History, however, offers a useful caution. Breakthrough technologies in medicine rarely achieve their full potential simply because they exist. Their real impact depends on whether the institutions responsible for health-care delivery know how to adopt them wisely, integrate them responsibly and align them with their mission to improve patient health.

Artificial intelligence now stands at that same threshold. The industry has moved beyond fascination with what algorithms can do and entered a more demanding phase: determining how these tools should be evaluated, governed, and integrated into the environments where care is delivered. At the same time, some health professionals are turning to AI – not to augment their knowledge – but assuming the information is patient-care ready.

Across the health ecosystem, leaders are discovering that the most important questions about artificial intelligence are not technological. They are organizational, ethical and operational. Which AI systems genuinely improve clinical decision-making? Which tools strengthen the efficiency of hospitals and health systems? Which innovations introduce complexity without delivering measurable benefit?

Answering those questions requires a perspective that bridges policy leadership, real-world care delivery, and the scientific foundations of biomedical informatics. That convergence of experience sits at the center of a “Views From the Top” mainstage discussion at the HIMSS Global Health Conference & Exhibition, where some 35,000 leaders whose work spans the global health ecosystem will examine how organizations can recognize the true value proposition of artificial intelligence applications before embedding them into health-care systems.

The perspectives shaping this discussion reflect three essential dimensions of responsible artificial intelligence in health: governance frameworks that guide innovation, operational insights from large-scale health care delivery, and scientific rigor grounded in biomedical informatics. Together, these vantage points illuminate the path from technological promise to practical value.

Governing Innovation in a Rapidly Changing Health Ecosystem

Digital transformation in health rarely succeeds simply because technology exists. It succeeds when organizations develop leadership frameworks capable of evaluating innovation, managing risk and aligning new tools with patient-centered goals.

Few leaders have observed the evolution of digital health across as many national systems and institutional environments as Hal Wolf, president and chief executive officer of HIMSS, Ran Balicer, MD, PhD, chief innovation officer of Clalit Health Services and Isaac Kohane, MD, PhD, chair of biomedical informatics at Harvard Medical School. The three will step onto the mainstage at HIMSS to share their “View from the Top” in a session titled: “Recognizing the ‘Value Proposition’ Criteria While Selecting AI Applications.”

Through his work with global government health ministries, hospital networks, and technology innovators worldwide, Wolf has consistently emphasized that technological progress must be anchored in governance and trust.

“Digital health transformation is not about technology alone. It is about leadership, governance, and the trust that allows innovation to improve care,” Wolf has said in discussions about global digital health transformation.

Artificial intelligence intensifies this leadership challenge because its influence extends far beyond traditional clinical tools. AI systems increasingly operate across multiple layers of healthcare delivery. Some applications assist clinicians by analyzing medical data or suggesting treatment options. Others function within hospitals’ and health systems’ operational infrastructure, helping manage patient flow, prioritize diagnostic reviews, and allocate scarce resources.

These operational algorithms rarely capture headlines; however,  they shape the environment in which health care is delivered. Decisions about which cases are reviewed first, how clinicians allocate their attention, and how health systems manage capacity can profoundly influence patient outcomes.

For leaders responsible for health systems, artificial intelligence cannot be treated as simply another technological upgrade. It must be evaluated through governance structures capable of understanding how algorithms function, what assumptions shape their recommendations, and how their use aligns with institutional priorities.

Without that oversight, innovation risks amplifying complexity rather than improving care. Instead of informing, it can spread misinformation.

Aligning Artificial Intelligence With the Values of Medicine

Governance provides the policy foundation for responsible adoption of artificial intelligence, but real-world implementation reveals a second challenge: ensuring that AI systems operate effectively within healthcare delivery itself.

Large population health systems increasingly use advanced analytics to anticipate risk, manage chronic disease, and allocate clinical resources across diverse communities. Within these environments, artificial intelligence is no longer a theoretical innovation. It is already influencing how health organizations prioritize patients, coordinate care and deploy limited resources.

That operational perspective is central to Ran Balicer, MD, PhD, of Clalit Health Services, one of the world’s most advanced data-driven health systems. The Clalit integrated infrastructure connects hospitals, clinics, and community health programs through longitudinal datasets that support predictive analytics at the national scale.

Experience within such systems reinforces an important insight: artificial intelligence models do not function independently of human judgment. They reflect priorities embedded in their design and the assumptions guiding their deployment.

“Algorithms are opinions embedded in code,” Balicer has observed in discussions about the role of artificial intelligence in population health.

In practice, this means that AI systems interpret clinical data through frameworks shaped by human choices. The way a model defines risk, prioritizes cases, or recommends interventions reflects decisions about what matters most within a healthcare environment.

Those decisions carry ethical implications. When artificial intelligence helps determine which patients receive immediate attention or which cases are escalated for further review, transparency about how algorithms function becomes essential to maintaining trust among clinicians and patients alike. The scientific frontier of health-care AI reinforces that concern.

Isaac Kohane, MD, PhD, who has also served as a co-author of the Institute of Medicine Report on Precision Medicine, which has served as the template for national efforts, has spent decades exploring how machine learning can advance medicine while preserving the judgment that defines clinical practice. His research emphasizes that artificial intelligence in healthcare must align with the ethical traditions and professional responsibilities of medicine.

“AI systems in medicine must ultimately reflect the values of the profession they serve,” Kohane has written in discussions about AI alignment in biomedical informatics.

This perspective highlights a crucial distinction between technological capability and clinical responsibility. Many AI models entering healthcare environments were originally designed for broader computational tasks rather than the nuanced realities of patient care. Medicine operates within a landscape shaped by uncertainty, empathy, and accountability, and technologies introduced into that environment must reflect those values.

Ensuring that artificial intelligence aligns with the principles guiding health-care delivery, therefore, represents one of the most important scientific and ethical challenges facing the future of health.

The Discipline Required to Make Innovation Matter

The health sector has experienced waves of technological enthusiasm before. Electronic health records promised seamless information exchange, but then introduced administrative burdens on health professionals when implemented without thoughtful workflow design. Data analytics promised unprecedented insight, but sometimes led to fragmentation when systems failed to communicate across institutions.

Artificial intelligence now stands at a similar moment in the evolution of health technology.

Its capabilities in supporting decision-making flow are extraordinary, yet realizing them will require disciplined leadership to evaluate, integrate and govern AI tools within health-care delivery systems. Health leaders must learn to ask deeper questions before embracing the next algorithmic breakthrough. What problem does this system truly solve? How does it strengthen clinical practice? What assumptions guide its recommendations? How does its use advance the mission of improving patient health?

These questions move the conversation beyond technological novelty toward operational practicality. It’s among the many reasons these three global leaders step to the HIMSS stage together.

Artificial intelligence will undoubtedly reshape the health ecosystem in the years ahead. Its long-term impact, however, will not be determined solely by the sophistication of algorithms or the speed of technological progress. Along with how to leverage AI, ChatGPT and LLMs, users require heightened cognitive awareness.

It will be determined by whether the health community develops the discipline and ability required to translate innovation into systems that strengthen care, support clinicians and improve the health of the populations they serve.

The real story of artificial intelligence in health is no longer about what machines can do. It is about how wisely the health sector chooses to use them.

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Scientific Promise and Practical Benefits

A major strength of brain organoid research is its potential to improve our understanding of neurological and psychiatric conditions. Researchers can generate organoids from people with known genetic mutations to study how specific genes affect early brain development. This method has been used to study conditions like autism spectrum disorders, epilepsy, schizophrenia, and Alzheimer’s disease. It helps scientists find cell abnormalities that might not show up in animal studies.

Brain organoids are also useful for drug discovery and safety testing. Many treatments that work in animal models do not succeed in humans, especially for brain disorders. Organoids give scientists a human-based way to test how drugs affect neural cells. This can help spot toxic effects or benefits earlier, potentially lowering the risk of expensive late-stage failures and reducing unnecessary testing on people.

Limitations, Misconceptions, and Ethical Concerns

Even though brain organoids show promise, they have important limitations that are sometimes missed in public discussions. They lack blood vessels, immune cells, and sensory input, all of which are needed for normal brain function. Because they lack a vascular system, organoids obtain oxygen and nutrients only by diffusion, which limits how large and mature they can become. Most organoids end up looking like early fetal brain tissue, not fully developed brains. Does the appearance of something mean it will have the same abilities?

Variability is another challenge. Organoids grown in different laboratories — or even within the same lab — can vary in structure and cellular composition. This makes standardization difficult and complicates the interpretation of results. Additionally, reports of electrical activity within organoids have sometimes been mischaracterized as evidence of consciousness. Most neuroscientists agree that current organoids do not possess awareness, sensation, or thought, but the debate highlights broader uncertainties about how consciousness arises in biological systems.

As the science has advanced, ethical questions have also increased. There are concerns about informed consent when donor cells are used to make neural tissue, especially if donors did not know this could happen. Other worries come up when human organoids are put into animals, which raises questions about species boundaries and oversight. Although these experiments are closely regulated, many ethicists say clearer rules are needed as the technology develops.

Future Directions and Responsible Progress

Researchers are now trying to make brain organoids more realistic and useful. They are working on adding vascular-like systems, combining different organoid types to study how brain regions interact, and making results more consistent between labs. These improvements could help us better understand complex brain disorders and lead to more personalized treatments.

At the same time, ethical guidelines are changing to keep up with new scientific advances. Many experts say that as organoid research moves forward, it should be matched by openness, oversight from different fields, and regular public involvement. Brain organoids are not miracle cures or major threats; they are powerful but imperfect tools that can help neuroscience when used carefully. The future of this research will depend on both technical progress and a strong focus on ethics and public trust.

If all of this sounds like something from a Frankenstein movie, that would be one approach to take, but it isn’t realistic. We are only at the very beginning of understanding what the potential and the problems involved are for us. The research holds great promise, but it also requires informed restrictions that will not prevent advances.

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That moment, when the T-800, a machine built for destruction, understands human emotion, is among the most powerful in action cinema. It is the climax of Terminator 2: Judgment Day, but also a beginning: the start of the android’s transformation, not into a human, but into something more self-conscious that recognizes the worth of organic life, even if it can outthink people, it can appreciate the human experience.

The metaphor feels timely as we stand at the edge of an AI-driven health future. Today’s GenAI tools are evolving rapidly, but are we, their creators and coders, evolving with equal intentionality? Are we teaching the owners of these systems why we heal, or just how?

We often speak of artificial intelligence as if it were separate from us. But AI is not alien. It is us—our ideas, data, values—encoded and amplified. It mirrors back what we feed it. In the realm of health, that reflection must be carefully considered. Unlike a Hollywood villain, GenAI doesn’t turn against us with malicious intent. But it can misalign from its purpose if we forget that behind every innovation must be a human-centered goal.

From the first recorded prayer for healing in the Bible—“G-d, please heal her now”—health has always been rooted in empathy, intuition, and relationships. The clinician’s pause before giving a diagnosis, the nurse’s touch when comforting a patient, and the community health worker navigating skepticism in underserved areas are not functions you can replicate with an algorithm. They are acts of presence, of judgment shaped by experience and emotion. Yet, technology now surrounds these moments, offering powerful new support.

Even Satya Nadella, CEO of Microsoft, captured this imperative clearly: “Empathy must be embedded in artificial intelligence from the moment it is created to ensure it becomes a positive force in people’s lives.” It’s not just about what technology can do—it’s about how it’s directed, and who it serves.

GenAI is already beginning to assist clinical teams by synthesizing medical records, supporting drug discovery, and interpreting diagnostic images faster than human eyes. It scales knowledge, translates complex science for patients, and identifies early signals of population health risks. These are welcome advancements—but only when guided by a human compass.

Let’s not look at a future of “us vs. them”—patients and providers versus machines. The more accurate framing is “us and them”: a coalition of human and machine intelligence, working together in the service of healing. Patients, payers, providers, product developers, and policymakers are the “us.” GenAI, LLMs, machine learning, and chatbots form the “them.” Power lies not in one side dominating the other, but in how we integrate these efforts.

Tim Cook, CEO of Apple, has often said, “At Apple, we believe technology should lift humanity.” In a world driven by rapid innovation, his words are a steady reminder that progress without purpose is not progress—it’s motion without meaning. Cook also noted at MIT, “Technology is capable of doing great things, but it doesn’t want to do great things. It doesn’t want anything … That part takes all of us.”

To do that, we must resist the urge to see AI as an all-knowing oracle. AI is not autonomous in values, does not possess a conscience, and lacks intuition unless we teach it patterns. Those patterns, if drawn from biased data, can replicate systemic inequities. In health, where trust is everything, we cannot afford such blind spots. Human oversight is not just necessary, it’s irreplaceable.

There’s also a danger in assuming technology alone can fix what’s broken. We already know the limits of scale without empathy. We’ve seen systems become more efficient but less personal. We’ve witnessed patients lost in data flows, their lived experience reduced to metrics. If GenAI becomes another layer of distance rather than connection, we will have failed to grasp its most powerful potential: to bring clarity, not complexity; to extend human capacity, not replace it.

OpenAI CEO Sam Altman acknowledges the promise and the peril: “This will be the greatest technology humanity has yet developed… We’ve got to be careful here … people should be happy that we are a little bit scared of this.” Fear, in this case, signals responsibility. Responsibility requires centering AI in the service of people, not pushing people to conform to the logic of machines.

There are lessons in Terminator beyond the thrill of a dystopian chase. Sarah Connor learns to trust the very machine that once tried to kill her. John Connor, the future leader of humanity, becomes the teacher. And the T-800—a symbol of cold efficiency—becomes the student. This reversal reflects what we need now: machines that learn how to act and why their actions matter, not just how to optimize workflows but why saving time matters when time is the difference between life and death.

We cannot forget how this transformation from killer machine to protector occurs. In “Terminator 2: Judgment Day,” the T-800 model evolves into humanity’s hero because John Connor reprograms it from the future to protect his younger self and his mother, Sarah Connor. The human is the creator—the coder.

Somewhere in this cinematic science fiction lies a guiding truth for our future reality: technology learns from humanity. Just as this version of the Terminator changed by being close to people, our AI systems will evolve based on what—and who—they are near. If surrounded by empathy, equity, and ethical standards, they can amplify what’s best in us. If left untethered from human purpose, they risk scaling our worst habits.

We often frame digital health progress in terms of speed and scale. But what if we reframed it through the lens of dignity? What if the measure of innovation wasn’t just how fast a model can generate results, but how well it supports the human healing experience?

In the end, the T-800 sacrifices itself to protect a better future. It understands that some decisions aren’t logical; they are meaningful. It doesn’t cry—but it finally sees why we do.

Let’s not wait for machines to catch up with our humanity. Let’s lead with it.

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The practice of providing everything from computers to expensive medical textbooks, seminar speaking fees, research funding, lavish trips, meals, and other incentives was supposed to have been capped at about $25 years ago. Now, research has uncovered a most disturbing place where this practice can have an enormous influence on the diagnosis and treatment of psychiatric disorders, and it relates to their holy book, The Diagnostic & Statistical Manual of Mental Disorders Disorders (DSM).

Industry money influences how doctors prescribe cholesterol medications, blood thinners, medications for multiple sclerosis and Alzheimer’s disease, and even which drugs are used to treat cancer. Perhaps most concerningly, it influences how many opioids doctors prescribe. This influence is consistent across all medical specialties and drug types.

I have been in physicians’ offices where prominent items related to specific drugs and the companies that make them are displayed. I’ve also been present when lavish breakfasts and hot, multi-item lunches were delivered to an office prior to a “detail” person from a pharmaceutical firm giving an “educational” seminar as the staff ate.

I’ve even been on a hospital ward visiting a friend when a physician came around to see patients, and in his hand was a medical bag with prominent lettering indicating a pharmaceutical company had supplied it. Was he naive, or didn’t he care? You decide.

I’ve also seen psychiatrists leave worksites for periods of time to provide seminars at hotels in the area. For their services, they were very well paid, and the most shocking part was that the individual had no special background in the drug and had received a script and a prepared PowerPoint presentation to be shown.

But the latest and most disturbing finding relates specifically to the panel on mental disorders, how disorders are added to the DSM, who is evaluating what should be added, and how they may, consciously or unconsciously, be influenced.

The AMA has clearly outlined a code of conduct that states:

“To preserve the trust that is fundamental to the patient-physician relationship and public confidence in the profession, physicians should:

Decline cash gifts in any amount from an entity that has a direct interest in physicians’ treatment recommendations.

Decline any gifts for which reciprocity is expected or implied.

Accept an in-kind gift for the physician’s practice only when the gift:
will directly benefit patients, including patient education; and
is of minimal value.

Academic institutions and residency and fellowship programs may accept special funding on behalf of trainees to support medical students’, residents’, and fellows’ participation in professional meetings, including educational meetings, provided:
a) the program identifies recipients based on independent institutional criteria; and
b) funds are distributed to recipients without specific attribution to sponsors.”

Are all physicians members of the AMA? No, it is not a requirement, but we have to wonder if non-members should adhere to this code.

Recent disclosures of the DSM committee members’ financial conflicts are a serious concern for everyone, and we have to wonder why conflicts weren’t readily admitted or were withheld from those responsible for placing members on the committee.

Investigations have noted there were a lot of conflicts of interest among the DSM-5-TR panel members. Since diagnostic and treatment guidelines have a big influence, there should be high standards for being on a panel that develops guidelines.

The Diagnostic and Statistical Manual of Mental Disorders should have a rebuttable presumption that prohibits conflicts of interest among its panel and task force members. In cases where there are not any independent experts, people with industry associations could consult the panels, but they should not be able to make decisions about revisions or the addition of new disorders.

How have these conflicts affected the resulting revised DSM-5-TR? We have no way of knowing and must depend on the integrity of the panel members despite any conflicts they may have had. If we think otherwise, the foundation for this essential book is shaken, and we can only surmise that patients may, in some way, be harmed.

No, patients will not die because of a faulty psychiatric diagnosis, but they may suffer self-esteem, work-related harm, or even insurance-related harm. The threads of harm spread far and wide.

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It was a rude reminder of what I witnessed and how the public needs to rein in their gullibility in medicine, medical advances, and treatments. We are now seeing major campaigns in the service of medications. You know the ones that tell you to “Ask your doctor.” Is your doctor informed enough to advise you, or did they receive materials from a company?

In my experience, two significant areas of medicine cried out for remediation, and public relations was waiting with open arms; Alzheimer’s disease and anxiety. With an aging US population and a burgeoning one worldwide, SDAT is prime for anyone who wants to help or become incredibly wealthy. The silver tsunami is rolling over us as medicine keeps us living longer. The firm with the first patented SDAT “cure” or effective treatment for SDAT will make billions.

My respect for Dr. Jonas Salk has grown because he did not patent the rights to his polio vaccine. A similar instance of research integrity and ethics has been shown by Dr. Peter Hotez and his co-researcher, Dr. Maria Elena Bottazzi. They created a patent-free, low-cost vaccine for Covid-19, not so in the case of the HeLa cells on which millions were made, and that helped to originate vaccine production.

Anxiety, a mental health disorder that can be crippling in nature, affects approximately 284 million worldwide. When you have those numbers, the possibilities are highly enticing in terms of PR and money to be made.

But so are sleep disorders, where up to 60% of patients may have insomnia. Have you noticed how much attention sleep is receiving, especially when there’s a major conference? I’ve been to the conference, served in the press r, written the releases, bought the morning buffet goodies, and met the experts. Eye-opening, to say the least.

Now we come to the question of patient advocacy and who originates or funds it. Skeptics will pooh-poo such questions stating we need advocates to lobby for effective treatments. But do they spring up out of patient-caregiver zeal, or are they promoted for different purposes?

Of course, we want medications or treatments to address the need, and numbers must be used to lobby those who can supply the resources. Primarily, this means donations from the public or, more likely, from the government that will fund research.

Advocacy groups in which I once played a small part, are created by pharmaceutical firms that seek out famous persons or suffering patients to be the faces of their campaigns. I know that when we were working on anxiety disorders, our personnel tried furiously to find famous people (they shall remain nameless here) with serious anxiety disorders. The staff found a famous TV weatherman, a famous singer, an actor who drank himself to sleep, at least one actress with panic disorder, another who had bipolar disorder, and one was an incredibly wealthy man — who remained hidden from everyone’s view.

Assuredly, we need attention and in seeking the help these patients deserve, we have to make Faustian deals. Reviled as they may be, they are necessary to get the funding wheels turning. But always keep in mind that they are not as pure as the driven snow. And entertainers are paid to appear in service of the products — they aren’t experts. Your next-door neighbor might be as knowledgeable.

Disorders may be treated because someone has a new “cure” for it and the only way to make money is by advocacy. Do we have pharmaceuticals in search of a disorder? I’ve heard that question asked.

I’ll close, as I often do, with the proviso; caveat emptor.

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The study obtained consent for exposure to a pathogen with a 12-week delay in curative treatment. Details that are withheld are relevant to human subject concerns in current COVID-19 vaccination research.

The article published in Annals of Internal Medicine sparked a brief, but intense expression of outrage on social media from infectious disease experts, clinical trialists, and ethicists.

Little sign of this controversy is preserved in the biomedical literature. What was said by experts on social media about the ethics of studying infectious diseases in this unusual study should be available in a systematic search of the literature. Especially with the urgency of determining the efficacy and safety of vaccines for COVID-19 with healthy research participants.

Sensitive to the controversy this article had elicited, the official Twitter account of the journal tweeted

Apparently, there were few on Twitter who took advantage of this offer who succeeded in getting a letter published.

What was said by experts on social media about the ethics of studying infectious diseases in this unusual study should be available in a systematic search of the literature. Especially with the urgency of determining the efficacy and safety of vaccines for COVID-19 with healthy research participants.

Our published letter to the editor has largely gone unnoticed because of an exceptionally stubborn journal paywall, combined with delays and glitches in the indexing of letters to the editor. I could not find this letter in recent searches of the journal website or through Google Scholar.

My best friend and colleague University of Pennsylvania Professor of Medical Ethics & Health Jon Merz, MBA, JD, Ph.D., had made polite, persistent, but ultimately futile attempts to get the details of what was told to the two students and what assurances were given in securing their informed consent.

Jon wrote emails to the first author, senior author, and Research Evaluation Board of the Leiden University Medical Centre, Leiden, The Netherlands.

After some exchange of niceties, the response seemed to be an emphatic “Echt, niet!”

The article’s senior author noticed that Jon was an ethicist and presumed that Jon might want to publish on this issue. She reserved the right to protect her team to be the first to publish what was done to ensure informed consent. The team was collaborating with ethicists at Leiden University and she suggested that they would be publishing details.

The senior author also noted that her research staff had not given serious consideration to self-experimentation involving deliberately infecting themselves.

She ended further correspondence with:

Given the ethical debate around controlled human infection studies, we believe that it is important to take the utmost care in informed consent procedures, guidance of our volunteers and the public opinion.

Subsequent publications from this group have not revealed what was told to these students, not even in advisement about how to manage risks to normal volunteers in COVID-19 vaccine research.

Actually, a strong case can be made for cohort-specific informed consent, which involves disclosing specific risks to prospective subjects with particular personal characteristics.

The Head of the REB replied that she preferred that Jon obtain information and consent forms from the senior author of the study. She did not respond to further inquiries.

Our letter

The journal did not require us to sign over the copyright of the letter, so here it is in its entirety:

We read with interest the short report by Roestenberg and colleagues about the experimental infection of 2 graduate students with male cercariae of Schistosoma mansoni.1 The overarching hypothesis of this study is quite provocative. Results would be potentially clinically relevant, except data from only 2 of the originally proposed 17 subjects proposed in the trial registration were reported.2 Information in the trial registration indicates that recruitment is no longer occurring.

No reason is given for writing up the paper with such a small subsample of what was proposed. One is left wondering whether recruitment failed because of the risks and burdens of a study requiring exposure to a pathogen and a 12-week delay in curative treatment. No information is provided about recruitment strategies, target subject population, or information disclosed in the consent form. Was an incentive offered and was it consistent with the risks and burdens of the study? We requested the consent form from the senior author and the IRB, but our request was refused.

Despite recruiting only two subjects, there were six authors and a larger coHSI clinical trials team of 20. We wonder why no members of the team experimented on themselves. The Nuremberg Code provides some guidance for dangerous experiments that hold out no prospect of therapeutic benefit: “5. No experiment should be conducted where there is an a priori reason to believe that death or disabling injury could occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects.”3 While death or long-term injury from this experiment was unlikely, the principle behind this provision of the Code has a persuasive rationale.

If an experiment is too dangerous or imposes too high a risk and burden, only those who are most informed and free of undue pressures and coercion should be experimental subjects — namely, the investigators. No researcher (or IRB member) should ask others to do anything that they themselves would not do. If recruitment failure was due to the inability to find enough unaligned people willing to undertake such an experiment, we find it ironic and telling that none of the investigators would step into the breach for the good of their science.

We hope the investigators will be open and transparent about their recruitment and consent methods, as others may face similar barriers in trying to replicate and extend their important work.

The authors’ reply

We thank the authors for their interest in our research and sharing their ethical deliberations. Recruitment for this trial has been completed as proposed (n=17) and final trial visits for the last group of volunteers are currently taking place as planned. We aim to provide a full report of the trial results as soon as possible and anticipate final data collection in April 2019. Volunteers were financially compensated for their time and travel expenses according to accepted Dutch standards for medical research with healthy volunteers.

We have performed a thorough review of our informed consent procedures, volunteer expectations, risk assessments and motivation. The results of this study will also be made publicly available. Given the importance of the clinical findings of the first participants in this study to the medical community, we have been specifically requested to publish the clinical details of these initial cases as soon as possible and not await the end of the trial. We apologize for any concerns we might have caused with regards to failed recruitment or early termination and will keep you updated on trial publications.

Note that this reply seems to promise that the results of the larger study will be published. It did not say whether these publications would include the details of the protection of human subjects, including this study’s procedure for ensuring informed consent.

It is very odd to publish results obtained from the first two research participants when a larger study is in progress. This article could be seen as premature and inappropriate because any effects may prove false positives with the accumulation of more data. The authors want to attract attention to their preliminary results, but risk the likelihood of promising results getting more attention than the not-so-promising, but more valid results they will have later.

Responsible researchers do not publish preliminary results from an ongoing study without a very good reason. That is Best Research Practices 101.

Particularly since this group is taking the extraordinary step of publishing results obtained from the first two of a planned larger study, the medical and scientific community have the right to know how consent was obtained and if there were any participants who declined participation once they were fully informed.

If the results of this study are so important that they must be shared at this preliminary stage — after collecting data from only two subjects — then so are the procedures by which the results were produced, including informed consent.

There are unaddressed ethical concerns about this study. What were prospective participants told about possible adverse events, including the risk of death? How much were participants compensated in recognition of this risk? Are there special issues in these participants being students at the research team’s university and their perhaps feeling pressured to give consent?

Our suggestion that the investigators consider doing this research experimentally expose themselves — not someone else — to the pathogen has strong precedent.

A systematic review identified 465 documented instances of medical self-experimentation, including by researchers who went on to receive the Nobel Prize.

Walter Reed’s Yellow Fever Commission in Cuba in 1900 allowed mosquitoes suspected of carrying the deadly disease to bite Commission members, but Reed excused himself from having to do so. One member of the commission developed yellow fever and suffered lifelong chronic ill health. Another member died from the disease.

A classic paper in the New England Journal of Medicinethat is regularly assigned reading in medical ethics classes discussesAuto-Experimentation — An Unappreciated Tradition in Medical Science.

The paper notes

Obermeier, in his efforts to find a cure for cholera that then was epidemic in Berlin, allegedly injected blood from a patient with cholera into himself, and died.

Swiss chemist Albert Hofmann accidentally poisoned himself with LSD and then began purposely auto-experimenting with lower dosages to discover its psychedelic effects.

The NEJM article poses an important ethical question for the Leiden research team:

Investigators cannot serve as subjects in all scientific experiments. But the widespread practice of auto-experimentation raises a fundamental question about the philosophy of research: Is it ethical to subject another person to an experiment if the researcher did not do the experiment on himself first?

What are Katayama syndrome and schistosomiasis?

According to Lancet Infectious Disease, Katayama syndrome

Is an early clinical manifestation of schistosomiasis that occurs several weeks post-infection with Schistosoma spp (trematode) worms…Katayama syndrome appears between 14–84 days after non-immune individuals are exposed to first schistosome infection or heavy reinfection. Disease onset appears to be related to migrating schistosomula and egg deposition with individuals typically presenting with nocturnal fever, cough, myalgia, headache, and abdominal tenderness.

According to the World Health Organization (WHO), schistosomiasis:

Is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus Schistosoma. Estimates show that at least 229 million people required preventive treatment in 2018. Preventive treatment, which should be repeated over a number of years, will reduce and prevent morbidity….

Transmission occurs when people suffering from schistosomiasis contaminate freshwater sources with their excreta containing parasite eggs, which hatch in water…

Chronic schistosomiasis may affect people’s ability to work and in some cases can result in death. The number of deaths due to schistosomiasis is difficult to estimate because of hidden pathologies such as liver and kidney failure, bladder cancer and ectopic pregnancies due to female genital schistosomiasis.

Are psychology graduate and medical students members of vulnerable populations?

Regulations vary by country, but in the U.S., federal rules require that institutions overseeing research conducted with human subjects take special precautions to ensure that consent is obtained is fully informed, voluntary, and without coercion. The concern is heightened when individuals are in situations in which they can easily be manipulated, or they may be a convenient and readily available study population.

U.S. regulations especially cite children, economically deprived persons, and prisoners as vulnerable populations. Students and employees of an institution are not explicitly mentioned.

Yet, researchers can expect that in the review of applications to experiment with students, consideration will be given to how consent is obtained without coercion and how students and employees can decline participation or withdraw from research without fear of reprisals.

Special issues with Leiden University psychology graduate students

The Dutch academic environment is highly competitive. Career advancement is dependent on the demonstration of research productivity, as quantified by the number of authorships on peer-reviewed publications.

Dutch Ph.D. theses consist of a collection of peer-reviewed publications with interspersed commentary. Co-authorships on research conducted by graduate students figure heavily in the hiring, promotion, and tenure of junior and senior faculty.

The publications listed on the curriculum vitae of many department and laboratory heads in the Netherlands consist mostly and sometimes almost entirely of authors stemming from Ph.D. student research.

Dutch psychology students face particular challenges in being able to recruit patients for Ph.D. research from medical hospitals and clinics staffed and controlled by other disciplines. Most of us who have done research in those setting find that authorships can be expected for anyone willing to authorize access to medical patients. These academic administrators are responsible for securing publications for their own colleagues, staff, and Ph.D. students and can be expected to look after them.

I have had to acquire a new data set at another Dutch medical center for a completed manuscript reporting results based on secondary psychometric analyses of self-report measures.

The head of the clinic had given permission for use to some data from a study completed long ago in the clinic, before her time. But she did not respond to repeated emails offering authorship for a minimal of effort sufficient to comply with journal guidelines for determining authorships.

We asked at the last minute before the manuscript was uploaded for her to provide permission to name her in an acknowledgment. The clinic head insisted that she be able to recruit her two new postdocs to read and make comments on the paper. The three of them should then become authors or else the manuscript could not be submitted. We got a new data set elsewhere to reanalyze. As customary, we again offered an opportunity to the source to become an author, but we received a note thanking us but declining.

Decision-making about authorships in Dutch medical settings often involves some compromise between international ethical standards for awarding authorships and the need to maintain collegial relationships with those in control.

In recent years, Leiden University has had a number of scandals about research integrity, gift authorships, and denial of credit for student and early career persons’ contribution to research in the Schools of Education and Psychology.

This past year, the Netherlands Board on Research Integrity (LOWI) concluded that a former professor of psychology at Leiden University was guilty of breaching several rules of scientific integrity. This conclusion was based on the findings of the Academic Integrity Committee (CWI) of Leiden University:

The CWI identified four violations of scientific integrity: (1) blood sample testing without the legally required permission of the Medical Ethics Review Committee, (2) irregularities with publications, (3) repeatedly selectively omitting research results without reporting or explaining this, and (4) submitting grant applications with incorrect (incomplete and manipulated) research data.

Transparency in research ethics during the pandemic

Achieving control over the world COVID-19 pandemic depends on unprecedented international cooperation and the sharing of data obtained from diverse settings and the ethics and informed consent with which these data were obtained.

These were always Best Research Practices and now, more than ever is the time to enforce them.

Academic institutions are expected to share data as well as basic details of their methodology to allow their research to be replicated. Especially in the midst of a pandemic, researchers should be forthcoming and disclose fully the details of how they informed health volunteers about the risks of unprotected exposures to pathogens in their research and how truly voluntary consent was obtained.

We did not anticipate that pandemic would soon be upon us when our letter was published in Annals of Internal Medicine. But we saw no reason why these authors from LUMC should not answer a reasonable question about how they protected human subjects.

Dear Professor Meta Roestenberg of Leiden University Medical Centre,

Could you please inform the scientific community about how you persuaded two students to put their health at risk in your study by getting exposed to pathogens?

Kind regards

Jim

References

1. 1.Langenberg MCC, Hoogerwerf MA, Janse JJ, van Lieshout L, Corstjens PLAM, et al. Katayama Syndrome without Schistosoma mansoni eggs. Ann Intern Med 2019; Jan. 8. doi:10.7326/L18–0438.
2. 2. Roestenberg M. Single-sex controlled human Schistosomiasis infection: safety and dose-finding. https://clinicaltrials.gov/ct2/show/NCT02755324 (accessed January 20, 2019).
3. 3. Nuremberg Code. United States v. Karl Brandt et al, 6 Fed Rules Decisions 305 (1949).

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Little did they know their luncheon would lead to a clash between personal liberty and a 19th-century philosophy concept called the harm principle.

All in their 70–80’s, the women have varying degrees of health conditions. Diabetes, hypertension, asthma, and a cancer survivor sat at the round table inside a restaurant, enjoying a meal together.

The friends reconnected by reminiscing and sharing stories from their decades-long friendship. They hugged and returned home.

A few days later, the first in the group mentioned she tested positive for Covid-19. She did not call to warn the others or to recommend testing and quarantine. She casually mentioned her illness in passing.

She is a Covid-19 denier. She believes Covid-19 is real, but it is not the big deal the liberal #fakenews media portrays it to be. The pandemic did not deter her lifestyle.

She proudly sang in the choir at an evangelical Megachurch, where thousands of maskless worshipers celebrate their faith each week. She hosted her 30-person Sunday school inside of her home throughout the pandemic. She wondered aloud how she could have caught Covid-19.

She did not acknowledge she exposed her lifelong friends to a potentially deadly infection.

Luncheons, weddings, family barbecues, and other get-togethers serve as a reminder that our life choices now determine others’ fate. We may be socially isolated, but our lives are more connected than ever. Our decisions affect other people more than ever before. Our expression of personal liberty may impinge on the health and well-being of our loved ones.

“A person may cause evil to others not only by his actions but by his inaction, and in either case, he is justly accountable to them for the injury.” — John Stuart Mill.

Freedom to Do Whatever We Want vs. Others’ Rights Not to Suffer

Our world requires a collective effort to navigate through the pandemic. Each of us must make sacrifices to squelch the viral scourge.

Not all Americans share pandemic beliefs. The diversity of opinions are an inherent aspect of being an American. Historians will determine who is right and who is wrong. In the present, we each must make decisions about how we live our day-to-day life.

We are living in Pascal’s Wager.

Any of us may be asymptomatic carriers of SARS-Cov-2. Each of us may spread the virus before symptoms began and inadvertently pass the infection to another person.

Covid-19 is spread through person-to-person contact via respiratory particles. Breathing, talking, sneezing, and coughing spread large droplets. When we gather in groups, each of us is only as safe as the least compliant person.

We have two disparate choices:

1. The utilitarian approach follows nonpharmaceutical interventions such as social distancing, hand hygiene, and wearing a face mask. Individuals make a small sacrifice for the greater societal good. Wearing a mask is the easiest thing we can do to slow the spread of coronavirus and save others’ lives. Masks are an act of kindness towards others.
2. The deontological approach focused on personal freedom. In order to preserve individual liberty, one disregards precautions recommended by scientists, epidemiologists, hospitals, The Center for Disease Control, The World Health Organization, The Joint Commission, The American Medical Association, and The National Institute of Health.

Applying the Harm Principle

How do we reconcile the idea of honoring personal liberty while ensuring we limit the potential of hurting other people?

19th-century philosopher John Stewart Mill espoused the concept of the harm principle. This idea proposes people should be free to do whatever they want unless their actions cause harm to others.

Applications of the harm principle are evident throughout society. We respect the freedom of speech, but it is illegal to yell fire in a movie theater. People are free to drink alcohol but not drive a car while intoxicated.

Covid-19 deniers and skeptics are expressing individual freedom, but they are causing harm to others. Personal liberty does not include making others sick or possibly killing them.

I wear my mask to protect you. You wear one to protect me.

The United States has 6.8 million confirmed Covid-19 cases so far. There are over 31 million confirmed cases worldwide. 200,000 Americans are now buried in coffins. We have to do better.

We are living in dangerous times. SARS-Cov-2 does not care about our opinions or where we get our news. It infects and kills without considering its victim’s political views.

Covid-19 is a nonpartisan pandemic, but both political parties are deeply entrenched in their Covid-19 beliefs. We owe it to ourselves to pause for a moment of self-reflection asking, “What if I am wrong?”

We each should consider the possibility that our actions may be harming others. Until a vaccine or an effective treatment is available, the safest course of action is for every American to live as though we are all asymptomatic carriers.

One of America’s founding fathers famously said, “Give me liberty or give me death.” Our country celebrates an individual’s right to live life as they choose, but a functional society asks each person to consider the potential for harm to others.

The post Why We Sacrifice Personal Freedom to Protect Other People appeared first on Medika Life.

A therapist or, more appropriately, a psychotherapist, in this case, is a word we never associate with evil. The word evil is reserved for use in the religious realm as is the concept of the Devil (see Elaine Pagels’ “The Origin of Satin” or Bart Ehrman’s “God’s Problem”).

With the popularization of therapy, possibly related to its extolling by the wealthy and famous and availability of health insurance, change has come. Psychiatrists even considered whether or not if “evil” exists in anyone. Were there evil people (like Jeffrey Dahmer, John Wayne Gacy, and Dennis Rader) or were they exhibiting a form of mental illness or a personality disorder?

The question is no mean feat of theory consideration but one that has medical and legal implications. Does evil exist, or are we reverting to a less enlightened age where religion explained all for us in our wish to have answers?

Psychotherapy is dependent on introspection but if evil exists in some persons, is this concept relevant? An evil drive pushing toward acts concomitant with it wouldn’t seem open to change by careful inspection of one’s psyche.

If someone, with a predilection toward skirting the rules of ethics related to psychotherapy, were to be in a position of power, what would they do? Could they harm us in some way? If so, what would the harm be?

We need only to read some of the newspaper reports of questionable or unethical behavior of famous therapists such as Freud. What did Freud do? For one thing, he pressured patients to contribute to his own therapy association. Then, too, Freud considered his patients “riff raff” and convinced a man that he was a homosexual, urged him to divorce his wife and marry another of his patients.

Urging his patients to rid themselves of their neuroses, Freud failed to heal himself from the serious anxiety that stopped him from facing patients (he sat in a chair at the head of his famous couch), and his enuresis.

What about the equally famous Albert Ellis, the father of Rational Emotive Behavioral Therapy, who “Like Kinsey, Ellis is not the monogamous type. He has admitted to having sex with patients, though only after treatment had ended.”

Depending on state licensing laws, therapists may have a relationship with a former patient under certain circumstances. Some states this is never condoned, others say it’s fine two years after therapy ended. All licensing authorities, too, have a code of ethics by which licensees must abide.

Anyone engaged in the mental health field as psychiatrists, psychologists, social workers or counselors of any stripe need to do it be truthful to themselves and their patients. But there are those who are in the field for reasons which, if revealed, would lead to professional sanctions.

Famous or infamous?

The question of evil in a psychiatric setting would seem to have been settled by an editorial in one of the psychiatry journals.

As the editorial indicated, “Psychiatrists are medically trained in the scientific method, not in the diagnosis and treatment of evil.… (This) is the province of the philosopher and theologian and… Introducing the concept of evil into forensic psychiatry hopelessly complicates an already difficult task.”

The editorial writer indicated that evil is an exclusively human quality, and one not observed in animals. He was attempting to address one psychiatrist’s formulation of a “Depravity Scale,” which was to standardize measures of evil to provide some guidance for other psychiatrists.

In the context of this article, I am not attempting to categorize evil as anything other than a therapist’s wishes to optimize power, prestige, individual desires, or money. I do not believe they are genuinely evil, but some are not what I would see as sterling characters. Most try their utmost to deserve the trust their clients’ place in them.

However, some of the most famous names in mental health have been accused or have committed the most egregious actions. For some, it was a casual concern with their academic preparation (Erik Erickson); for others, it is ethical violations, sexual deviancy, murder case involvement, or drug use. Some engaged in unethical research. All of them are human with feet of clay.

The media is rife with the more sensational stories of therapists who have engaged in non-professional behavior. For example, they have slept with their patients, borrowed money, were involved in business relationships, controlled their patients’ lives as in the case of one famous music star, and generally allowed themselves to freewheel their lives as they wished. Of course, none of this is acceptable and violates ethical guidelines for all of the mental health professions.

Psychotherapists are supposed to help us deal with the difficulties in our lives, but that’s not always the case. Too many therapists are unqualified to practice as they do, are not licensed, got degrees from unaccredited schools, lack the training required, or are in it for the money.

Freud detailed his own love of money in his letters where he referred to it as “laughing gas.” Others may have more nefarious reasons for hanging out their shingle.

According to Dr. Jeffrey Masson, Freud denied the sexual abuse of children. ‘’The silence demanded of the child by the person who violated her (or him) is perpetuated and enforced by the very person to whom she has come for help,’’

The shingle designating a professional may also be deceptive as it indicates the person is “Doctor…” Does that mean MD, Ph.D., or what? And what type of Ph.D. did they receive? Honesty in this profession, as in others, is not a strong suit for all. How do you tell who to avoid? No one provides guidelines.

The knaves with degrees

Some therapists are so taken with their alleged ability to perform “semi-miracles” in their patients’ lives that they have stated things which are more than unacceptable. For example, one therapist who, in violation of ethics, encouraged group members to socialize and date. I know of this having heard it from others.

This licensed individual also told one of the patients that if she discontinued therapy with her, the patient would commit suicide within one year. The patient went on to work with another therapist.

In a few years, she earned her master’s degree and then went on to study for a doctorate in psychology. Thoughts of suicide never entered her mind. The therapist remained in practice and, seemingly, no charges were filed. The patient wanted to walk away and forget about it entirely.

A psychologist, who had a young man referred to her, began to engage in what she called therapeutic sex with the young man. The sessions went on for almost a year. After each sexual encounter in her office, he gave her a check for $150 and scheduled their next session. One of my professors told our class, “I have never heard of a therapeutic erection” when he heard about this.

The unethical behavior continued until he worked up the courage to discuss it with his parents. They reported the woman to her licensing board, and the board suspended her license.

One of the problems with suspension is that these individuals often return to practice in the future. During the period of supervision, they do nothing untoward, but afterward, we have to wonder. The system, in general, relies on the patient pool and the public to report.

Active violators of ethics or who engage in illegal activities are not sought out by investigators because there are so few who are hired to perform this work. Many states have only two people to look at all the licensed persons within that state.

This ongoing surveillance does not include those in the medical profession since they perform their own investigations, but, here too, it is left to someone to report. Often these persons are not reported for a variety of reasons which may include intimidation, blackmail, or threats of being cut off from treatment or being sued.

Steps to protect yourself

A short guide to assist in therapist selection is needed. Here is a list of suggested questions to ask and places to find help should you need it.

1. Do not depend on ads for therapists. Big ads mean that a person is willing to pay for these displays. They will expect to recoup the funds in therapy fees. Ads=no assurance of anything.

2. No one can guarantee you anything. It is against ethical guidelines for psychologists to provide any assurance of results or a guarantee.

3. Ask all the questions where you need answers. Don’t permit anyone to intimidate you. You are paying for a service, and you are a customer no matter whether they call you a patient or a client.

4. Some questions: What degree do they have and in what discipline? A school administration doctorate is not a doctorate in psychology. A doctorate or a Ph.D. needs explanation. Do not skip over this one. Where did they go to school, and where did they do their internship? Plaques on the wall are meaningless. Too many wall decorations can be bought.

5. What license do they have? Being “certified” is not equivalent to being licensed.

6. What is their theoretical orientation? Have them explain it to you. Take notes. Google anything you don’t understand if they tell you something unusual.

7. What is the treatment plan, and what is the timeframe for your therapy?

8. In what do they specialize? Examples: medical illness, anxiety, stress reduction, family therapy, cognitive-behavioral techniques, etc. Is a specialist someone who treats anyone who comes through the door? No, they’re not. We are not dealing with a Chinese restaurant menu here.

9. To which professional organizations do they belong? Google that one, too.

10. What is their cancellation policy? Insurance cannot be billed for missed sessions.

11. Check online with their licensing board to see if there are any actions pending currently or past violations. Also, check for lawsuits online.

If you need more assistance in deciding whether to report a therapeutic transgression or not, where do you go? The usual course would be to your state’s licensing board.

An internet search for “(state) licensing board for (psychologists, psychiatrists, social worker, counselors)” should return the result you seek. At this time, there is no national licensing board for the professions.

AI is getting in on the act

As in so many things, technology is being brought into the realm of therapy, but is it free of the problems we’ve seen in artificial intelligence (AI)? Large data sets are not devoid of major issues of bias, miscalculation, and assumptions.

The construction of an AI algorithm that would help to select a good candidate as your therapist remains problematic. Some data sets are heavily loaded in terms of bias. Hidden bias includes ageism, sexism, and racism.

For persons with specific wishes, such as someone of a similar ethnic background or religion or any other particular, the program may select only those individuals. At the same time, it will exclude individuals who might be better suited in terms of forming a therapeutic relationship.

The therapeutic relationship

The therapeutic relationship is the basis of all successful therapies. It is here that you must be most attuned to how you feel when you are in the company of that person. Of course, this assumes that you will have a screening or initial consult after you have made a selection for a therapist.

Would selecting a therapist based on shared demographic features result in a good match? The belief may be that this individual has shared life experiences which would make them more apt to understand the individual’s life experiences.

Often, a person who seeks a therapist with a similar racial or ethnic background as a preferred provider may delay therapy while waiting for a “match.” But an analysis that looked at individuals matched in terms of background and those who weren’t matched indicated the treatment outcomes were similar. Therefore, the therapist doesn’t have to share a collective life experience, ethnicity, or other background feature. But AI might skew the results in that direction.

The selection of a therapist is of utmost importance because they are dealing with your life and assisting you to make needed changes. As you would with any significant decision, check carefully, be satisfied, and never hesitate to question. It is your life.

The post Beware the Strike of an “Evil” Therapist appeared first on Medika Life.

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.

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