EDU hosted yet another great public lecture this past 10 October 2021, as part of the Leadership in Healthcare event series. The virtual series is open and free for the public to attend.
The second lecture of this series, titled Lessons from the Pandemic: Moral and Ethical Dilemmas in Prevention, Prevalence and Care in the COVID-19 Pandemic, focused on moral distress in pandemic-related health care, as well as global and national COVID-19 vaccine distribution in the United States. The COVID-19 pandemic in the US has unveiled societal and healthcare inequities and created moral distress for public health and health care providers. Additionally, harsh political divisions have exacerbated the pandemic and hindered efforts to control the virus.
Once again, our host and moderator for the seminar was our very own EDU professor Dr. med. Elliot Goodman. Dr. Goodman is a general surgeon who trained at Maimonides Medical Center in New York. He has been on the surgical staff of Mount Sinai Beth Israel for the last 18 years, and on the faculty of the Mount Sinai School of Medicine for the last 8 years.
Alongside him was the main speaker of the event, Dr. Nancy Rudner. Dr. Rudner is an Associate Professor at the University of Alabama at Birmingham, USA. Her work focuses on population health and prevention: working with individuals, families and communities to improve health. Dr. Rudner earned her Doctorate in Public Health from the University of Michigan as a Pew Scholar in Health Policy, her Master’s in Public Health from the University of North Carolina and her Master’s in Nursing from Pace University. Prior to the pandemic, Dr. Rudner participated in an international medical brigade in Guatemala’s chronic disaster highlands and also worked with the Registered Nurse Response Network to provide nursing care to refugees at the Mexico-U.S. border.
Dr. Goodman kickstarted the lecture by sharing an observation from his involvement during the first wave of the COVID-19 pandemic in New York City:
“There was one day in our ICU where there were about 6 deaths in one day. They were all middle-aged or elderly, obese, black men. And it was not surprising perhaps that the difference in mortality and morbidity of COVID, in terms of ethnicity and race, also correlated with the fact that the patients with the highest risk of dying from COVID were in those parts of the city which had fewer hospital beds and fewer health care facilities.”
Such occurrence is not specific only to New York. The risk of severe or mortal infection from COVID-19 between black and white populations is evident in other parts of the United States, with over 4-fold increases in risk of death in black versus white communities in New Orleans, and similar numbers in Michigan, Illinois, and North Carolina.
But again, this is a recurring theme. Dr. Goodman remarks: “There is a higher incidence of COVID – a higher likelihood of death from COVID-19 – in populations which have less access to good health care in the United States. And this is not just a problem in this country, it’s a global problem.”
Following his introduction, Dr. Elliot Goodman gave the floor to Dr. Nancy Rudner. As mentioned earlier, Dr. Rudner’s lecture focused on the moral and ethical distress the COVID-19 pandemic has put on health care professionals. She engaged in this topic by posing multiple questions.
Why do we expect healthcare professionals to risk their health/lives in this pandemic?
First, according to Dr. Rudner, there is the social contract: a promise to care, to provide medical care to those in need. With that comes the formal training and skills that only medical and nursing staff have, which make these skills untransferable. Thus, healthcare professionals cannot be easily replaced by untrained staff.
Furthermore, Dr. Rudner acknowledged that medical professionals have this ability to provide care, but also expect to have reciprocal employer commitments of safety and support. “It all goes back to leadership. Leadership is so important. Viewing that your employer understands your stress makes a big difference.”
Such considerations raise another dilemma:
Is it ok not to provide care if: You or your spouse is immunosuppressed? If the patient refuses to wear a mask? What if the patient refuses vaccination, or you as a practitioner are not provided sufficient PPE (personal protective equipment)? Or what if the patient is hostile and claims COVID is a hoax?
In essence, as Dr. Rudner pointed out: “Everybody makes their own decisions based on where their ethical compass is set.”
Should there be a focus on prevention or treatment?
Dr. Nancy Rudner, being a specialist in population health, has thoroughly noted the challenges in balancing clinical ethics and public health ethics: “We have this duty to care, fidelity to the patient, to relief from suffering and to respect the rights and preferences of patients. So that part prioritizes individuals.” On the other hand –as she strongly remarked– there is also a set of public health ethics: looking after the overall public or community safety, how to protect community health, how to fairly allocate limited resources?
The balance between these two has been immensely played out in the COVID-19 pandemic. As a punctual example, Dr. Rudner highlighted how history keeps repeating itself in terms of prevention vs. treatment. Take for instance the 1900’s smallpox outbreak, where people protested vaccine mandates, or in 1918 with the H1N1 pandemic, where anti-mask meetings were held. Prevention efforts such as vaccinations, masks or social distancing have been present since medieval plagues, but have never been fully accepted.
And it is a similar story now with COVID-19. While preventive efforts are questioned, treatments for the virus are heavily embraced by the public: hydrochloroquine, monoclonal antibodies, high-dose steroids, and the latest one, Ivermectin, which not only does not help against COVID-19, but rather poisons the people who take it, mentioned Dr. Rudner.
Between prevention and treatment, Dr. Rudner quoted: “An ounce of prevention is worth a pound of cure.” It is better and easier to stop a problem, an illness, from happening than to stop or correct it after it has started.
But even within the prevention measures there are issues. Such is the case with vaccinations, Dr. Rudner reflected. Distribution, resistance and mandates all play a part, as well as “fatal politics” (vaccination disparities by political party: 54% Republicans vs. 86% Democrats).
From these issues stems the next main ethical and moral dilemma:
What happens to those who refuse a preventive measure such as a vaccine?
According to Rudner, the problem with choosing to refuse a vaccine, is that it is not a purely individual choice, because it leaves other people at risk. For example, people with cancer or transplant patients are more vulnerable to severe disease. “So as long as COVID is circulating in our population, we’re leaving other people at risk.”
From the unimmunized come further clinical ethical challenges:
When ICU beds are scarce, who do you prioritize? Do you prioritize the vaccinated or the unvaccinated? The unvaccinated are highly likely to have a much more difficult course of disease, so should doctors give priority to vaccinated patients?
Dr. Rudner asks, “Does that put us on a slippery slope of value judging patients? Or is strategic prioritizing and triaging?”
Dr. Goodman asked Dr. Rudner an interesting question along these lines:
How do you as a medical professional then decide that you have reached the end of the line with regards to the duty of care for that patient?
From Dr. Rudner’s perspective, who focuses on population health and public health:
“The slogan of John Hopkins School of Public Health (now Bloomberg School of Public Health) is ‘saving lives – millions at a time’, and I like saving a million lives over one-on-one. Ultimately, our (USA) medical training and our medical schools have been very focused on individual care. We are moving over to a more of a population health focus. (…) We need both.”
Are we one world?
This ongoing tension between individual rights and the obligation to our communities further seeps into other aspects of immunization issues, such as uneven global vaccine distribution.
This problem becomes visible in contrasting numbers, with countries such as Portugal reaching a vaccination rate of over 90%, whereas Africa as a continent has less than 3% of its population already immunized (data from September 2021).
Dr. Rudner further illustrated this inequality with the following numbers: 6.5 billion vaccines have been administered globally, providing 47.5% of the world population with at least one dose. But only 2.5% of people in low-income countries have received their first shot (data from September 2021). Therefore, if one looks at vaccination rates by continent, it is evident that this is not an issue of vaccine refusal, but access. And that raises the question: what is the obligation of resource-rich nations to ensure other nations have vaccine access? Is the vaccine a private commodity?
To conclude, Dr. Nancy Rudner acknowledged that the COVID-19 pandemic has exacerbated the moral and ethical choices that health care professionals face every day, with several unique aspects that have made it particularly stressful: contagion, duration, fatigue, disparities, political division. Nevertheless, all this distress circles back to how a situation is managed:
“We talked about a catastrophe, a disaster, and there is a quote we like to use in disaster care: There are no natural disasters. There are phenomena that become disasters by how we manage or mismanage them.”
If one thing must be taken away from this lecture, it is the final analogy presented by Dr. Rudner and Dr. Elliot in their closing discussions:
Is the COVID-19 pandemic a phenomenon or a disaster?
Dr. Rudner explained that when one thinks about a hurricane, the hurricane is a natural phenomenon. It becomes a disaster due to how buildings are built and how communities respond to the phenomenon. The same applies to COVID-19, as Dr. Goodman reflected:
“If you look at the pathology of COVID, the difference between a mild attack and a severe or fatal attack, in large part, is how we respond to it as patients. Take the immune system: if it responds just enough to eradicate the viral disease, you are ok. But if the immune response goes out of control, it then produces a cascade of events, such as filling up your lungs with fluid. This makes blood clot more easily, which can then develop into a thrombosis in the lungs, heart or brain. Then organs shut down. So again, it’s not about the initial phenomenon, it’s about the response. The response can be the catastrophe.”
This lecture ultimately showed how effective health care management and leadership rely not only on responsive measures but also on prevention in health care to avoid an overwhelmed, exacerbated and distressed health care system. Lectures like these –with cases, lessons and experience provided by prominent speakers– really focus on the importance for future medical practitioners to be trained as leaders. The aim of this event series is to provide our audience with different views on a global issue that is still very much present in the life of each and every one of us.
Moreover, these lectures reflect on the foundations of our medical programme, allowing value to be placed both in individual clinical care but also in public health care. EDU as a medical institution is educating the next generation of health care practitioners to take on leadership roles and attitudes to protect their communities, whilst also preparing them for moments of crisis.
If you missed this specific seminar, but are interested in this event series, find out more about our upcoming lecture The Ethics of Rationing Care during the COVID-19 pandemic and register already! This free public lecture will take place on 10 March 2022 and will be held online. By registering you will be the first to get notified about all the details of EDU’s upcoming lectures.