Assessing Bioethics in a Public Health Emergency

Authors | Janice Firn | Reshma Jagsi | Andrew Shuman | Kayte Spector-Bagdady | Christian Vercler

*Authors contributed equally and are listed in alphabetical order

When dealing with a global pandemic of proportions not seen in 100 years, a shift from the status quo must occur. From an ethics perspective, this requires framing issues from a public health perspective — looking at overall risks and benefits to communities — rather than the patient-centered, autonomy-focused approach generally practiced in clinical medicine. 

In mid-March, everything changed for both the research and clinical sides of Michigan Medicine. Many researchers redirected their energies into COVID-19 projects, addressing everything from diagnostics and therapeutics to the sociological effects of stay-home orders on families, and so much more. Clinicians limited nonessential in-person interventions, rapidly scaled up capacity for virtual patient care visits, freed up hospital space to convert into intensive care units, and offered clinical updates and free online information and training to the community at large. 

As front-line clinical staff and researchers took on these challenges, bioethicists from the Center for Bioethics and Social Sciences in Medicine (CBSSM) joined the response. Established in July 2010 and currently directed by Reshma Jagsi, M.D., D.Phil., CBSSM includes faculty who serve the university as ethics consultants for clinical and research matters. We've refocused many of our efforts to supporting our colleagues as they think through the many complex decisions that must be made during a recalibration of this scale. 

The drastic shift from a clinical (patient-focused) ethic to a public (community-focused) ethic can cause understandable and significant challenges and distress among patients, family members, and the clinical team — but this shift is a necessary result of the pandemic.

One area in which this tension is most apparent is the allocation of scarce resources, including rooms in the hospital, trained staff and clinicians, medical devices such as ventilators, disposable respirator masks worn by clinicians, and much more. 

Ethicists generally caution clinicians not to "ration at the bedside," as in-the-moment decisions in the context of a clinician/patient relationship are inexorably biased. Instead, ethicists generally recommend that institutions articulate transparent, consistent, and fair criteria for allocation that consider which patients will benefit most from the scarce resource. Michigan Medicine has been planning for this possibility for over a decade, since the onset of the H1N1 influenza pandemic in 2009, and thus we were well prepared to update and refine our guidelines for the current crisis.

In addition, continued hospital admission, treatment, and discharge planning have become more complicated as the balance of risks and benefits changed in light of COVID-19. For example, asking a patient to present for a routine intervention, such as a non-urgent visit with their obstetrician or annual bloodwork to check their cholesterol, might no longer yield a net benefit to that individual in the context of the elevated infection risk they would face from leaving home — even without considering consequences for others. In another example, prior to COVID, discharge from the hospital to a skilled-care facility might have been viewed as the safer, less risky, and medically recommended option for some patients. During the pandemic, which has struck communal living facilities especially hard, this is no longer the case. Also, discharging patients without stable housing or the ability to self-isolate at home may pose a harm to their communities. 

As front-line staff and clinicians become more physically and emotionally exhausted during the pandemic, it becomes increasingly difficult to focus on and process novel features of individual cases. We are continually challenged to help clinicians work within an ethically sound triage process, making space for reflection and creative thinking, and attending to the emotional well-being of the individuals involved.

Last, in the area of research, important questions include: Will individual protocol proposals do more good than harm for individual patients and generate information that we can use to improve care for others? Are we acting as responsible stewards of scarce research resources, including materials, human resources, committee review time, and research participants? How do we ensure an equitable allocation of both the risks and benefits of research across society and communities? Michigan Medicine has created a robust framework through which to assess and prioritize COVID-19-related research as well as clinical trials.

We continue to be inspired by the energy, strength, compassion, and passion of our clinical, research, and front-line colleagues, including environmental, food, and other essential service providers. We have faced many complex, and sometimes devastating, decisions together since the onset of the pandemic. But we have been able to come together across specialization and disciplines in solidarity toward the overarching goal of providing the best care possible for our patients and the state of Michigan. 

More Articles About: bioethics Ethics covid Covid-19 coronavirus pandemic
Featured News & Stories Pill capsule pushing through a paper with amoxicillin printed on it.
Health Lab
Rise seen in use of antibiotics for conditions they can’t treat – including COVID-19
Overuse of antibiotics can lead bacteria to evolve antimicrobial resistance, but Americans are still receiving the drugs for many conditions that they can’t treat.
Health Lab Podcast in brackets with a background with a dark blue translucent layers over cells
Health Lab Podcast
Managing Chronic Pain for Patients with Long COVID
Therapies for pain conditions like fibromyalgia provide clues for helping those with long COVID.
Minding Memory with a microphone and a shadow of a microphone on a blue background
Minding Memory
The Intersection of Artificial Intelligence & Alzheimer’s Disease and Related Dementias
In this episode, Matt and Donovan talk with Dr. Jason H. Moore, Director of the Center for Artificial Intelligence Research and Education (CAIRE) and Chair of the Department of Computational Biomedicine at Cedars-Sinai Medical Center. Jason discusses the coming impact of artificial intelligence on a spectrum of Alzheimer’s disease and related dementia (ADRD) issues. We discuss how tools such as AI-powered chatbots may improve quality of life for people living with dementia (and their caregivers) and how AI may contribute in the future to diagnosis and treatment.
Provider takes a pulse oximetry reading from a patient's finger
Health Lab
Inaccurate pulse oximeter readings could limit transplants, heart pumps for Black patients with heart failure
Racially biased readings of oxygen levels in the blood using pulse oximeters may further limit opportunities for Black patients with heart failure to receive potentially lifesaving treatments, such as heart pumps and transplants
Woman sleeping on a couch holds her stomach, as if in pain
Health Lab
Long COVID-19 is linked to chronic pain conditions
Therapies for pain conditions like fibromyalgia provide clues for helping those with long COVID-19
Surgeon's tray with gloved hand reaching into wallet
Health Lab
Worries about costs, time off work and COVID-19 kept some older adults from having surgery
Elective surgery study shows older adults have concerns about what it will cost them, how much work they’ll miss and whether they’ll catch COVID-19.