INTERVIEW BY KARA BETTIS March 31, 2020
Medical professionals across the US are preparing COVID-19 units in a suspenseful quiet, while others in places like New York are already overwhelmed with patients. The city has ordered hospitals to increase capacity by 50 percent, and they are looking at ways to use temporary facilities, including a recently arrived Navy hospital ship, hastily built field hospitals, and even hotels.
In the midst of all this, doctors and nurses are preparing to face agonizing ethical decisions as their Italian counterparts have already in recent weeks. According to some estimates, the number of projected coronavirus patients needing ventilation in the US could reach anywhere between 1.4 and 31 patients per available ventilator.
There are three main ethical concerns that medical professionals are now facing, according to the Center for Bioethics and Human Dignity: protecting the vulnerable by not overwhelming health care systems, allocating insufficient medical supplies, and keeping medical workers safe who lack the proper protective equipment against the virus. The questions are very real: Who should receive medical care when there aren’t enough resources to go around?
Two ethicists aiding US medical workers with these dilemmas are Carol L. Powers, a lawyer and the co-founder and chair of the Community Ethics Committee out of Harvard Medical School’s Center for Bioethics in Boston; and David Stevens, a physician and CEO emeritus of the Christian Medical & Dental Associations in Bristol, Tennessee who spent 11 years on the front lines of the HIV/AIDS and malaria epidemics in Africa.
CT spoke to Powers and Stevens about how Christians should approach issues of life or death.
How does the relationship between the physician and patient change during a public health crisis like a pandemic?
Powers: In the normal course, the physician-patient relationship is shaped by two different “spheres of decision-making.” Typically, the patient is charged with articulating their individual goals of care based upon their personal values and preferences. The physician then responds with various treatment options that would accomplish those individual goals of care.
In a public health crisis where health-care resources become limited, the physician-patient relationship changes drastically. The weight accorded to an individual patient’s goals of care diminishes in light of the community’s increased need for health care resources. Rather than focusing solely on the patient in the bed, the physician must now consider the many patients in many beds. Treatment options available to both the physician and the patient become necessarily limited.
Critical care resources—an isolation unit or an ICU bed or a ventilator or dialysis—may not be a treatment option offered or it may even be withdrawn. In the case of non-critical medical needs, surgeries or treatments may be delayed or become completely unavailable. Resource allocation questions force a shift in the physician-patient relationship so that the patient’s desires for specialized medical treatments cannot be accommodated and the physician reluctantly becomes a gatekeeper for access to any care at all. Medical care that was once assumed to be available may become limited or completely unavailable.
For the physician, an uncomfortable shift occurs from providing patient care supported by evidence-based medical standards offering a full panoply of treatment choices to operating under crisis standards of care providing limited treatment options in an attempt to save as many people in jeopardy as possible.
Whenever the question arises “what should we do?” then you are in the arena of ethics. The focus of decision-making in ethics often centers upon balancing benefits and burdens of competing “good or right answers.” In our pre-March 2020 world, a patient was able to exercise a good deal of decision-making authority about what treatment options they wanted based upon an ethical decision-making principle of autonomy. In our post-March 2020 world, the ethical principle of justice asserts itself and physicians must find ways to allocate limited resources in ways that are fair and do the most people the most good. For years, we have stayed away from talking about rationing health care and now, because of a crisis beyond our control, we are being forced to ask hard resource allocation questions.