Soon after the early reports of rapidly spreading COVID-19 infections, hospitals throughout the United States and beyond began reviewing their emergency preparedness guidelines. With the realization that COVID-19 was becoming a pandemic, public health officials and institutional leaders recognized the need to prepare for an influx of COVID-19 patients that would challenge an institution’s ability to deliver its standard of care.
A March 16 report from The Hastings Center (Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic) called on institutional leaders’ pandemic preparations to focus on three fundamental obligations: to plan (manage uncertainty); guide (draft guidelines to address the potential disruption to standard healthcare); and safeguard (healthcare providers and vulnerable populations). Leaders can learn from a review of how these preparations were set into motion at the start of the COVID-19 crisis, and determine their implications for future crises.
Leadership’s Duty to Plan
At the start of the COVID-19 pandemic, healthcare leaders recognized their responsibility to plan, constructing various approaches involving administrative and clinical leaders, ethicists, and legal counsel to ensure preparedness plans would be developed in the context of an ethical framework. There was a potential need to shift an institution’s focus from the care of individual patients to the allocation of limited resources in an effort to optimize health outcomes for the population as a whole. Preparing for this scenario necessitated particularly thoughtful planning.
Leadership’s Duty to Guide
To help manage uncertainty related to the public health emergency, institutions developed guidelines to prepare for potential challenges. As noted in The Hastings Center report, the tension between equality and equity, expressed through the fair allocation of limited resources, “is stark when life-sustaining interventions are not available to all patients who could benefit from these interventions.” In an effort to address such ethical conflicts, institutions across the United States drafted allocation guidelines designed to ration scarce resources if a surge of critically ill patients necessitated the need to distribute critical resources, including staff and ICU beds, and supplies, such as ventilators and medications. The fundamental purpose of such guidelines has been to maximize the number of lives saved and to prevent suffering while protecting the equitable worth of every person.
Leadership’s Duty to Safeguard Staff
Equally central to planning and guiding during the pandemic is an organization’s responsibility to manage the use of employees as a resource while safeguarding their health. This is particularly important, given that the COVID-19 virus is highly contagious with significant associated morbidity and mortality. Notably, the ability of leadership to manage the allocation of employees hinges on healthcare professionals’ ethical duty to provide care even with a heightened risk of harm.
As the pandemic continues, some healthcare providers have questioned their professional responsibility to provide care for infected patients when their actions have implications for themselves and their loved ones. There has been concern about the expectations of medical providers of all ages—from older primary care physicians with their own underlying health conditions to newly minted medical school graduates—to serve when their own health might be at risk. In attempting to fulfill the beneficence-based ethical obligation to provide patient care despite potential risks, however, healthcare leaders should also acknowledge ethically justifiable limits to providers’ duties to serve. Such limits are covered in an April 15 article in the journal Academic Medicine titled “Teaching Professional Formation in Response to the COVID-19 Pandemic.” The authors describe “the professional virtue of self-sacrifice, which creates the ethical obligation to accept only reasonable risks to oneself to fulfill beneficence-based ethical obligations to patients.” They continue, “it is essential that the judgment of reasonableness [of risk] be made in a disciplined way.”
In the case of the COVID-19 pandemic, the consideration of adequate personal protective equipment is crucial to distinguishing between reasonable and unreasonable risk, and between recklessness and heroism. An analogy can be drawn in considering the role of a firefighter, who would not be expected to rush into a burning building without personal protection.
While many institutions have drafted guidelines to ensure adequate staffing to treat patients, such guidelines must be balanced with an equivalent obligation to ensure staff safety through necessary infection control supplies and protocols for patient engagement. Without such preparation and protection, the risk undertaken by healthcare professionals may be considered unreasonable and thus exempt from an ethical obligation to serve.
Two additional areas of focus necessary for safeguarding healthcare professionals need to be captured in institutional guidelines. Healthcare professionals should be assured when needing to implement approved triage protocols that they will be protected from legal liability. Without such protections, the implementation of the triage guidelines can be impaired. Providing effective emotional support for front-line staff is another important component of safeguarding staff. The need to ration resources, including withholding or withdrawing ventilators, can cause disabling moral distress for some clinicians. Institutional guidelines cannot necessarily prevent such stress during the pandemic or other emergencies; however, strategies to reduce long-term moral injury are essential.
Preparing for Future Emergencies
The institutional responsibility to plan, guide and safeguard persists through the course of this pandemic, as it was in prior and will be in future public health emergencies. It is not an easy task because COVID-19 is wrought with ethical challenges. To address them, institutional guidelines need to be ethically grounded and clear and include transparent triage protocols to save the most lives while being fair and equitable in resource distribution. As the COVID-19 pandemic eventually eases its grip on every aspect of society, crisis management guidelines need to be assessed. Leaders should ask questions about their organizations’ guidelines, including: Did they achieve patient care goals? Did the ethical principles that guide healthcare professionals’ duty to care conflict with the institution’s failure to adequately safeguard employees? Leadership needs to recognize healthcare workers’ ability to appropriately fulfill their ethically grounded roles and responsibilities is dependent on administrators’ ability to adequately fulfill their own role of creating a safe environment.
William Nelson, PhD, HFACHE, is director, Ethics and Human Values Program, and professor, Geisel School of Medicine at Dartmouth, Hanover, N.H. (william.a.nelson@dartmouth.edu). Raina H. Jain is a fourth-year medical student, Geisel School of Medicine at Dartmouth (raina.h.jain.MED@dartmouth.edu).