ear to ethics.
About the author :
James C. Thomas, is an Associate Professor of Epidemiology in the University of North Carolina Gillings School of Global Public Health. He was one of the authors of the American Public Health Code of Ethics and served as an ethics advisor to the Director of the US Centers for Disease Control and Prevention.
I have read and understood the BMJ Group policy on declaration of interests and declare that I have none.