The COVID-19 Conundrum

The coronavirus pandemic highlights the essential role of bioethicists in guiding crisis care
Ken Goodman

Kenneth W. Goodman, Ph.D. ’91

Hurricanes, tornadoes, floods, fires, mass shootings, bridge collapses: Large-scale emergencies typically present harrowing — yet not unheard of — public health challenges.

And then there is COVID-19.

With its extreme contagiousness, erratic severity, and sometimes tragic outcomes, the coronavirus pandemic is catapulting these challenges to an unprecedented level.

Clearly, amid such a crisis, standard procedures will not suffice. But exactly what should take their place? Far from being solely an operational puzzle, it is a dilemma with profound ethical implications.

“Just ‘winging it’ and making it up as we go along are not appropriate,” said Kenneth W. Goodman, Ph.D. ’91, director of the Miller School of Medicine’s Institute for Bioethics and Health Policy. “We need to establish ethical justifications for altering ‘normal’ standards of care to protect the caregivers who are making unimaginably tough choices.”

Toward that end, the Florida Hospital Association recently approved a set of COVID-19 crisis care guidelines for hospitals and health systems statewide that was drawn up by the state’s bioethics resources. UM’s bioethics institute spearheaded those efforts in close collaboration with the Florida Bioethics Network, multiple government institutions, and health care and ethics leaders across the state and beyond.

Much of the complexity stems from a heartbreakingly simple arithmetic problem.

“Usually, in a mass casualty incident with several victims, hospitals will take in a few dozen patients with various injuries based on county surge planning; others get sent to neighboring institutions with appropriate expertise,” explained Vincent Torres, emergency manager for the University of Miami Health System and the Miller School.

“But every COVID-19 patient — and their numbers grow geometrically every day — requires the same medications, ventilators, clinical specialties and personal protective equipment, which are already in short supply.”

The situation, said Jeffrey Brosco, M.D., Ph.D., professor of pediatrics and director of population health ethics at the Miller School, “raises a classic ethics issue: what to do when resources are outstripped by need. We need to determine how to allocate those resources in a way that does not exacerbate inequality.”

The overarching goal of such efforts — to provide compassionate care to all patients without regard to race, ethnicity, gender, age, sexual orientation, or any other trait — appears straightforward. But, as is often the case, the devil is in the details.

The process of ironing out those details must, in turn, be rooted in a broad consensus among all stakeholders on guiding values, principles and priorities. To be successful, it also needs to be transparent, not only to patients and their families, but also to the public at large.

“We need to get to a place where we combine epidemiologic data with deeply held values to meet these challenges in a way we can all live with,” Dr. Brosco said.

The Florida Bioethics Network’s “Ethics Guidelines for Crisis Standards” working document, currently being updated in real time to respond to constant changes in medical and epidemiological understanding of COVID-19, begins with a narrative that explains, as Goodman puts it, “Here is why this matters and is the right thing to do.”

That includes a reexamination of the “duty to treat” customarily associated with caregivers’ training and their commitment to their professions. During resource-straining emergencies, patients may not necessarily be treated on the usual “first come, first served” basis or receive interventions that, based on the best available evidence, are unlikely to benefit them.

“We don’t want an individual physician to have to decide who gets a ventilator or receives CPR in the heat of the moment,” Dr. Goodman said. “Health care institutions need to establish triage teams to help determine a patient’s likelihood of survival and support doctors who are making excruciatingly difficult calls.”

“The virtue of ethically designed, evidence-based public health guidelines is that they don’t know what color you are, your ethnic background or whether you have a disability. They don’t know whether you have private insurance or Medicaid. They exist only to maximize the number of people who survive and the total number of life-years saved.”
— Kenneth W. Goodman, Ph.D.

An important tool for making that determination is the SOFA score. The rather cozy-sounding term is actually a grim acronym for Sequential Organ Failure Assessment. Each patient’s SOFA score reveals his or her likelihood of survival and recovery in light of preexisting conditions such as heart disease, diabetes, metastatic cancer, renal failure or dementia.

“Physicians typically take extraordinary measures to rescue patients at death’s door,” Dr. Goodman said. “But, when patients have minimal chances of surviving a COVID-19 infection, it may make the most sense to let them pass peacefully.”

Importantly, such guidelines also protect caregivers who could sustain heavy exposure to the virus during aggressive treatments.

“Our colleagues are putting themselves at risk to save lives,” Dr. Goodman said, “and their own well-being is vital to public health. We don’t want them going through the motions and potentially falling seriously ill themselves when the outlook for a patient is clearly not good.”

Paradoxically, these data-driven metrics yield a degree of humanistic equity that would not otherwise be possible in such intense, emotionally fraught moments.

“The virtue of ethically designed, evidence-based public health guidelines,” Dr. Goodman pointed out, “is that they don’t know what color you are, your ethnic background or whether you have a disability. They don’t know whether you have private insurance or Medicaid. They exist only to maximize the number of people who survive and the total number of life-years saved.”

Beyond its present challenges, Dr. Brosco said, the COVID-19 crisis lays bare larger, more pervasive ethical issues.

“Policy decisions that affect how we organize our health system and who has access to it — and who doesn’t — reflect deeply imbedded values,” he noted. “When we get through it, we will have an opportunity to reimagine our health system and be better prepared to protect public health going forward.”

In the meantime, Dr. Goodman is grateful that the guidelines he and his colleagues and collaborators worked so hard to craft were approved by the state’s elected leaders.

“We will be able to say that we helped design the plan that is helping Florida save lives.”

Be In the Know

“In the Know” virtual town halls are conversations with UHealth and Miller School of Medicine experts on a range of important health topics. Physician-scientists and researchers explored UHealth’s response to the COVID-19 pandemic in our first two town halls, which were moderated by South Florida news anchor, Tony Segreto, a University of Miami alumnus. Both town halls included UHealth experts in public health, hospital operations, clinical care and research, who answered questions about treatment protocols, vaccinations and rapid testing.

Watch the latest “In the Know” video recording here.

UNIVERSITY OF MIAMI MEDICINE
SPRING 2020