Ethical Challenges, Opportunities Revealed by the Pandemic

Because trauma takes time to process, America’s healthcare experience during the COVID-19 pandemic will not be fully understood for many years. Ira Bedzow, PhD, director of the Project in International Ethics and Leadership at Emory University Law School, however, says some things are already clear.

Despite the many challenges healthcare organizations faced before the pandemic, they have largely survived the unprecedented crisis, treating more people than they believed possible and adapting in ways that were previously unthinkable.

“From a health organization perspective, the pandemic has been somewhat of a success story,” says Bedzow, head of the unit of the International Chair in Bioethics (a World Medical Association Cooperation Centre). “On the other hand, if we don’t learn from what has occurred, it will be a travesty.”

In interviews with Physician Leadership Journal, Bedzow and other ethicists shared some ethical challenges and opportunities highlighted by the pandemic and how physician leaders can address them.

The Need To Think Proactively

While the specific details of the COVID-19 pandemic could not have been foreseen, many healthcare organizations were caught more flat-footed than they should have been. Bedzow says that, among other reasons, the situation reflects the way physicians are trained to react: Diagnose a problem that has emerged and figure out a way to address it.

“Medicine is a very reactive profession — always one step behind because people intellectually are waiting for a thing to happen before they respond to it,” he says. “That’s an ethical challenge because you can’t get ahead of something if you’ve never thought about it.”

Aside from the pandemic, he points to more longstanding challenges; for example, social determinants of health and race- and ethnicity-based health and healthcare disparities, in which the failure to address the root of a problem continues to cost lives.

The lesson to be learned from the pandemic is that just as a security company hires hackers to uncover its vulnerabilities, healthcare organizations should proactively identify their weaknesses. They must ask themselves, “What happens if the supply chain is disrupted?” and “Do we care enough about our staff to keep them safe during a crisis?”

Bedzow maintains that the answers to those questions should prompt healthcare organizations to align their values with their preparation for the lingering pandemic as well as future crises.

Resource Allocation

Most healthcare organizations have tended to become more competitive than cooperative in recent decades, but the pandemic forced a new level of collaboration, says Matthew Wynia, MD, MPH, director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus.

In pre-pandemic Colorado, for example, about 10% of the state’s hospitals were submitting the required intensive care unit capacity data to the state. When the surge of COVID-19 patients threatened to overwhelm some hospitals, a state-level protocol was developed to move resources and patients from one hospital to another with the goal of providing the best care to the greatest number of people.

With relationships and the infrastructure for sharing data among organizations now in place, Wynia wants to see them maintained.

“I hope that mindset — seeing the whole state as your client and recognizing that, while you have a competitive relationship with other health systems, there is a benefit in seeing them as your partners when it comes to statewide issues — has some spillover,” Wynia says.

Workplace Safety

It is well-documented that patient safety is imperiled by healthcare’s hierarchical culture, a lack of trust among so-called “team members,” and widespread fear of pointing out problems. The pandemic revealed that culture also threatens healthcare workers.

“It was clear at the outset that not only did a lot of healthcare workers and professionals feel that they were being placed in untenable positions, [but also] they didn’t even have the means to speak out about it without adverse consequences,” says F. Daniel “Dan” Davis, PhD, chief bioethics officer at Geisinger, a nine-hospital system based in Pennsylvania.

Davis suggests that the healthcare industry should follow the lead of the airline industry.

“We haven’t really grappled with the promise and the possibilities of interprofessional education, which was the first thing the airline industry did when it started to tackle its problems with customer safety,” he says. “This has exacerbated the conditions that healthcare professionals labor under on a daily basis, even without a pandemic, and now it’s accentuated with the pandemic.”

Physician and Staff Fragility

The burnout crisis in healthcare, in full flame even before the pandemic, added fuel to the fire. Wynia expects to see high turnover as many in the current workforce bail out of healthcare entirely.

“Fortunately, we’re having many new people come into the healthcare system right now — nothing like a pandemic to drive people into medical and nursing and public health school,” he says. “But it is also driving people who are already in the medical profession out. So how do we learn from where we have been?”

Asking physicians, nurses, and others to take sole responsibility for mitigating their own burnout is not an ethical position.

“Interventions that focus on improving resilience at the individual level are well-meaning and they can be of value to some people,” Wynia says. “But if you’re continuously overbooked and you never have enough time with any given patient, inviting you to take an hour during lunch to do yoga, which you probably can’t do anyway because you spend your lunch hour on documentation, is not going to solve the problem.”

Burnout is a symptom of the moral injury healthcare workers suffer when they perceive that overwork, lack of support, technology hassles, and other conditions prevent them from providing optimum patient care. Their work experience during the pandemic made everything worse.

“Physicians, nurses, and allied health professionals have been tapped out and yet continue to work because they are relying on a sense of their professionalism — helping people is who they are,” Bedzow says. “But when they are being dis-incentivized to continue, given the way the system is set up, that is going to come crashing down.”

Triage Protocols

As the severity of the pandemic became clear, many health systems created or updated protocols for distributing care during an overwhelming surge of patients. The crisis-standard-of-care protocols require physicians and staff to shift their usual clinical ethic of providing the best care to the patient at hand to a public health ethic of triage care providing resources to the patients most likely to benefit.

Although Geisinger’s Davis is unaware of any organization that publicly acknowledged invoking those triage protocols, many health system leaders are considering whether those plans were, in fact, useful. “Many of these protocols are very elegant in terms of their ethical framework, but there is a question about how practical they would be,” Davis says.

For one thing, effectively communicating new care standards across a multi-hospital system during a major patient surge might be impossible. For another, implementing the protocols might reduce capacity to deliver timely care.

“Most of those protocols include some sort of appeals mechanism, which requires time that clinicians in the midst of overwhelming surge would not have,” Davis says.

His thinking has been influenced by a 2020 essay, “In Response to COVID-19 Pandemic Physicians Already Know What to Do” by ethicist Larry McCullough, an AAPL faculty member. In the American Journal of Bioethics article, “[McCullough] argues that these triage protocols actually are an overlay on what most physicians — especially those who work in critical care and emergency care — already know how to do,” Davis says. “So really what health systems need to do is step up and support them in that.”

Health Disparities

An analysis of COVID-19 death rates in the early months of the pandemic revealed vast disparities: 5.6 per 10,000 population for Black and Hispanic patients; 4.3 for Asian patients, and 2.3 for White patients, according to a January 2021 article in JAMA(1). As every healthcare leader knows, these and other COVID-19 disparities are just the newest additions to a long list of race- and ethnicity-based inequities in healthcare delivery and health outcomes.

“Not that we couldn’t see them before if we were attentive to them, but they certainly have been thrown into really sharp relief,” Davis says.

In Bedzow’s view, those disparities often reflect a chasm between an organization’s stated values and the way it delivers care. “Mission and values statements usually are conceptual. ‘We hold all people with great respect’ sounds wonderful, but who cares? What are we doing to put those values into practice?” he says. “If there is a race, gender, or socioeconomic disparity in 30-day readmission rates to the hospital, that reflects true values in practice.”

New Modes of Care Delivery

When COVID-19 made in-person visits unsafe, telehealth technology, along with the relaxed regulations that supported its use, transformed care delivery almost overnight.

Nearly two years later, it is clear that telehealth improves access to care for people who have barriers to in-person care, such as inflexible work schedules and lack of transportation, money, and physical stamina. But ease of access may be driving up healthcare costs in a way that threatens to overwhelm state Medicaid budgets.

“Telehealth appears not to reduce the other costs within the healthcare system because it acts more often as a complement [to other modes of care] than a substitute,” Wynia says.

He believes that in some cases, the problem may stem from unscrupulous providers taking advantage of the pay rates for telehealth services during the public health emergency. More broadly, because telehealth appointments are so easy, people access them for concerns for which they would not have made an in-person visit. However, the telehealth visit may trigger an in-person visit or a trip to the emergency department.

State Medicaid programs, in particular, will be challenged to find the ethical balance between expanding access to care for underserved groups and not wasting money.

“If this higher utilization means that some individuals and communities are better served, maybe this is appropriate,” Wynia says. “But they are working with limited budgets.”

Don’t Just Think; Act

Wynia and Bedzow are co-directors of the Aspen Ethical Leadership Program, an annual conference designed to support ethical awareness, analysis, and action among healthcare leaders. AAPL is a program partner.

The program seeks to bridge an important gap, Bedzow says. Almost everyone in healthcare aspires to serve with integrity, and most individuals know the right thing to do when faced with an ethical dilemma, but healthcare leaders typically are not trained in the action steps to follow through in the face of financial, cultural, and other barriers.

“Continuing education is needed to address the question of ‘how do I do that?’ ” he says. “What particular steps are needed? Who do I speak to? Are there other stakeholders that I can bring in? How do I speak to shared values if others have conflict over a decision I want to implement?”

The program draws on the work of Mary C. Gentile, PhD, professor of ethics at the University of Virginia Darden School of Business. She is creator/director of Giving Voice to Values (GVV), which trains individuals to decide not only what the ethical thing to do is, but also to practice required action steps to carry out the decision.

“One of the most important lessons of COVID is that we need to build organizational — not just individual — resilience,” Gentile says. “In a situation like the pandemic, you can’t predict when and what is going to happen, so training people how to deal with the unpredictable is the most effective strategy.”

One example of resilience is from the early weeks of the pandemic when many frontline healthcare workers came up with innovative solutions to the shortage of personal protective equipment (PPE). In taking the initiative, many frontline workers railed about unethical leaders who asked them to work without proper PPE.

“This was not the kind of thing where someone at the top of the organization can understand all the different challenges and opportunities,” Gentile says. “Some of the interesting fixes that people came up with during the pandemic were because they were figuring out what they could do to help a family member or a patient or a colleague.”

One GVV strategy would be to practice problem-solving with a joint approach that involves individuals from all levels of the organization — that would be a more familiar and natural approach to meeting challenges.

“That allows everyone to get on the same side to search for the solution, rather than the leader feeling that he or she has to come up with the answer and then impose it on everyone else,” Gentile says. “Involving more people from throughout the organization in the decision makes it easier to find a solution, but it also means you’ll probably have a better decision.”

Reference

1. https://jamanetwork.com/journals/jama/fullarticle/2775687