In a 2018 talk, Dr. Matthew K. Wynia shared tips on ethical dilemmas involving infectious diseases that remain incredibly relevant today.As COVID-19 continues on its path around the planet, providers and policymakers face tough choices. Equipment shortages, data monitoring and quarantines have intensified the ethical dilemmas involving infectious diseases. And given the magnitude of the novel coronavirus, the scale of these issues are much greater than what most physicians could have ever imagined.
At the most extreme, they might be choosing who gets the last ventilator - in other words, who will live and who will die. These dilemmas have serious and lasting consequences that could long outlive the current pandemic. For example, physicians making such choices are themselves at risk for lasting mental health issues, as Vox reports.
Yet many providers are now wrestling with these impossible situations, as we've seen in Italy and Spain. Physicians there are doing the best they can with the resources they have, and even then, they're overseeing tremendous loss of life. Triage could soon make its way to other countries as the virus spreads.
How should physicians manage these ethical issues going forward? A special session from the 25th Trauma Symposium held in 2018 in Florida could provide some inspiration. At the session, Dr. Matthew K. Wynia, MD, MPH, explored how questions of quarantine and resource allocation connect back to quality of care in a crisis environment. His insights ring eerily true for the current state of COVID-19.
Now available for CME credit on AudioDigest, "Ethical Issues During Outbreaks of Infectious Disease" reviews historical and modern examples of infectious disease outbreaks, from the plague and the origins of the word "quarantine" to the epidemics of syphilis, HIV and Ebola.
The ethics of quarantine
Dr. Wynia discusses ethical considerations around social distancing - a term most of the world has become familiar with by now - and whether mandatory quarantines improve outbreaks or make them worse. Many of the points he makes have relevance in the present climate:
- Quarantine, social distancing and isolation are levers that should be pulled when necessary, but providers should understand and expect that some measures can backfire. For example, some patients during the HIV outbreak stopped showing up for testing out of fear they'd be quarantined.
- Biological factors such as a disease's incubation period can render certain isolation measures inadequate if they're only activated once patients self-report symptoms.
- Social factors, including a population's willingness to temporarily sacrifice its freedoms for the good of public health, may make voluntary quarantines more sensible in some places.
- Socioeconomic factors like a person's ability to go into quarantine without losing their source of income can impact disease spread.
- Some studies suggest that if just half of people follow a voluntary quarantine, it could help flatten the curve so that healthcare systems don't buckle under the volume of patients.
With these and other quarantine considerations, the talk underscores the fact that public health should align with public policy. Dr. Wynia adds that all strategies have strengths and weaknesses, and during disaster, providers and policymakers should select plans that work best for the situation at hand.
The ethics of resource allocation
One of the most critical ethical questions during COVID-19 has been that of resource allocation, from personal protective equipment to beds and ventilators. Citing examples of hospital systems stripped of resources in the wake of Hurricane Katrina, Dr. Wynia discusses these triage considerations from the lens of a comparison between standard of care and quality of care:
- Standard of care should not change during a disaster. It is, and should always be, to do the best you can with the available resources.
- Quality of care will necessarily and naturally degrade during a crisis. You can't provide the same level of care quality during a disaster.
- In the moment, care delivery deserves more than a cold calculation about who has the most adjusted years of life left. However, providers should know that taking someone off a ventilator and putting them into palliative care is not euthanasia because it is a forced choice.
- Providers should refer to their states' crisis standards of care for guidance on handling ethical dilemmas involving infectious diseases.
Dr. Wynia acknowledges that these are uncomfortable topics but stresses that providers should feel confident about their medical decision-making and about following the standards of care for all patients. That balance may be difficult to reach, but it's one that every provider in the world faces in solidarity, now more than ever.