March 27, 2020

The Difficult Decisions Confronting Doctors During The Coronavirus Crisis


My “baby” sister, Subha Airan-Javia, is a hospitalist at the Hospital of University of Pennsylvania.  Her husband is an ENT surgeon at the Children’s Hospital of Pennsylvania.  They are on the front lines along with hundreds of thousands of other health care workers around the world.  As the pandemic of COVID-19 was beginning to globally spread, our entire family made the decision to self-quarantine about two weeks ago.  I have many cousins around the country and in India and all of us told our parents to completely isolate.  I am lucky enough that my parents live across the street and so when they go for a walk in the evenings, I sometimes walk my dog at the same time and walk on the opposite side of the street to maintain the 6 feet of distance between us.  I go to Publix, CVS and the Indian grocery store when they need anything and I am doing my best to protect them by reminding them to use gloves and wipe down every single thing that comes in the house.  Both my parents have pre-existing conditions and are considered “high risk” based on initial information about this unique virus.

Yesterday, my sister forwarded an article that was written for clinicians and published to give health care providers guidance on how to make resource allocation decisions.  Subha said that she and my brother-in-law were reviewing the article so “we wouldn’t crumble having to make these choices.  I’m crying just reading them.  But this.  THIS is what we are thinking about ALL the time.” (See “Fair Allocation of Scarce Medical Resources in the Time of Covid-19.”  The New England Journal of Medicine. March 23, 2020.

I spent some time digesting and trying to understand the article as best I could given my very limited knowledge and grasp of medical vocabulary and concepts. I came across the section titled “Who Gets Health Resources in a Covid-19 Pandemic?”  My first inclination was shock.  But, I had been hearing the news reports from Italy and the growing concern here in the US about lack of health care resources and the need to #flattenthecurve.   But, here in this official article in a reputable medical journal, was an ethical analysis as to how resources are to be distributed based on a number of factors.  I suppose I should have innately known that there must be some guidance for clinicians in the field so subjective decisions aren’t made arbitrarily.

The article suggests that over the years, in other scenarios, there have been previous proposals for allocation of resources in a pandemic or other setting of scarcity.  The four fundamental values that are considered are: maximizing the benefits produced by scarce resources; treating people equally; promoting and rewarding instrumental value; and giving priority to the worst off.  “These ethical values …. yield six specific recommendations for allocating medical resources in the Covid-19 pandemic.”  (See article).

  1. maximize benefits
  2. prioritize health workers
  3. do not allocate on a first-come, first serve basis
  4. be responsive to evidence
  5. recognize research participation
  6. apply the same principles to all Covid-19 and non-Covid-19 patients

It is beyond my comprehension how our doctors, nurses, technicians, and other health care workers will make these difficult decisions.  For example, the article discusses “number of lives” versus “years of life” and “maximize improvements in length of life” versus “reasonable life expectancy.”  These are subjective decisions that many of the world’s health care providers will face (or have already faced) in the coming months.  These decisions will be underscored and made based on recognition across the sector of the four ethical values researched and set forth by medical leaders.

Even though I am not a health care professional, I am asked to share my story and consult on the topic of ethical decision-making across the globe.  As my sister, her husband and their colleagues around the world will be faced with difficult decisions, I implore each of them to be cognizant of their implicit biases, judgments, inclinations, rationalizations, and assumptions – all of which play a role at some point in our decision making.  Taking the time to pause to reflect on their inner voice and aligning with the ethical values set forth, will allow each professional to make the best possible decision in this unprecedented and stressful time.

May we all continue to practice kindness, empathy and continue to recognize the humanity around us.

Rashmi Airan‘s mission is to help organizations create cultures focused on integrity, authenticity, and accountability by connecting these efforts to human performance, behavioral ethics and emotional intelligence.  Rashmi is a keynote speaker and consultant specializing in organizational culture, reputational risk, and human performance. Contact Rashmi to see how she can help your organization.

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