By Stephen Trevick, MD
I am writing from Chicago on March 20. I feel this is important to share as the COVID-19 pandemic is developing so rapidly that some concerns that I discuss here may be less relevant by the time you read this. There is an incredible amount of uncertainty in the pathophysiology, epidemiology and social impact of this disease. The eyes of the world are on healthcare providers now, and we have all become leaders of our communities. We will be called upon not only to provide medical care and information, but, ideally, to help guide the many ethical concerns that may arise as well.
Obviously, much of the medical care of COVID-19 is based around critical care, and neurology is one of the many fields that may fall by the wayside. Neurocritical care is a model specialty for understanding some of these competing concerns.
Most ethical conundrums arise when we have two forces pulling us in opposite directions, when our moral guidelines force us to be the servant of two masters. Individuals and institutions in healthcare have principles and promises they have made: to serve our patients, to embetter public health, to leave no human abandoned and many more. It is when the needs of one principle conflict with the needs of another that ethical analysis is needed.
Our institutions will almost certainly run out of resources. Concepts we are used to tackling, such as the weight of future disability and uncertain prognosis, will become all the more vital in triaging limited ICU and hospital space. There will be a need to utilize healthcare professionals outside of their typical fields. Neurointensivists may be among the first asked to help fill the need for intensivists, and yet our typical brain- and spine-injured patients will still require our expertise. How can we balance the overwhelming immensity of this disease with our established role in the needs of neurocritical patients?
Our government will encounter horrible choices. Resource and collective effort will have to be directed toward competing needs. Will the sickest and most strapped patient needs win out with ventilators and advanced care, or will these be abandoned to more scalable interventions? How will standard safety measures of the FDA toward new treatments be balanced against the current medical emergency? Eventually, closures and quarantines will run up against economic realities. Lives will be balanced against livelihoods.
We, as individuals, will face nearly impossible decisions. Allocation of limited resources is not unknown, even in the most advanced medical units. However, the decision of who will receive life-saving treatment will likely need to be made more rapidly and frequently, and thus, possibly with fewer colleagues to share the experience. Individual healthcare workers will have to decide what roles they will choose to perform and what risks they will undertake given their own factors in the face of strapped medical systems and an uncertain disease.
Moral distress is the discomfort we face when we have an idea of what action is right and cannot perform it due to external forces. This is a well-known cause of burnout across the healthcare fields. We will all be called on to help lead others. By evaluating our societal and personal ethics during this time, we can help protect ourselves from some of the distress we will have to live with after.