Clinical ethics in the time of COVID-19
I am a clinical ethicist. I prefer this label over the alternatives like “healthcare ethicist” or “ethics consultant.” One reason for this preference has to do with the word “clinical.”
The English word “clinic” owes its meaning to the Greek word klinikos: the word often used to describe Greek physicians who would visit the beds (kline) of the sick. I take the bedside as the place where clinical ethics happens. The ethicist’s responsibilities often include assessing ethics issues, analyzing them, and offering recommendations.
In the last few weeks, our ethics service has been advised to avoid the hospital and perform our activities by phone and email. The reasons for this make sense: the hospital needs to preserve personal protective equipment (PPE) and minimize the number of healthcare professionals in the building to curtail the spread of COVID-19.
This guidance changes my default practices. Three weeks ago, I would be at the bedside for most questions. The patient and I could talk face-to-face. By sitting down, looking at them, and introducing myself, I could mark myself — and my role — as distinct from other providers. Patients might notice my clothes are different. No white coat. No suit and tie. I always leave my card. A small gesture, but a material reminder of who I am and my availability.
Video calls might mitigate some of these concerns but being there in person shows my investment. I am worried patients will be skeptical of my attempts at understanding their wishes if I am not able to show a physical investment in their care.
For those who lack the ability to make their own medical decisions, I have had to reach out to families and loved ones. For the more technical side of clinical ethics (such as identifying a surrogate decision-maker), a phone call might have been my choice even without access restrictions.
My default for any complex issue, however, has been in-person conversation. I worry that I might not explain my role in a way they understand, leaving them wondering why this tinny voice with no medical updates is asking them personal questions. As limited visitor policies pop up across the United States, other clinical services will struggle with these limitations, too. But we ethicists often have unique responsibilities that families (and healthcare professionals) might struggle to appreciate without a sit-down, face-to-face conversation.
As a recent guidance points out, this pandemic requires healthcare professionals, especially nurses and doctors, to shift their focus from the duty to care for the individual to the duty to care for the community if a triage protocol is put in place. This shift means distributing resources as fairly as possible, to as many as possible. Those responsible for speaking with patients and families about these decisions — even if they are not making triage decisions themselves —will feel distress and may want the help of the ethics service.
Suppose I conclude that I should go into the clinic to speak with the team, or family, face-to-face, what could I do? I am not deciding who gets what. Nor am I responsible for leading such conversations.
Still, I can do a few things if our triage policy is activated. I might explain, in person, the ethical reasoning that forms the backbone of the triage policy. My hope is that a clear explanation could help a family be comforted by the fact that the decision is not idiosyncratic or based on reasons other than the patient’s chance of survival.
An ethicist’s agreement with the decision might show that humans, rather than faceless others, have put thought into these policies. The choice to converse face-to-face might cut both ways, of course. One family might appreciate my presence, another might see me as the face of an unjust, bureaucratic decision. In either case, being there would be important, even when I can’t anticipate how someone might respond.
For the healthcare team, I’m a person with them in a time of transition and catastrophe. I shouldn’t do their jobs, but I could acknowledge that an action might feel unfair, even if — at a theoretical level — it is fair. Or as close to fair as we can get.
Also, ethicists help clinicians have difficult conversations. A conversation about withholding or withdrawing a ventilator for the sake of another patient would be hard for even experienced and confident professionals. In fact, I can’t imagine a more difficult conversation in medicine.
I’m not a chaplain, mental health professional, or social worker. But I am a clinical ethicist. If I am honest with myself, I imagine I would tell the healthcare team I will be there even if the best I can offer is being there.
-By Trevor M. Bibler, HEC-C, MTS, Ph.D., clinical ethicist at Houston Methodist Hospital and assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine