By Georgina Morley.
Effective triage and allocation of resources based on clinically and ethically supportable criteria is undoubtedly the correct way to respond to COVID-19 as we aim to mitigate the effects and likely unprecedented impact this novel virus will have on healthcare systems across the globe. However, as some commentators have overlooked, the burden of this moral work is not the sole purview of physicians. Difficult moral decisions should be, and indeed frequently are, informed by a multidisciplinary moral community.
In an ideal world, ethical frameworks, triage tools and guidelines would have been prepared before such crisis points are reached and would have already received input from key stakeholders, such as those that can be found from Maryland and Minnesota. This work would have broad consensus from ethicists, legal experts, healthcare professionals – of different disciplines – and the public. Importantly, individuals from racially and socio-economically diverse backgrounds would have central roles in this process.
Absent this ideal state, the moral work – and moral burden – of decision making should not be assumed to fall to doctors alone. While current structures within health systems do frequently place the weight of decision-making with physicians, there are ways to distribute responsibility. In North America, one way this is routinely achieved is by integrating clinical ethicists into decision-making. In many institutions, clinical ethicists are now also helping to guide resource allocation decisions. Clinical ethicists are crucial for shaping and informing decision-making processes and incorporating views of keys stakeholders. The UK may not have these integrated systems and ease of access to (dare I say) clinical ethics experts, but NHS Leaders, NICE and Public Health England should be looking to the Bioethics community to help inform the difficult decisions ahead so that it isn’t left to doctors to decide “which victims go on ventilators”.
In addition to Bioethicists, political and healthcare leaders need to recognize the expertise that non-physician healthcare professionals provide during times of emergency, rather than simply proposing headline generating solutions – such as the call for manufacturers to build more ventilators. These sorts of responses show a lack of consideration for the multidisciplinary nature (and expertise) of healthcare teams – suggesting that the solution is to simply find more machines, whilst forgetting that these machines are useless without the appropriate personnel to operate them. Use of a ventilator requires immense expertise not only from anesthetists but also critical care nurses, physical therapists and respiratory therapists to ventilate using lung protective strategies, adjust ventilator settings in response to arterial blood gases, prone patients, suction safely and titrate inotropes, vasodilators, sedatives and analgesics based on body weight. Focusing on doctors only – both in political and media discourse – fails to acknowledge the important role that others play, risks publicly disenfranchising people in those roles, and places an unreasonable expectation that physicians alone carry the weight of responsibility.
Headlines and news articles that focus purely on the physician experience are deeply unhelpful as they fail to capture the way that healthcare should function: as a moral community. News stories and Twitter debates too easily become focused on physician-patient dyads and neglect the work of other crucial healthcare professionals. Rather than adopting the view that “doctors must decide which patients get oxygen, intensive care, both, or neither” and suggesting this work is only “a decision for doctors”, consider instead ways to integrate nurses and the multidisciplinary team. This is important not only because others provide important perspectives and considerations, but also because they will lift the moral burden from physicians and mitigate their moral distress. Indeed, it is disappointing to once again witness a potentially society-splitting bioethics issue unravel which (thus far) seems to lack nursing perspectives, critique and leadership (with a few exceptions).
Relieving the burden of decision-making also needs to be a reciprocal process. Physicians are in a position of institutional power, but that does not mean they are, or should be, the only people at the decision-making table. Others can and should be joining them – whether invited or not. Our aim at a time like this should not be to place yet more responsibility at the feet of physicians, but rather to encourage them to lean on, and learn from, others. Difficult moral decisions ought not be made in silos by individual physicians with their own implicit (and unavoidable) biases, but rather ought to be framed and shaped by multidisciplinary perspectives and teams. This is precisely why triage guidelines exist. In fact, guidance from New York, Maryland and Michigan suggest that a Triage Team should assist a Triage Officer in decision-making to relieve their moral distress and moral burden. The New York guidelines also suggest that a perspective from “outside the medical profession” could be reassuring for the public albeit potentially difficult to implement. The very recently published guidelines from NICE reference decision aids for patients but do not clearly elaborate how physicians will be supported in decision-making.
As with other pandemics and natural disasters, the healthcare community and public is once again faced with immense suffering and unavoidable moral failure, but we should bear the burden together. It is not too late to incorporate these considerations into emergency work now, and we must strive to do so.
Author(s): Georgina Morley
Affiliations: Cleveland Clinic, Center for Bioethics
Competing interests: None
Social media accounts of post author: @morley_georgina