Bioethics Discussion Blog: Bioethics and Dealing with the COVID-19 Pandemic

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Sunday, May 17, 2020

Bioethics and Dealing with the COVID-19 Pandemic














Graphic: : St Roch Ministering to Plague Victims
by Jacopo Tintoretto (Italian, 1518-1594)

Yes, there is science. Yes, there are politics. Yes, there are laws to obey. Yes, there is religious doctrine. Yes, there is public opinion. And yes, there is the ethics--the concept of fulfilling all  these domains fairly, logically and yet in the direction of "doing good". 

In the dealing with the Covid-19 pandemic, ethical issues are fully present and ethical issues cannot be ignored if it is the goal to proceed to a better and safe and healthy society despite our current handicaps.  

To get a quick idea of the scope of the consideration of ethics and its role in this present pandemic, simply go to the website of a major ethics institution, the Hastings Center and learn what was of already being considered in March of this year.  

At the time of initiating this blog thread in May, a lot has happened since March and in so many ways the ethics of what has happened and what is considered to happen in the months ahead require our understanding and consideration.  ..Maurice.

38 Comments:

At Sunday, May 17, 2020 3:07:00 PM, Blogger Maurice Bernstein, M.D. said...

The topic is not strictly dealing with patient modesty or patient dignity but with the ethical, philosophical, civil and legal approaches to the management of this dominant world-wide problem. What is needed from the public is an understanding of the many elements of such a pandemic and approaches to limits its trauma, utilizing for example the 4 principles of ethics:autonomy, justice, beneficence, and non-maleficence. There are potentially productive and potentially destructive results which could be identified as of value or of no value or destructive in any political policy. The goal of the public in this world-wide disaster is to sort out one from the other and follow and contribute to the path to safety and health for all. ..Maurice.

 
At Sunday, May 17, 2020 8:33:00 PM, Blogger Maurice Bernstein, M.D. said...

Let us look at one action which we understand has been happening in many hospitals when a patient is admitted for COVID-19 infection and serious symptoms or perhaps may have advanced to the ICU and is on a respirator to maintain life or may be on the verge of dying..and family members are not allowed, by hospital policy, to visit the patient. The emotional need by both the patient and the family is to be together at this critical and emotional time of their lives. Do you see an example of unethical behavior by the medical institution?

Let's discuss this one simple example with regard to the ethical principles. Are there two sides to this decision? Which do you feel or find is the most ethical? Remember, one ethical principle may trump another and yet reach an ethical behavior...but an explanation of that conclusion is always necessary. ..Maurice.

 
At Sunday, May 17, 2020 9:58:00 PM, Blogger Maurice Bernstein, M.D. said...

Let's first look at what is happening in the medical and social world specifically in terms of the 4 commonly accepted principles of medical ethics: autonomy, justice, beneficence and non-maleficence.
Here are the brief description of each as written in web.stanford.edu and edited by me for this presentation.

What are the Basic Principles of
Medical Ethics?

Bioethicists often refer to the four basic principles of health care ethics when evaluating the merits and difficulties of medical procedures. Ideally, for a medical practice to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and non-maleficence.

Autonomy
Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care
procedures. Therefore, the decision-making process must be free of coercion or coaxing. In order for a patient to
make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of
success.

Justice

The idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in
society. Requires that procedures uphold the spirit of existing laws and are fair to all players involved. The health care provider must consider four main areas when evaluating justice: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation.

Beneficence

Requires that the procedure be provided with the intent of doing good for the patient involved. Demands that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients, and strive for net benefit.

Non-maleficence

Requires that a procedure does not harm the patient involved or others in society.


Let's consider how each principle is applicable to what we understand is occurring in the current pandemic. ..Maurice.

 
At Sunday, May 17, 2020 10:15:00 PM, Blogger Maurice Bernstein, M.D. said...

Please excuse me for a bit of disorganization of the commentaries above. Now that all 4 ethical principles have been identified and a bit defined, lets move on to the analysis of the example issue I presented dealing with keeping a hospitalized patient and family apart. ..Maurice.

 
At Monday, May 18, 2020 4:34:00 AM, Blogger Biker said...

The most common complaint I have heard is family members being unable to be with their loved one while hospitalized, sometimes including end-of-life. I experienced this myself to a small degree when my wife was an inpatient for a non-coivd-19 matter when these new policies were being implemented. As things were rapidly unfolding, each day as I left the hospital I didn't know if I'd be allowed back in the next day, and then the day arrived that I couldn't. Her condition was sufficiently fragile that had she gotten the virus she likely wouldn't have survived and so rather than be upset with the new policy I thought what took them so long.

If preserving the life of the patient trumps all other concerns, then in an environment with limited PPE, limited staffing (the hospital in question was short staffed when the schools and daycares closed and some parents had to stay home with the kids), and limited ICU capacity, removing me from the list of things they needed to be concerned with was the right move for my wife and all the other patients. I don't see what they did as violating any of the pillars of medical ethics.

What did violate medical ethics hugely was the policy of some States to force nursing homes to take in infected patients who were not sick enough to remain in the hospital. One does not need a medical degree or training in infection control to know such a policy would end badly, and it did in neighboring NY with thousands dead as a result. Here in my State (VT) most nursing homes shut down visitors and instituted rigid infection control protocols weeks before the State started shutting things down, and we have not had the problems seen in NY. NY knowingly put fragile nursing home patients in harms way which fails the Justice, Beneficence, and Non-maleficence tests.

The last piece of this that I will comment on is the most controversial. This is resuscitation of covid-19 patients. Not having proper infection control PPE for staff forced some to decide between attempting to save the patient vs protecting themselves and possibly their own families. I posit that it was an ethical lapse on the part of federal & state govts for not being even minimally prepared for a pandemic in this regard but also to the hospitals themselves for not be prepared not only with adequate supplies but also with policies and training that wouldn't have left the staff bearing the burden of this decision-making. This was not a black swan event but one that was known would happen sooner or later. The only missing elements was when would it occur and how severe would it be. As an ethical choice I don't think medical staff should potentially sacrifice their lives in order to save mine and as such were I the patient and there wasn't adequate PPE to protect the staff, I'd of said let me go. This too breaches the Justice, Beneficience, and Non-malificience tests.


 
At Monday, May 18, 2020 5:20:00 AM, Anonymous Anonymous said...

JF speaking.
I kinda wonder if going to a hospital for a Corona Virus patient is the best option at all! We hear different things on the internet about what MIGHT help and maybe not. One theory that I have heard is that the ventilators themselves are dangerous. And that patients that are put on them often don't make it.
That could mean two conflicting things, either the ventilators are harming the patients or the patients are already critical when the patients are put on those ventilators.
So far as Im aware, nobody I know has been infected with Covid 19. I also heard recently that not every country has suffered a breakdown in their economies. I sure don't know what to think about all this!

 
At Tuesday, May 19, 2020 12:31:00 PM, Blogger Maurice Bernstein, M.D. said...

Reginald, wrote the following today on the long running blog thread topic "Preserving Patient Dignity (Formerly Patient Modesty)j Volume 111:

Hello,

I submit to you the URL of a doctor who understands empathy.

Reginald

https://suneeldhand.com/2020/05/19/how-doctors-should-communicate-over-the-phone-during-covid-19/



Yet, such behavior on the part of the physician represents more than personal understanding of the patient's physical suffering (empathy) but also the patient's concerns and the patient's need for family emotional support. The physician, taking time and communicating with the appropriate family member is in fact supporting the patient's autonomy (desire by the patient to have communication with his or her family member). The physician is also promoting beneficence ("doing a good for the patient involved and the family").

Think about the emotional disturbance of members of the family of a patient who can't communicate with them and their presence is not allowed. Yes, the subject of a doctor-patient relationship is, of course, the patient. But a physician has a responsibility as needed and legal to provide support in varying degrees to members of the patient's family. The clinical-social consequences of the COVID-19 pandemic puts extra-emphasis on following the ethical principles. ..Maurice.

 
At Wednesday, May 20, 2020 9:16:00 AM, Blogger Maurice Bernstein, M.D. said...

In the management of the COVID-19 crisis, it is important that all recommendations to the public meet the ethical principle of non-maleficence in that the recommendation has been adequately investigated and has been found to be appropriate for the situation and will not lead to harm to those who follow the recommendation.

Sometimes, a recommendation has not been fully evaluated to guarantee to the recipient that such harmlessness is proven. If that is the case, this deficiency in evaluation must directly be made aware to the recipient. The recipient must be made aware of the harm but also the limits available to investigate and deal with the harm. Ignorance by the recipient of some decision or action and the rationale should never be considered as ethically acceptable. ..Maurice.



 
At Thursday, May 21, 2020 10:30:00 AM, Blogger Maurice Bernstein, M.D. said...

A very current ethical principle issue as we deal with the Corona-19 pandemic is what does society think and do about those who have been sentenced to prison for their criminal actions and are now imprisoned in close quarter prison institutions exposed to a much higher degree of risk for acquiring and dying from the virus infection. The ethical issues involved is, of course, justice and non-maleficence .

If prisoners cannot be protected from the very high risk of infection and death as compared with the general population not imprisoned, is the ethical principle of justice being observed and served by continuing to keep all prisoners of varying history for their imprisonment together and not released to a safer health environment?

And then we have to consider the ethical principle of non-maleficence--to do no harm. If we know that keeping masses of prisoners in close quarters with no means of separation except removing some out of prison to safer environments, then society is failing in this ethical principle in preventing sickness and death for those imprisoned and even for the guards who attend the prisoners.

Where does society meet the ethical balance between punishment for prior acts by those imprisoned and yet attending to preventing the likely illegal harming of those imprisoned as a consequence of this pandemic? ..Maurice.

 
At Thursday, May 21, 2020 1:35:00 PM, Blogger Biker said...

Dr. Bernstein, we as a society should be able to do more than one thing at a time, but at present how we are managing nursing homes leaves much to be desired in at least some States such as NY & NJ. We as well have yet to assure that front line healthcare staff have the PPE and training to do their jobs safely. Not to be harsh but nursing home patients and front line healthcare staff are a higher priority for me than prisoners. If we can't do the first two (nursing homes & healthcare staff), then let's not focus our efforts and resources on the third (prisoners).

That said, I don't object to moving the lowest risk (to the public) prisoners out of prisons if it can be done with minimal risk to the public. Sometimes the choices people make have unforeseen consequences and the risk of covid-19 does not give anyone the right to an early release from prison. Move the non-violent type ones into alternative facilities if we can, but the violent ones need to stay where they are.

 
At Thursday, May 21, 2020 7:09:00 PM, Blogger Maurice Bernstein, M.D. said...

Biker, ..And how about the individuals held within the prison awaiting trial and as yet have never had the opportunity of a trial to be found guilty? These specific folks provide a particularly difficult ethical and legal dilemma when we are faced with the matter of increased danger even to the potentially legally innocent? It would be wonderful for society not to have been faced with this dilemma. ..Maurice.

 
At Thursday, May 21, 2020 9:01:00 PM, Anonymous Medical Patient Modesty said...

I think the zero-visitor policy at hospitals across America is very unethical and ridiculous.

Here are my thoughts:

As founder of Medical Patient Modesty, a non-profit organization that works to educate patients about their rights to dignity, privacy, and freedom from abuse in medical settings, I am very concerned about the zero-visitor policy at many hospitals in America due to COVID-19.

The zero-visitor policy is too extreme and it is a violation of patient rights. While I understand the important undertaking which has fallen on hospital administrators to help control the spread of COVID-19, they fail to understand two important things.

1.) It is ethically imperative that all patients have access to someone who is physically and exclusively present on their behalf—someone who is not subject to the conflict of interest that exists when caregivers are employed by someone other than the person needing medical services. In addition, it is impossible for even the best medical professionals to give personalized attention to each patient since they have to devote time to other patients also. Every patient must have the right to have a chosen person with him/her at all times. Technology cannot substitute for in-person interaction, respectful advocacy, and the protection from abuse which (despite even best efforts by hospitals) can only be guaranteed by the constant presence of a loved one.

2.) Most asymptomatic family members are much less likely than the hospital employees to have COVID-19. Medical professionals are seemingly at a higher risk of contracting COVID-19 than the average person because they regularly interact with numerous sick patients.
It is very encouraging that most hospitals allow pediatric and obstetrical patients to have at least one visitor with them and that other hospitals in the nation have already abandoned the zero visitor policy. The truth is that all patients deserve to be treated in a similarly ethical manner.

Screening patient’s visitors such as taking temperatures, special questionnaires to determine exposure to COVID-19, and requiring masks and protective clothing would be a better solution.
The inability for patients to have a family member present with them as they recover has many consequences which hinders the overall recovery. Some of the consequences are: loneliness, lack of comfort, no one to advocate for patients’ wishes for modesty and numerous other issues, etc. Numerous patients prefer that their family member (especially spouse) to help them with personal care such as bathing and dressing. Those patients should always have their wishes honored.
Too many patients have been forced to recover, or even die, without one family member present due to this policy.

Here are a few examples of sad cases affected by the zero-visitor policy:

1.) A man had an accident at work that seriously injured his hand and he required surgery. He was required to stay in the hospital for a few days and his wife could not visit him at all. She did not have COVID-19 at all.

2.) A man had a massive heart attack and spent over a month in the hospital before dying. The zero-visitor policy went into effect a few weeks later and his family could not visit him much at all. Sadly, he passed away alone without the presence of his wife and his two daughters who did not have COVID-19.

Misty

 
At Thursday, May 21, 2020 9:40:00 PM, Blogger Maurice Bernstein, M.D. said...

Misty, you definitely bring up an important unethical behavior of the medical system as the system fights against the COVID-19 pandemic.

I look at this unethical issue related to the ethical principles of Justice and Autonomy and ignorance of Beneficence. Justice: Where is the attention to obligations to both the patient and family? Autonomy: Where is the response to the patient's request. Finally Beneficence: Where is the attention to the "doing good" to the patient and to the family?

Is the lack of protective equipment to be applied to both the staff and to the family visitor the excuse to prevent attendance? Is the anticipated legal issue to be of concern to the hospital if the visitor becomes a victim of the viral infection, related to the hospital visit? Do we really know?

Here is a link to a current article by NPR on this very topic: https://www.npr.org/2020/05/17/857531789/federal-government-asked-to-tell-hospitals-modify-visit-bans

I wonder if the hospital management really understands the ethics and the therapeutic and humanistic aspects of patient or family's request for attendance. ..Maurice.


 
At Friday, May 22, 2020 4:50:00 AM, Blogger Biker said...

Dr. Bernstein, I understand the "presumed innocent until proven guilty" aspect of this but one needs only look to NYC's new "no bail" policy that immediately puts offenders back onto the streets on that presumed innocence theory. The results have been disastrous with the ensuing crimes committed while awaiting trial for the first crime. If the police and courts cannot reasonably assure the public that they will be safe from further crimes when releasing these arrestees during the covid-19 period, then they shouldn't be released. It can't be a one way street where we only worry about the interests of the arrestees.

My covid-19 solution for the presumed innocent arrestees would be the same as for low risk prisoners, put them is a secure but safer setting until trial, assuming they don't otherwise qualify for bail.

 
At Friday, May 22, 2020 10:28:00 AM, Blogger Maurice Bernstein, M.D. said...

Here is the link to a detailed current article on the issue of prisoner release related to the current COVID-19 pandemic:
https://www.nbcnews.com/news/us-news/early-release-cohen-manafort-shows-how-unfair-prison-system-experts-n1212001

Of course, in everyday life, prior to the current pandemic, there has always have been ethics vs justice conflicts. One commonly brought to mind is the use of the death penalty . For those interested, here is the link to the issue against the death penalty from Markkula Center for Applied Ethics at Santa Clara University, California<. ..Maurice.

 
At Friday, May 22, 2020 11:18:00 AM, Anonymous Anonymous said...

Hello Dr. Bernstein,

I question whether medical ethics is considered by any hospital in the US today until a “situation” occurs. I would submit that, in the hospital setting, medical ethics is only approached ex post facto. I welcome your considered criticism of the following.

The typical scenario of hospitalization requires signing an informed consent form and, subsequent admission to the facility. If the (usually electronic) consent form is not signed in toto, one is not admitted (I know this from personal experience.). I submit that justice has been denied in this circumstance. Once one objects to any aspect of the form (allowing pictures, filming, presence of students, etc.), one is denied services. Medical help is not given to this individual. The proper approach would be to interview the individual in an attempt to offer accommodations. (How can we justly satisfy your needs within hospital parameters?) Typically, wishing to amend (line-out) portions of the consent form will bring referral to a supervisor who will mechanically reiterate the policy. Again, if one does not sign the form “as is”, one is denied admission. Of course, there are reasons for this policy. The form is essentially “boilerplate”. It’s created by lawyers to protect the hospital. An attempt is made to account for all possible eventualities which would create “problems” (i.e. lawsuits) FOR THE HOSPITAL. The form is really a misnomer. It IS NOT a form in which one gives informed consent. There is no mention in the form of what procedures one will be undergoing or, anything which is specific to the individual. It’s a generic form in which the hospital is informing you of that to which YOU WILL consent. This is not informed consent. This might, more aptly, be termed informed coercion. If one does not sign the form, one is turned away and denied JUSTICE (an equitable access to the potential benefits of medical treatment). If one signs the form, (wishing to change it but, knowing the aforementioned consequences), one compromises AUTONOMY. S(H)e has not FREELY agreed. The agreement was made solely to avoid the negative consequences of objecting. This seems to be an ethical dilemma. If one objects to any element of the consent form, that individual either will be denied JUSTICE (not admitted) or denied AUTONOMY (unfreely signing). Beneficence and Non-maleficence can be left for another day.

There are remedies to the above situation. This problem could be addressed in a particular setting. That setting might be an in-depth Medical Ethics Committee Study to rectify the so-called informed consent form. Why has this not been undertaken? Others have commented regarding the farce of the informed consent form. A first semester Ethics 101 student could recognize the above dilemma. Why hasn’t the initial step in the medical encounter been addressed in an ethical manner? How can one ponder the lofty questions of life and death, if the first step is not considered? Where is the august Medical Ethics Committee? (This question is rhetorical. I realize that ethics has acquiesced to legalism. The doctors have acceded to the lawyers.)

Would it be incorrect to say that, aside from being what might be termed a perfunctory disquisition, medical ethics, in the hospital setting, is considered ex post facto?

Reginald

 
At Friday, May 22, 2020 2:30:00 PM, Blogger Maurice Bernstein, M.D. said...

Reginald, within the hospital to which I am a member of the clinical ethics committee and previously chairman, I am not aware of the current administrative ethics committee or equivalent issues being considered with regard to your point. I know that in our clinical ethics committee we have never discussed in detail the construction of hospital admission form itself, nor was that our assignment. I strongly suspect, as you do, that the anatomy of the form is greatly structured by lawyers since one might say that "hospitals are businesses" and as businesses certain issues of "self-protection" ("prophylaxes" might be a medical term) would be felt to be appropriate. But thanks to you and Misty for bringing up the issue. ..Maurice.

 
At Saturday, May 23, 2020 12:20:00 PM, Blogger Maurice Bernstein, M.D. said...

There is a specific ethical dilemma that faces all states in the United States as well as countries around the world. That dilemma is the preservation of the ethical principle of Non-Maleficence. This dilemma becomes political since both opening closed businesses and effective control of the pandemic can represent an immediate conflict of hazard and value of which there may not be of uniform agreement by the affected populations.

Non-maleficence (to do no harm) sets the two needs at conflict. And this conflict may perplex the state or country governing authority in setting rules which are fair to the different geographic locations where conflicts may easily appear. Here is an example of the current perplexity facing a United States governor and the affected population in the state of California.

Anyone on this blog thread would like to be Governor at this time a face the dilemma of providing non-maleficence to each and everyone under his or her public responsibility during this pandemic? ..Maurice.

 
At Saturday, May 23, 2020 1:39:00 PM, Blogger Biker said...

Dr. Bernstein, I wouldn't want to be a Governor right now because I would find it too frustrating to be battling an entrenched bureaucracy and those others trying to use the pandemic to gain political advantage. Never let a crisis go to waste and all that. I would insist on science based solutions and common sense, and there is no room for either in modern political arenas. Essential vs non-essential is nonsense at a scientific level nor has the making of those designations demonstrated much common sense.

The decision-making variables should have been based on infection transmission and control. Pertinent variables include PPE, social distancing, disinfecting protocols, HVAC systems, and the like, not on the nature of the goods and services being sold, yet for the most part they focused on the nature of the goods and services being sold.

In NJ they knowingly sent infected patients from hospitals into nursing homes and then banned two large tulip farms from having people take driving tours through the farm, never leaving their car, and having bought their tickets online. Where was the science behind that, let alone common sense? In Michigan you could go out on a lake or pond to fish if you did so in a canoe or a sailboat, but not if your boat had a motor. In Wisconsin I think it is a restaurant can now have up to 50 people dining outdoors but a church can only have 10 people listening to a service outdoors. How is eating food multiple times more safe than praying? Such examples abound and now they're wondering why social unrest is growing and people are starting to ignore their mandates?

So no, I wouldn't want to be a Governor because the public service unions and civil service laws wouldn't allow me to fire people as quickly and extensively as I would need to do in order to manage the pandemic response using science and common sense.

 
At Monday, May 25, 2020 12:42:00 PM, Anonymous Medical Patient Modesty said...

Dr. Bernstein,

It’s heart breaking that the lady with Down’s Syndrome had to die by herself. I cannot believe that they would not allow her family members to be present with her.

The truth is the zero-visitor policy has a bad effect on medical professionals. There is just no way they can give specialized attention to patients that their family members could. Good family members help medical professionals by making sure they give right medicines and treatments. For example, think about how some patients may be allergic to certain medications and their family members can give that information. Even the best and most compassionate medical professionals can never help patients like their family members can.

There are many consequences of a patient not being able to have their family members present. A family member can help to play a role in making sure their loved one is given the right medicine. Nurses are often overworked and it’s hard for them to remember everything for all patients they have to take care of. Many years ago, I noticed my grandfather was overmedicated in a hospital and I went to ask them to take him off the medicines. He was much more alert and better when they stopped giving him some sedatives.

Think about patients who have dementia who cannot advocate for themselves. Some patients with dementia who may need assistance with feeding may refuse to eat for a staff member, but will eat for a family member.

The zero-visitor policy is not patient centered at all. There is also a concern that this could be implemented for other contagious illnesses in the future.

Here’s my response to your questions:

Is the lack of protective equipment to be applied to both the staff and to the family visitor the excuse to prevent attendance? Is the anticipated legal issue to be of concern to the hospital if the visitor becomes a victim of the viral infection, related to the hospital visit? Do we really know?

No, this should not be an excuse. Hospitals should work to have enough protective equipment for both staff and family members. I believe that all family members (visitors) should be required to sign a form agreeing that they will not hold the hospital liable if they contract the virus. The truth is anytime you go in a hospital, you risk getting a viral or bacterial infection since there are germs in hospitals. As you know, medical professionals and hospital staff members are at high risk of getting coronavirus. One of my cousins who is a radiologist contracted coronavirus a few months ago and he thinks he got it from the doctors’ lounge. Thankfully, he has recovered and is doing well.

I believe it is very important to reduce risk of spreading coronavirus, but the no-visitor policy is too extreme. I do agree that they should not let children under 12 visit since some children especially toddlers touch everything and put their hands in their mouths and eyes. I believe only adult family members who are willing to take precautions such as wearing gloves, mask, and washing their hands should be allowed to visit patients.

Misty

 
At Monday, May 25, 2020 2:17:00 PM, Blogger Maurice Bernstein, M.D. said...

Misty, pertinent to your last presentation here, there is a short 2018 article written by a 3rd year medical student and reviewed by a physician editor which supports your comments and appears a reasonable summary to me regarding the value of family "in with the patient".

By the way, I want to emphasize that this issue of family visitation as requested by the patient meets the ethical principles of autonomy and beneficence ..Maurice.

 
At Monday, May 25, 2020 5:45:00 PM, Blogger Biker said...

I agree that families should be able to visit and that hospitals should have the necessary PPE for that to occur safely, but the reality is this pandemic caught federal, state, & city governments w/o actual pandemic response plans and it similarly caught hospital systems w/o actual pandemic response plans.

Real plans would have taken into account that in a global pandemic, standard just-in-time procurement systems would fail overnight. And they did fail which meant PPE given to family members would have been all the less available for staff. Hospital system plans would have taken into account that the feds & states did not have plans and did not have adequate stockpiles and that the hospital systems needed to create their own stockpiles. But they didn't have plans and they didn't have stockpiles enough for staff let alone family members.

There was never a question in the public health community that there would be a pandemic. The questions were only when it would come and how severe it would be. This was not a black swan event but rather one that they could have been prepared for. But they didn't plan for it and the need to keep family members out of the hospitals was one of the prices that had to be paid.

 
At Monday, May 25, 2020 7:52:00 PM, Blogger Maurice Bernstein, M.D. said...

Biker, as the current patient population of COVID-19 cases actually comes down (at least hopefully not temporarily but "permanently") shouldn't one expect that family members would be allowed to be present? Or do you think there are factors involved in hospital decisions not related to PPE resources and use but other legal concerns which would put an additional burden on the management of a hospital? For example, to protect against a visitor from making an argument that the visitor's subsequent COVID illness was really the hospital itself as the source. Should hospitals now require all visitors to sign a legal document before visiting any patient taking full responsibility for a subsequent personal COVID-19 infection? Would this support the ethical principle of justice toward the visitor? ..Maurice.

 
At Tuesday, May 26, 2020 4:46:00 AM, Blogger Biker said...

At this point we probably are in a position to begin allowing family members back into hospitals, perhaps with mandatory wearing of masks, screening at the door, and restrictions on where they can go. In areas of the hospital with actual covid-19 patients, the hospital itself would have to provide the required PPE being it is more than simply wearing a mask.

A few days ago I had to bring a urine sample to the lab for my wife. I was required to wear a mask and was screened at the door with a series of questions and my temp being taken. It all made sense. My guess is that the lawyers haven't fully caught up with the risk to visitors aspect of this but they likely will for the reasons you indicate and some form of public notice or formal consent will be required. My guess is they'll go with public notices being posted given the logistical problems with doing actual consents.

I'll throw in an interesting twist to the discussion. Can or should hospitals prohibit visitors who come from out-of-state? Both the local hospital and where I get my scheduled care at in NH want to know if you have been out-of-state in recent weeks. VT is OK with you having been in NH and NH is OK with you having been in VT given we have very low levels of the virus relative to our populations, but our neighbors MA & NY have bungled their response badly with disastrous results, as did their neighbors NJ & CT. Would it be OK right here and now to not allow visitors from MA/NY/CT/NJ and those who admit to having traveled to those States while allowing visitors who have only been in VT & NH?

Bear in mind that though we have had very little in the way of cases here, a good share of what we have had came from people fleeing Metro NYC. Roughly 1 in 7 homes in this State are 2nd homes and many did high taui

 
At Tuesday, May 26, 2020 8:36:00 AM, Blogger Maurice Bernstein, M.D. said...

I think what JF wrote on the Preserving Patient Dignity Volume 111 and my response to her is worthy of reproduction here on this topic. ..Maurice.


At Tuesday, May 26, 2020 7:18:00 AM, Anonymous JF said...
Dr B, WHY do you think you couldn't self diagnose? You could probably be approximately as accurate as another doctor doing it for you. Maybe if the college was a more responsible wage we could have many more doctors and there'd be more accountability from them. I kind of think more self treatment MIGHT be the way to go if people could force themselves to study up. At least to the point where doctors need patients as much as patients need doctors. Without that kind of equality we can always be mistreated by the medical staff who desires to mistreat us.

At Tuesday, May 26, 2020 8:26:00 AM, Blogger Maurice Bernstein, M.D. said...
JF, if you look at the current medical news and journals at this time of the COVID-19 pandemic, you will read that doctors do need patients for their financial and mental health. With some loosening up in parts of the United States and clinic or hospitalization for elective procedures are beginning to be permitted, for example, more routine visits with your doctor may be coming but with return soon of ongoing COVID flareups divorce between patient and doctor may still be an ongoing reality.

And yes, that means that patients for the foreseeable future may require self-medical education more than previously and self-treatment.

What I wrote above is real and is happening now. However, self-education and self-treatments will always have limits even with methods of self-electronic diagnosis and self-treatments. There is a reason why medical school education to become a physician is a 4 year exercise and even after 4 years more knowledge and experience is necessary before a physician becomes fully educated in medicine. But who knows what the future may bring in this upset and dangerous world and perhaps this respite from everyday professional care to self-diagnosis and management may be what will be a major public behavior in the future or even near future. COVID-19 is now known to attack and damage many bodily organs beyond the respiratory tree and even attack the healthcare providers in their work or at home and therefore it will end up with any "mistreatment" if present as exercised by the now "medically-educated" patients themselves. ..Maurice.

 
At Tuesday, May 26, 2020 9:48:00 AM, Blogger Biker said...

Not sure what happened with my last post but the final paragraph was supposed to be:

Bear in mind that though we have had very little in the way of cases here, a good share of what we have had came from people fleeing Metro NYC. Roughly 1 in 7 homes in this State are 2nd homes and many did high tail it up here to their 2nd homes.

 
At Tuesday, May 26, 2020 10:27:00 AM, Blogger Maurice Bernstein, M.D. said...

I want to emphasize that the topic which JF and I was currently covering actually deals with the bioethical principle of patient autonomy and the degree to which it can be practiced in the matter of the health of the patient involved but also with regard to the health of those humans who are in the vicinity or are being affected in other ways by the decisions and actions of that patient.

Patient autonomy in medicine should be an ethical principle with decision-making by the patient but should not be primarily directed to cause ethical or physical harm to others. Repeating: A wrong autonomous intent or final decision by a patient should not lead to the ethical error of maleficence toward others. So patient autonomy should be utilized by the patient with education and care. Does anyone here disagree? ..Maurice.

 
At Tuesday, May 26, 2020 9:47:00 PM, Blogger Maurice Bernstein, M.D. said...

As a followup to my last posting regarding patient autonomy..there is a current (today) interesting article in the American Medical Association website regarding the ethics about rushing to give cardio-pulmonary resuscitation (CPR) to Covid-19 patients. This issue has also been a topic discussed on the medical ethics listservs to which I subscribe. In many cases related to managing a Covid-19 patient there is a matter of the clinicians weighing benefit vs risk and, unfortunately, the infection risk to the doctors and nurses are is on the scale to weigh. ..Maurice.


 
At Thursday, May 28, 2020 8:41:00 AM, Anonymous JR Issues4Thought.com said...

Okay, let me get this straight. Saving a person who has COVID it not important as they must give the germ to the medical worker but when a normal patient declines/refuses a gold standard treatment than the medical worker has the right to force that treatment on the patient? It is funny how such a double standard can exist? Using this logic why do firemen rush into burning buildings at risk of their lives? Why do any of the jobs that put the job holder at risk still do those jobs? What about the military--should they be able to say it is too risky and not doing it? It didn't work for those during the years of the draft. For those who do things that put them at risk such as a mountain climber, does this now mean there will be no rescue operation because their careless, selfish actions could/may put the rescue team in danger? Does this mean because someone smokes cigarettes and set their bed on fire that firemen will not have to put their lives at risk to save them or put out the fire? How far does this go and to what "special" people does this apply to?

As far as patient autonomy, patients really only have autonomy on paper and not in practice. For a patient to have real autonomy, they must avoid medical care because at any time the medical community will take away the paper granted autonomy. I have personally witnessed this happen. The medical community made a decision that lead towards maleficence toward my husband but yet because he didn't die because of it, it is viewed as being okay. His decision to refuse invasive treatment did no harm to any of the medical people involved but yet they forced their gold standard of treatment on him. Where or at what circumstances will a patient be allowed autonomy? When is the convenient time for medical personnel to allow patient autonomy? So does this include anyone with flu symptoms from getting treatment because the flu can kill hundreds of thousands? Why can EMTs ignore DNR orders from a patient but yet can chose not to give CPR to a COVID patient? Does a person's DNR wishes not matter in the big scheme of things if the medical community sees it as not mattering for whatever reason?

This rule book is very confusing and is bound to be very thick. Will it be written in a language us non-educated common people can comprehend or do we need to rely on the medical community's superiority to dole out the instructions?

Why would a COVID infected individual even go to a hospital is my question? You are isolated and die alone. You may be abused but they now have immunity. They may put you on a ventilator which ultimately will probably kill you as it has done so many. You are drugged and get very little human interaction as all within your sight are like space invaders. They may or may not have to give you care as it might be too dangerous for them. Okay, I'll just stay at home and die and will do it more cheaper.

 
At Thursday, May 28, 2020 11:54:00 AM, Blogger Maurice Bernstein, M.D. said...

JR, I think that patient autonomy is a complex "freedom of self-decision making" and is even more complex when injury to others is an obvious issue. Here is a worthy article to click here and read regarding limits to patient's autonomy.
And let's then discuss this bioethics principle here since this is an important aspect of medical ethics and actions in this COVID-19 pandemic. ..Maurice.

 
At Thursday, May 28, 2020 12:56:00 PM, Blogger Biker said...

JR makes some good points. To clarify my earlier remarks, if the hospital staff did not have proper PPE as has sometimes been the case, and I was a covid-19 patient, I would not want them taking undue risks to resuscitate me. I don't want to live at the cost of some much younger nurse, tech, or doctor possibly losing their life. To me this would be me expressing my personal autonomy. I am not advocating that as the correct solution for everyone, nor what choices those nurses, techs, and doctors should be making for themselves in such a situation. I'm just saying I don't expect them to put me before themselves in such a situation w/o proper PPE.

My role model for autonomy is my grandfather. He had been a longshoreman back in the days before machines did all the work and I can recall seeing him w/o a shirt at about age 75. He still had a physique most men never had. Other than a pacemaker he was still in pretty good health at 85 when diagnosed with stomach cancer. The doctor recommended surgery which at his age certainly presented risks and possibly a long recovery. My grandfather refused any treatment, had another good year living his life as normal, became ill and passed at home at 87 with my grandmother having been his primary caregiver during his illness.

 
At Thursday, May 28, 2020 5:26:00 PM, Anonymous JR Issues4Thought.com said...

Going through that article you referenced, I have many points to add. I am painting w/ a broad stroke so I know there are exceptions.

The two concepts--the first being well-informed to make a decision. This is a problem area bc many drs don't want their patients to be well-informed as they feel threatened by patients w/ knowledge. True informed consent doesn't exist in most circumstances as most drs will gravitate towards the special procedure they are proficient in so they generally do not present the options or if they do, not in a favorable light. W/ the Internet, many more pts are becoming knowledgeable of options which seem to displease the medical community who thinks bc they have spent long yrs in getting education, we should bow to them.

It is the obligation of the dr to provide the info but many choose not to as they think pts don't really need to know but rather should rely on their judgment.

The extent of autonomy by this article should be limited if "its exercise causes harm to someone else or may harm the patient". This is totally BS. While their autonomy should not seek to harm others, they do have the right to decide their treatment options or no treatment at all. That is fully within their rights. A patient has the full right to refuse any treatment they do not wish to have. No has the right to force treatment on them. But the issue is, if a medical member disagrees they will merely call the person incompetent or unreasonable and do treatment against that person's desire or belief. But in saying the paragraph goes on to say "autonomy is limited when its exercise violates the physician's/healthcare team's medical conscience". So in other words, medical personnel are the only ones allowed to have beliefs or conscience. Wow! What a total double standard. I thought medical people left their personal feelings at the door such as sexual desires, racism, discrimination, etc. Apparently not but then I already knew that.

I totally agree that a dr does not have to provide treatment for giving antibiotics for a cold, etc. but that does not mean the medical team can force treatment upon a patient. They can deny treatments that are not medically needed but cannot force treatment especially if a patient says NO.

Just because a patient like Biker's grandfather declined the gold standard treatment does not make them incapable or mentally unbalanced. It means they have the right to control their fate. Doing an unneeded mental assessment on a patient just because their views of medical treatment is different is totally immoral and unethical. The thing about living is knowing that in the end you will die. Some choose to accept a more natural approach than others and no one has the right to disallow that.

My issue is medical people are said to not let personal feelings intrude into their professional conduct but it is and does. That is why many patients are denied basic patient rights such as dignity, respect, and autonomy.

While no one should purposely harm others, some jobs and professions are riskier than others. That is a fact of life. No one makes anyone become a member of the more riskier professions as of yet but that may come as politics change. But right now there is the freedom to choose. Doctors/nurses have always faced a certain amount of danger given they do deal with diseases that can kill if they are infected with them. It is a risk of their job just like it is for police, firepeople, military, bank tellers, convenience store clerks, etc. If you want a less riskier job, then you are free to choose that job.

But it is this very real admission of "moral distress within the team" which really bothers me and would explain why some patients face harm such as sexual and medical assault as it is clear the medical team seems to think they can use their personal feelings whenever necessary. Very troubling indeed!

 
At Thursday, May 28, 2020 8:53:00 PM, Blogger Maurice Bernstein, M.D. said...

I am greatly impressed by the dissection of the relationship between patient and caregiver autonomy through the views of JR and Biker. The issues, particularly in the cases of firemen (for example) and their risks as described by JR and by Biker regarding hospital staff in the context of the current COVID-19 pandemic and the limitations of protection to those not as yet infected, something which should be considered at least by the family of the patients if not, at the time, by the patients themselves.

There are times, as brought out by both JR and Biker when autonomy to be fair and of value, needs more thought and reasoning than at other times. Thanks. ..Maurice.

 
At Friday, May 29, 2020 6:59:00 AM, Anonymous JR Issues4Thought.com said...

The whole trouble with "autonomy" being at the whim of another (i.e. dr) is you have the situations of common person and celebrity. This is where the differences meet the road.

Everything is done to save someone like a George or Barbara Bush along with a Jimmy Carter. We, taxpayers, have probably paid millions to prolong their lives until it got to the point where even George and Barbara Bush said enough is enough. Jimmy Carter whose health is bad is saved at every cost even though he has co-morbidities. My father was not that lucky. His hip fractured due to Warfarin and he fell. He had Parkinsons but was functioning well. But in the ER that night, he was told he would not be saved as there was nothing they could do for him. At that point, I saw him close down instantly bc of that ER monster's words--You have no choice but to die. So they let him to linger with a broken hip unable to move for 3 weeks on hospice drugged to the max with no food or water or IV for any type of nourishment as hospice said they do not do IVs for nourishment. If he had been a Bush or Carter than it would have been different. This highlights why patients must have autonomy as there is a difference in care standards. To that ER dr., my father was unimportant but that certainly was not the case. We could have had him longer if that dr. did not feel it was within his right to pronounce for my father a death sentence. If my father had been "somebody" I am sure his "ethical" reasonings would have different. This is why I say it is dangerous to let the medical community have free reign when patients have a right to chart the course of how medical care is delivered or not. That is not to say pts have the right to have surgery just because but the same standards of care should be given to John Smith as it to Jimmy Carter.

I will stand behind that some professions have more inherent risks than others. If you do not want to have a job with risks, take another job. My job at a school wasn't suppose to have violence in it but it gradually grew to have it. I had choices though to continue or not. I continued knowing that any time a kid could commit violence and I was a victim of student violence but I accepted that risk. I knew at any time a student could stab, shot or run over me. I also knew that part of my job was to protect the other students. So with this in mind, is it okay in the minds of society for a teacher when faced with danger to abandon their students to save their own life? There was a cop at Parkland who took a lot of heat because he hesitated because of the apparent danger. Do cops like drs/nurses have the option to say not today--it is too dangerous? Do we need a flag/marker system so we know the mood of the day of whether they accept the risks on a particular day?

Do we need to know when we are going to be "allowed" rights and when the whim of someone says we do not have rights? How does that work exactly? But then that is how it works now. Sometimes we have rights at least on paper but when it comes right down to it we don't have rights bc in healthcare the medical community reigns supreme over us bc only they know what is good for us. This is why I like many others avoid healthcare. It is my body, my choice. If it works for women wanting to kill a baby bc they carelessly had sex, it should work for a responsible adult wanting to make their own healthcare decisions?

 
At Friday, May 29, 2020 9:55:00 AM, Blogger Maurice Bernstein, M.D. said...

And JR, there is the ethical principle of justice that ends up as "injustice" within the medical community workers itself. Just read this current article "Nurses Disciplined, Fired for Wearing Hospital-Issued Scrubs". There is injustice all around. ..Maurice.

 
At Friday, May 29, 2020 11:41:00 AM, Anonymous Anonymous said...

Hello Dr. Bernstein,

Thank you for your article from Hospital News re patient autonomy. It rekindled my remembrance of Logic 101 - from a faulty premise anything follows. I suppose that the essence of the article is the following initial line: "As they [health care workers] work with patients and families who are making healthcare decisions, the goal is to move care in the right direction." What is the "right direction"? Would this be what is most expedient for the health care "professionals"? The next statement is ridiculous. "First, to be autonomous (literally a self-lawmaker), an individual must have adequate knowledge to explore and examine all options relevant to the healthcare decision that needs to be made." NO!!! Nowhere in the definition of autonomy is there any implication of "knowledge"!!! This is why Epistemology (Theory of Knowledge) and Ethics (Theory of Morals) are separate disciplines. There's no reason to further dissect this ludicrous article. Maybe health care individuals should also be given a course in Logic before they delve into the more nuanced field of Ethics.

Reginald

 
At Friday, May 29, 2020 1:06:00 PM, Blogger A. Banterings said...

Reginald,

I was much impressed at your previous post about consent forms. Well written.


Maurice,

As to autonomy, justice, beneficence, and non-maleficence, this is marketing fluff, it is NOT the law. Providers do what they want. The oath only helps to quell (what ever is left after med school of their) conscience for doing what they were taught to do.

You speak of ethics as if it is practiced in healthcare. I hate to beat this dead horse, but as long as intimate exams on anesthetized patients without proper consent continue to occur, the profession is devoid of any morality. It applies to the entire profession, because if one is not part of the solution, then they are part of the problem.

What this pandemic has shown is how tight the leash society has put on providers really is. It still needs to be tighter and they need to be muzzled as well.

Now the pandemic is pushing us to realize what is really necessary and what is not. Hands on physicals are being replaced by video chats.

I see the larger picture. The providers are losing.








-- Banterings



 
At Saturday, May 30, 2020 4:33:00 PM, Blogger Maurice Bernstein, M.D. said...

There is so much concern now about how long it would take to obtain a proven effective vaccine for the prevention of illness and death by the CORONA-19 virus infection. Well, I found a numerous cartoon related to the length of time to prove the effectiveness of an "immortality vaccine' if even one could be invented. I have used this cartoon to present an introduction to the issue of "Ethics of Immortality". To inspect and perhaps contribute a thought click here. ..Maurice.

 

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