Feb 10, 2021
Rebecca W. Brendel, MD, JD, and Allen R. Dyer, MD, PhD, join
guest host Carol A. Bernstein, MD, to discuss the ethical
challenges that have been occurring during the COVID-19
pandemic.
Dr. Brendel is director of law and ethics at the Center for
Law, Brain, and Behavior at Massachusetts General Hospital, Boston.
She also serves as director of the master of bioethics degree
program at Harvard Medical School, Boston. Dr. Brendel has no
disclosures.
Dr. Dyer
is professor of psychiatry and behavioral sciences at George
Washington University, Washington. He also serves as vice chair for
education at the school of medicine and health sciences. Dr. Dyer
has no disclosures.
Dr. Bernstein, a past president of the American Psychiatric
Association, is vice chair for faculty development and well-being
at Montefiore Medical Center/Albert Einstein College of Medicine,
New York. She has no disclosures.
Take-home points
- Medical ethics often deal with decisions between doctors and
patients, but during the COVID-19 pandemic, the medical community
has been forced to reckon with ethics on a population scale.
Examples of ethical challenges include issues of scarcity, justice,
transparency, and navigating distrust of the medical system.
- In the beginning of the pandemic, individuals such as Dr.
Brendel and Dr. Dyer participated in ethical planning so that
hospital systems would be prepared to deal with scarcity of
resources that could result in some individuals going without
lifesaving interventions. During times of scarcity, transparency
and accountability are necessary, because the community will ask
questions about the fairness and justice of specific outcomes.
- The philosophy of utilitarianism
is a reason-based decision-making model that strives to maximize
the greatest good for the greatest number, and it has been commonly
used as a template for ethical discussions during the pandemic.
Yet, utilitarianism calculus is complicated by questions of how to
define “good” and the challenge of accurately predicting the
outcomes.
Summary
- In situations of urgency, demand, and scarcity, ethics usually
turns to utilitarianism with the intention of maximizing the
greatest good for the greatest number. Inevitably, people or
populations are harmed. Especially in the beginning of the COVID-19
pandemic, American society grappled with the issue of scarcity and
allocation of medical resources, ranging from personal protective
equipment, ventilators, medical staff, ICU space, and the vaccine.
- Now we must think about the ethical decisions influencing
COVID-19 vaccination, including weighing the risks and benefits of
who gets the vaccine and when – and how certain vaccine schedules
forestall the spread in the population. For example,
institutionalized individuals are at great risk of contracting
COVID-19, yet society debates the “good” of vaccinating elderly in
nursing homes versus incarcerated individuals. Question of defining
good and grappling with the consequences are present throughout the
entire vaccination algorithm. Communities contend with the question
of who in their ranks are essential workers: Health care workers?
Teachers? Restaurant staff? Factory workers?
- Justice and transparency are commonly discussed ethical
principles, especially when we think about the algorithms created
to allocate resources. Transparency is required to foster trust in
the public health system, and actors within the system must
demonstrate their accountability through being honest about the
evidence behind policy decisions, following set parameters, and
acknowledging historical reasons for distrust.
- The pandemic has pushed society to think about the ethics of
community solidarity and reflect on governmental and individual
responsibility of protecting the health and well-being of the
community. As the pandemic ravaged the U.S. economy and further
disadvantaged already vulnerable communities, we must use this
opportunity to reexamine the ethics of how health care is
distributed in the United States, and work toward a just and
equitable system.
References
Ethics and COVID10: Resource allocation and priority-setting.
2020 World Health Organization.
AMA Journal of Ethics.
COVID-19 Ethics Resource Center.
Emanuel EJ et al. N Engl J Med.
2020 May 21. doi: 10.1056/NEJMsb2005114.
Dyer AR and Khin EK.
Int Encycl Soc Behav Sci. 2015;63-70.
The
principles of medical ethics with annotations especially applicable
to psychiatry, 2013 edition. American Psychiatric
Association.
American Psychiatric Association.
Ethics.psychiatry.org.
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Show notes by Jacqueline Posada, MD, associate producer of the
Psychcast; assistant clinical professor in the department of
psychiatry and behavioral sciences at George Washington University
in Washington; and staff physician at George Washington Medical
Faculty Associates, also in Washington. Dr. Posada has no conflicts
of interest.
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