By Steven Reichert, MD, Director, Palliative Care
The COVID-19 pandemic presented oursociety with a crisis not seen for generations. One part of the COVID crisis has deep roots in medical ethics. The challenges have ranged from as simple as wearing a mask in public, to
as complex as usage of lifesaving treatments such as ventilators or dialysis. The decisions and judgments made by national leaders, hospitals and at times individual health care providers often invoked the concepts of medical ethics. The core principles of medical ethics are: autonomy (the right to self-determination), beneficence (do good), non-maleficence (do no
harm) and justice. During the COVID crisis, as much as all struggled to be beneficent and avoid non-maleficence, maintaining the rights of the individual (autonomy) has clashed with respecting the principles of justice.
Americans fiercely defend their rights to autonomy, perhaps more so than in any other country on earth. Whether it be free speech, the right to bear arms or women’s reproductive rights, Americans live in a society where individual autonomy is well understood and respected. The principle of justice, especially in relation to health care, is complex.
This principle states that when considering whether an action is ethical or otherwise, we must consider whether it is compatible with the law and the rights of the individual, and whether it is fair and balanced from a societal perspective. The final point about societal justice is particularly relevant to residents in the U.S. because we do not operate in a universal health system.
Unlike societies that have universal health care, our decisions regarding what treatments to provide to whom are not based upon the value to society, but to the individual. Other countries like the UK make decisions at times based upon the value to society instead of the individual. Hence some treatments, such as dialysis for the very elderly, are not offered in the UK.
How to approach a scenario with respect to justice is complicated, as justice in medical ethics can be an extremely complex pillar to consider. Everyone’s concept of fairness tends to differ. But, in general we should consider the following aspects:
• Is this action legal?
• Does this action unfairly contradict someone’s human rights?
• Does this action prioritize one group over another?
• If it does prioritize one group over another, can that prioritization be justified in terms of overall net benefit to society or agreed moral conventions?
This concept of priority reflects the idea of utilitarianism,mwhich is a doctrine of ethics that the purpose of all action should be to bring about the greatest happiness for the greatest number of people and that the value of anything is determined by its utility.
The most dramatic example of the clash between autonomy and justice centered on the availability of ventilators during the peak of the COVID crisis. As emergency rooms and intensive care units swelled with patients, hospitals at the epicenter of the crisis faced the specter of choosing which
patients might not be offered the lifesaving opportunity of mechanical life support. While triage is routinely performed in emergency departments, it involves which patients will be seen first, not which patients will live or die. With the exception of mass trauma or wartime, doctors in the U.S. had never been placed in such a position. Even more concerning, there was no legal precedent to back the split second decision a health care provider would need to make in the event that a ventilator needed to be rationed. Hospitals and health systems rapidly drafted protocols, partially based upon a New York State document which created a triage committee. At St.
Barnabas, while we ran perilously low on ventilators, such a committee was never utilized. However, at other institutions an active triage committee made decisions regarding which patients should and which should not be offered lifesaving ventilators. These committees at times had to consider not just the individual, but the next person or group of people who might better benefit from the use of a ventilator. A less dramatic, but equally important and more far reaching struggle revolves around the wearing of face masks in public. Whether it be those people who believe that the COVID-19 crisis was simply a hoax, that masks don’t work, or simply those who want their individual right to self-determination preserved, [Give me COVID or give me death] the decision to wear masks exemplifies this same struggle between individual autonomy and justice. We are fortunate to live in a society where our rights as individuals are respected so highly. Some
view the mandate to wear a mask as an infringement of those rights. However, the decision/mandate to wear a mask in public invokes the social justice of forgoing one’s individual autonomy to protect the public.
On a personal note, my blessings go out to all in the SBH family who were sickened or lost loved ones over the past months. Together we are stronger than as individuals. I am proud to be a part of the SBH family and look forward to better days ahead. Peace.