The pandemic of the COVID-19 virus has denied all of us the “normal” lives we led before, but, in the world of healthcare, it has produced ethical dilemmas no one expected, either. The question?
How can a physician trained in dermatology, pediatrics, obstetrics, podiatry, or orthopedic surgery suddenly be pulled into life-saving, gut-wrenching work as an emergency medicine physician? What prepared them for this, and how can they perform adequately when no one has a few minutes to prepare them for the next emergency patient who needs ventilation? How do they handle the dreadful death toll of this virus? What about their medical ethical mandates when triage is indicated?
The practice of medicine for many of these out-of-specialty physicians will be and is dramatically different during the present and future pandemics. Once working in private offices, group practices, or standing in state-of-the-art operating rooms, these physicians will find themselves propelled from 20th-century medicine into new standards of 21st-century medicine within months. New-normal medicine will be uncharted territory and will tax many of their beliefs about healthcare.
Work may, at times, be in field hospitals set up by the military or in settings that formally were used for other purposes, including hotels, convention centers, factories, warehouses, tents, and even ships. Their former, somewhat predictable, daily routine will no longer be the routine that continues. How will it affect them?
Suicide Statistics Provide a Small Window
The consequences are far-reaching not only for the physicians but for their families and their fortunes. Physicians are not immune to emotion, and we know that by the statistics that lay out, in an eye-opening fashion, the suicide data relative to physicians.
“Suicide is the second most common cause of death for 10-to 34-year-olds in the United States. The average age of matriculating medical students in 2017–2018 was 24. Thus, it should come as no surprise that medical students, residents, and attendings — like other Americans — are affected by suicide and mental illness.” An estimated 300 physicians commit suicide each year, but that statistic is old and doesn’t factor in a pandemic with all of its increased stress and potential burnout in addition to PTSD (post-traumatic stress disorder).
Out of Specialty Work
Graduating medical students take the Hippocratic Oath, which sets their career course in terms of ethics and morals. The newly-minted physicians expect to undergo grueling years of advanced training. Each specialty has been carefully evaluated for their interest and their skill-level.
Personalities, too, were included in the search for their future career goals. Once the COVID-19 hit, the best-laid plans of new docs went awry in directions no one could predict.
Not all physicians are “people” people but now their choices would be limited by a pandemic. Some would have preferred the solitude of a lab or the absolute authority of the operating room rather than the M.A.S.H environments into which they were thrown.
Challenging is one of the words most often used by physicians and nurses who were placed into unfamiliar circumstances where they needed to refresh or learn new medical protocols. The main concern, now for all, was how to protect themselves and their families, once they were off shift. They knew they were dealing with an incredibly deadly, contagious virus, and it clung to clothing, cardboard, metal, and several other materials and hours if not days.
The virus was also resistant to heat, presenting an additional difficulty in labs and treatment rooms. It wasn’t easily killed or removed.
Even the protective materials that were to be used required special procedures for removal. An additional concern was whether or not there would be adequate masks and gowns on the next shift. If the work didn’t demand yeoman-like skills, the anxiety of not having PPEs (Personal Effective Equipment) available heightened the stress.
Whoever thought needed supplies or machines wouldn’t be there when needed for treatment or to save a life? It was out of the realm in which they had trained.
Ethical Concerns Arise
The difficulty which presented itself was whether or not to refuse reassignment to an ED (emergency department) or chance catching the virus while working in the ED. Did physicians come to their work as a “calling” or a profession that made difficult ethical choices a part of the bargain?
Some in healthcare would refuse to work if PPEs weren’t in adequate supply. Was ethics involved at all here? Is it mandatory that physicians and other healthcare workers put themselves in situations of extreme risk and death to satisfy their oath to serve? What does a physician do in situations of scarcity where staff or equipment is at a premium?
One article has addressed this situation in a forward-thinking manner. “Educators should begin to teach “scarcity thinking” in medical schools, residencies, and other training situations, with a focus on practical guidance for contingency planning and a deep understanding of the ethical principles of implementing crisis standards of care.” We can put this under “lessons learned” during a pandemic.
Is working in an area in which the MD is not a specialist an ethical issue? A medical license does not indicate a need to be a specialist and often states the person is qualified to practice medicine and surgery. But a license is poor protection.
The duty to treat has come up against new ethical issues outside areas of specialization. And the situation is not contained in one area of the country or the world or to one specialty. “We’re hearing a lot of anxieties from specialists who don’t know what the right thing to do is for their patients,” said Dr. Megan Ranney, an emergency physician in Rhode Island. “Dermatologists, ophthalmologists, we’re even hearing from dentists.”
As a result of the difficulty of the pandemic, “U.S. medical professionals on the front line of the coronavirus pandemic are lobbying policymakers for protection from potential malpractice lawsuits as hospital triage care and physicians take on roles outside their specialties.”
For any physician or healthcare professional, COVID-19 difficulties can be daunting. In the case of physicians wishing to volunteer or to come out of retirement, the American Medical Association has provided a series of guides.
For employed physicians, the AMA has another bit of assistance in “a guide that concisely covers key strategic, legal, and contractual considerations. The information is not to be construed as legal or financial advice, but it is meant to help physicians understand their rights and the opportunities available to them.”
In the greater scheme of things, a physician, NP (nurse practitioner), PA (physician’s assistant), or another licensed medical professional has to weigh the moral/ethical issues as well as the legal ones. Guides may provide some valuable information, but the law isn’t always so clear-cut on many matters, and medicine is one of them.
The swirl of a pandemic created in 2020 will change all of us and the world in which we live, the hospitals in which we work and the labs where advances are made to name a few. Many other changes may come as surprises or welcomed advances but that’s not for us to know today. We await a better tomorrow after this dark night in which we now find ourselves.