UC Irvine

Western Journal of Emergency Medicine: Integrating Emergency

Care with Population Health

Title
Healthcare Ethics During a Pandemic

Permalink
https://escholarship.org/uc/item/09j8f8h7

Journal
Western Journal of Emergency Medicine: Integrating Emergency Care with Population
Health, 21(3)

ISSN
1936-900X

Author
Iserson, Kenneth V.

Publication Date
2020

DOI
10.5811/westjem.2020.4.47549

Copyright Information
Copyright 2020 by the author(s).This work is made available under the terms of a Creative
Commons Attribution License, available at https://creativecommons.org/licenses/by/4.0/

Peer reviewed

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University of California
 Expert Commentary

Healthcare Ethics During a Pandemic

Kenneth V. Iserson, MD, MBA University of Arizona, Department of Emergency Medicine, Tucson, Arizona

Section Editor: Mark I. Langdorf, MD, MHPE

Submission history: Submitted April 3, 2020; Accepted April 3, 2020
Electronically published April 13, 2020
Full text available through open access at http://escholarship.org/uc/uciem_westjem
DOI: 10.5811/westjem.2020.4.47549

As clinicians and support personnel struggle with their responsibilities to treat during the current
COVID-19 pandemic, several ethical issues have emerged. Will healthcare workers and support staff
fulfill their duty to treat in the face of high risks? Will institutional and government leaders at all levels
do the right things to help alleviate healthcare workers risks and fears? Will physicians be willing to
make hard, resource-allocation decisions if they cannot first husband or improvise alternatives?
With our healthcare facilities and governments unprepared for this inevitable disaster, front-line
doctors, advanced providers, nurses, EMS, and support personnel struggle with acute shortages
of equipment—both to treat patients and protect themselves. With their personal and possibly their
family’s lives and health at risk, they must weigh the option of continuing to work or retreat to safety.
This decision, made daily, is based on professional and personal values, how they perceive existing
risks—including available protective measures, and their perception of the level and transparency
of information they receive. Often, while clinicians get this information, support personnel do not,
leading to absenteeism and deteriorating healthcare services. Leadership can use good risk
communication (complete, widely transmitted, and transparent) to align healthcare workers’ risk
perceptions with reality. They also can address the common problems healthcare workers must
overcome to continue working (ie, risk mitigation techniques). Physicians, if they cannot sufficiently
husband or improvise lifesaving resources, will have to face difficult triage decisions. Ideally, they will
use a predetermined plan, probably based on the principles of Utilitarianism (maximizing the greatest
good) and derived from professional and community input. Unfortunately, none of these plans is
optimal. [West J Emerg Med. 2020;21(3)477–483.]

Disclaimer: Due to the rapidly evolving nature of this professionals weigh risk factors related to their response and
outbreak, and in the interests of rapid dissemination of the actions the healthcare community can take, including proper
reliable, actionable information, this paper went through communication and mitigating responder concerns, to maximize
expedited peer review. Additionally, information should be and maintain our caregiver workforce. I then very briefly
considered current only at the time of publication and may discuss the ethics of scarce resources and suggest options, such
evolve as the science develops. as recalling retired clinicians to service, improvisation, and
husbanding available resources to mitigate rationing.
INTRODUCTION
Disasters recur on a regular basis. In any disaster, and ETHICAL ASPECTS OF THE CURRENT PANDEMIC
especially in those caused by disease, the public expects As COVID-19 devastates the world, bringing another
healthcare professionals to be on the front lines. Indeed, most feared and inevitable highly infectious pandemic to the current
healthcare professionals expect that of themselves and their generation of healthcare professionals, we face a slew of ethical
colleagues. In most disasters, and certainly during the current dilemmas. Some of our colleagues around the globe reportedly
COVID-19 pandemic, frontline healthcare professionals face have already had to make resource-allocation decisions about
two key ethical issues: (1) whether to respond despite the which patients to treat. Others have had to struggle to provide
risks involved; and (2) how to distribute scarce, lifesaving lesser degrees of (“degraded”) care. We have little direct control
medical resources. In this paper, I discuss how healthcare over these situations. Most of the world failed to recognize the

Volume 21, no. 3: May 2020 477 Western Journal of Emergency Medicine
Healthcare Ethics During a Pandemic Iserson

existential threat of this new coronavirus early enough to fully value system. The “duty to treat” when one’s health, life, or
prepare institutional, local, regional, national, and international personal well-being is threatened is not absolute. In a risk-prone
mobilization and response. Political expediency, hubris, situation, each of us will prioritize our personal and professional
scientifically ignorant leaders, and incomplete information led values, those traits in ourselves that we consider to be our
to this inadequate advance planning by minimizing the threat fundamental driving forces. “Most clinicians first assess the
when it appeared, further delaying vital public health action. risks to our own and to our family’s life, health, and safety. We
At this point, the most vital ethical decision in our war may then factor in, to varying degrees, our religious beliefs and
against an unseen enemy is the one over which each of us has personal motivations, all colored by elements of our personality.
direct control: Will we stay to help in the fight? Next, we may consider professional factors, including the
Most disaster plans depend on physicians, nurses, support precepts in our healthcare profession’s oaths and codes, as
staff, and prehospital personnel to maintain healthcare’s well as other ethical and religious dicta to which we subscribe.
frontlines during crises. Yet planners cannot automatically Most clinicians will focus on their concrete professional
assume that all healthcare workers will respond. Will our responsibilities.”5 These professional factors include:
hospitals and clinics have enough physicians, advanced
practitioners, nurses, technicians, maintenance, and • Supporting/assuming the same risk as colleagues
administrative staff to keep the doors open, the computers • Collegial pressure/consequences of not helping
running, the linens clean, the lights on, and the facilities • Augmenting community welfare
safe? Will our 9-1-1 systems still be able to dispatch medics, • Fulfilling public expectation and trust
firefighters, and police? That depends on the iterative, possibly • Using societally underwritten special training and
hourly or daily, decisions that each affected individual professional status
repeatedly makes. • Fulfilling implied consent to help those in need (social
Such decisions are not purely ethical, but rather are contract)
complex determinations based on religious and personal values,
family and community responsibilities, health and financial Emergency physicians may also feel that in these
stability, and risk assessment. In 2001, for example, the AMA situations they are compelled to use their special knowledge
Code of Ethics was modified from “solemnly commit[ing] about triage, allocation of scarce resources (eg, vaccines,
ourselves to apply our knowledge and skills when needed, prophylactic or treatment medications, or intensive care unit
though doing so may put us at risk”1 to “physicians should [ICU] ventilators), public health mandates (eg, isolation or
balance immediate benefits to individual patients with ability quarantine, or mandatory vaccination), and the use of altered
to care for patients in the future.”2 The American College of standards of care.4,6
Emergency Physicians, meanwhile, stated in its 2017 Code
of Ethics for Emergency Physicians: ‘‘Courage is the ability RISK ASSESSMENT AND MITIGATION
to carry out one’s obligations despite personal risk or danger. Risk Assessment
Emergency physicians exhibit courage when they assume When preparing for a disaster, planners should consider
personal risk to provide steadfast care for all emergency not how they expect people to respond, but rather why they are
patients, including those who are agitated, violent, infectious, likely to respond.7 The risks to physicians and other healthcare
and the like.”3 providers’ will vary by the nature of the causative agent, the
Despite these professional ethical codes, nothing— provider’s activities and underlying health, and the protections
either morally or legally—compels a response to risk-prone offered and used. People decide which risks to accept or to
situations. Other than military personnel, no one is required avoid based on their own perceptions of the source and quality
to respond to potentially life-threatening emergencies. of the information they receive.8,9 Quick, emotional impressions
Professional oaths and codes may serve to guide practitioners, often precede and guide ‘‘rational’’ risk appraisals.10 Provider
but they are not absolutes. The factors that guide people to and population perception of their risk from COVID-19 will
respond are very personal; healthcare workers’ individual probably not be congruent with reality. In part, this will be
behavior and that of our organizational, professional and due to the discordant messages from many senior politicians
political leadership can modify those factors to increase the and other officials, but also will be influenced by the real-
number that are willing to respond.4 time updates in scientific knowledge about the disease, its
transmission, and possible protective measures.
VALUES
The moral backbone of medical professionals—a duty to Risk Communication and Mitigation
put the needs of patients first—may be tested as they determine In crises, individuals must balance good information from
whether to stay and carry out their professional roles or to valid media, government, and other sources to help identify
step back and decrease their own personal risks. Whether the actual risks to themselves and their loved ones. Providing
providers will stay depends on their own risk assessment and the best current information about the risks as well as the

Western Journal of Emergency Medicine 478 Volume 21, no. 3: May 2020
Iserson Healthcare Ethics During a Pandemic

opportunities to assist during a crisis will help healthcare considered as an afterthought by administrators. “An important
professionals make defensible decisions in disaster settings.5 lesson from the SARS outbreak is that, whereas most clinicians
Transparent and consistent information generates the trust will ‘‘stay and fight,’’ vital support personnel, including
necessary for both caregivers and the population to develop a those in materials and supply, logistics, cleaning, information
reasonable risk assessment during conditions of uncertainty.11 technology communications, maintenance, and refuse removal,
Issuing incomplete or conflicting information, as was done may feel no commitment to assist; moreover, they may feel
during the first months of the COVID-19 outbreak, caused undervalued, unprotected from risks, and ignored when they are
many providers to make decisions to respond based on heated omitted from vital communications.”12
emotions and inaccurate risk perceptions. People have been If all the staff necessary to run medical facilities fail to
shown to naturally exaggerate the risk of phenomena that are receive timely, relevant and believable information, they
unknown or “dreaded,” such as those with delayed, irreversible may not respond, and the quality of available healthcare will
or manmade effects; those that have new, unknown, or deteriorate. Widely distributing accurate risk assessments and
unobservable risks; those that are global; and those that are descriptions of protective measures for staff will encourage the
“hyped” by the media.5 maximal number of clinicians and other necessary personnel
Historical precedent and the nature of the medical to respond to the situation. Therefore, disaster planners and
profession demonstrate that we will have enough physicians managers should do everything possible to communicate the
and, probably, nurses to treat patients. Other professional and risks clearly to all members of the healthcare system and to
non-professional staff needed to keep healthcare institutions provide them with as much support and security as possible.
operating may not be as willing to risk themselves. Recent Risk communication (Figure 1) is “the exchange of
history suggests that we probably will not have enough support real-time information, advice and opinions between experts
personnel because, although they may be at as much or more and people facing threats to their health, economic or social
risk than healthcare professionals, their personal safety is often well-being.” 13 Its purpose “is to enable people at risk to

1. Be First: Quickly sharing information about a disease 4. Express Empathy: Disease outbreaks can cause fear and
outbreak can help stop the spread of disease, and prevent disrupt daily lives. Lesser-known or emerging diseases casue
and reduce illness and even death. People often remember more uncertainty and anxiety. Acknowledging what people are
the first information they receive should come from health feeling and their challenges shows that you are considering
experts. their perspectives when you give recommendations.
• Even if the cause of the outbreak or specific disease is • For example, during a telebriefing for the coronavirus
unknown, share facts that are available. This can help disease 2019 response: “Being quarantined can be
you stay ahead of possible rumors. disruptive, frustrating, and feel scary. Especially when
• Share information about the signs and symptoms of the reason for quarantine is exposure to a new disease
disease, who is at risk, treatment and care options, and for which there may be limited information.”
when to seek medical care. 5. Promote Action: In an infectious disease outbreak, public
2. Be Right: Accuracy establishes credibility. Information should understanding of and action on disease prevention is key to
include what is known, what is not known, and what is being stopping the spread.
done to fill in the information gaps. • Keep action messages simple, short, and easy to
• Public health messages and medical guidance must remember, like “cover your cough.”
complement each other. For example, public health • Promote action messages in different ways to make
officials should not widely encourage people to go to the sure they reach those with disabilities, limited English
doctors if doctors are turning people away and running proficiency, and varying access to information.
out of medicine for critically ill people. 6. Show Respect: Respectful communication is particularly
• Always fact check with subject-matter experts. One important when people feel vulnerable. Respectful
incorrect message can cause harmful behaviors and may communication promotes cooperation and rapport. Actively
result in people losing trust in future messages. listen to the issues and solutions brought up by local
3. Be Credible: Honesty, timeliness, and scientific evidence communities and local leadership.
encourage the public to trust your information and guidance. • Acknowledge different cultural beliefs and practices
Acknowledge when you do not have enough information to about diseases, and work with communities to adapt
answer a question and then work with the appropriate experts behaviors and promote understanding.
to get an answer. • Do not dismiss fears or concerns. Give people a chance
• Do not make promises about anything that is not yet to talk and ask questions.
certain, such as distribution of vaccines or mediciations
without confirmed availability.
• Clinicians should be present at press or community
events to answer medical questions.
Figure 1. Crisis emergency risk communication in an infectious disease outbreak.16

Volume 21, no. 3: May 2020 479 Western Journal of Emergency Medicine
Healthcare Ethics During a Pandemic Iserson

make informed decisions to protect themselves and their “a physician, nurse, PA, first responder or other healthcare
loved ones.”13 Risk communication can help keep healthcare professional has the right to be removed from the schedule of
and other vital workers at their posts. But it must be done work requiring direct contact with patients potentially infected
by appropriate people, educated in risk-communication with COVID-19 for issues of personal health, such as being on
techniques, in a trustworthy manner (honestly, frequently, immunosuppressive therapy or other similar concerns, without
open/available), and through easily accessible means, which the risk of termination of employment.”15
includes role-modeling by those in charge.14 Rarely discussed, but a key part of maintaining our
In addition to providing information, research shows workforce, is to support the psychosocial needs of the
that to attain the maximal response during risk-prone and healthcare team. According to medical anthropologist Monica
other disasters, planners must do everything practicable to Schoch-Spana, “Pandemics aren’t just physical. They bring
mitigate perceived risks and to address other concerns that with them an almost shadow pandemic of psychological and
may prevent staff from being either able or willing to work societal injuries as well.”17 Psychosocial support for healthcare
in a disaster (Table 1). To address one concern, on March workers in the current war against COVID-19 will be akin to
20, 2020, the American Academy of Emergency Medicine post-traumatic stress disorder treatment for soldiers manning
issued a position statement saying, in part, that they believe the front lines for extended periods. People respond to the

Table 1. Disaster responders’ concerns and planners’ potential mitigating actions.5,18-25

Responders’ Concerns Mitigating Actions
Risk to/safety of responder • Actions to help protect responder: priority for vaccinations, priority for prophylactic/treatment
medications, appropriate/sufficient PPE, and prespecified responder decontamination procedures
• Clear, continuous, consistent, honest, and transparent communication to all responders
• Continuously available (and updatated as necessary) disaster plan
• Knowledgeable individuals available to answer any workplace safety questions
Risk to/safety of responder’s • Actions to help protect family: priority for vaccinations, priority for prophylactic/treatment
family and loved ones medications, decontaminating responder, and providing PPE at home
• Clear, proactive, consistent, honest, transparent, and ongoing communication from employer to
responder’s family
• Continuously available (and updated as necessary) disaster plan
• Knowledgeable individuals available to answer any questions about responder and family safety
Child and elder care • Provide paid sitters or care at health care facility
• Arrange, in advance, for local governments to keep schools open, whenever possible
Risk to/safety of responder’s pets • Provide or pay for pet care
Trust/confidence in health care • Have and communicate to all employees an all-hazard disaster plan, including risk-reduction
organization/leadership measures, that is easily accessible, practiced, and modified as necessary based on circumstances
• Maintain clear, continuous, consistent, honest, and transparent communication to all responders
about current disaster knowledge and plan
• Overtly and continuously demonstrate duty to protect and support responders
Inadequate disaster-related • Provide life/disability insurance and liability/legal protection for duration of disaster response
Human Resource policies30 • Responders may leave work as necessary
• Flexible work hours
• Clear return-to-work policies
• Provide responders with communication (if possible) to their families
Adequate reimbursement for time • Guaranteed appropriate pay/comp time/bonus pay for level of their activities
and activities
Safe, guaranteed transportation • Private vans or rooms and board at health care facility
• Arrange, in advance, for local governments to keep mass transit systems running, whenever
possible
Mandatory quarantine • Clear, consistent, and reasonable quarntine policy
Personal illness/PTSD • Guaranteed treatment for disaster-acquired medical/psychiatric problems
Job requirements • Effort to make all responders feel they are valued part of the disaster response
• Clear description of any modified job expectations/requirements during disaster
PPE, personal protective equippment; PTSD, postraumatic stress disorder.
Reprinted, with permission, from the Journal of Environmental and Occupational Medicine.7

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Iserson Healthcare Ethics During a Pandemic

risks differently, so experienced professionals will need to distribution, scarcity often requires clinicians to prioritize which
intervene before tragic, adverse events occur. patients receive the resources.33,34
As the COVID-19 pandemic extends its devastation,
SCARCE RESOURCES AND SOME SOLUTIONS physicians around the world are already facing the daunting
In the current pandemic, some key resources are and will task of rationing lifesaving resources. This is upending their
increasingly become scarce. Physicians will need to consider traditional method of treating the sickest first in emergency
how to distribute available resources and obtain or improvise departments or “first come first served” in the ICUs.31 In Italy,
others. The most ethical course of action is to do everything physicians have reported limiting ventilators to those less than
possible to delay having to ration. Vital materials already 60 years old, and China and Spain have implemented medical
in short supply include viral test kits and their associated resource rationing. The US government and many states that
equipment and reagents, personal protective equipment (PPE), have developed rationing plans have yet to explicitly implement
ventilators, and hospital – especially ICU – beds. While China them.35 Many of these plans may be outdated, and none have
rapidly erected new, prefabricated hospitals to treat patients and been tested to determine whether they will save lives. In fact,
many countries around the world are establishing alternative a Canadian study of H1N1 patients found that 70% of patients
care sites, the United States has been slow to act. that a rationing plan would have removed from ventilators
Often not considered, healthcare workers, especially those survived with continued ventilation.36
with expertise treating the critically ill, will inevitably become Dr. Laura Evans, an intensivist at the University of
a scarce resource. However, as the situation changes, most Washington, is working with her state to devise a triage plan
healthcare workers will constantly reassess their decisions that would be doing “the most good for the most people and
about responding. As increasing numbers of personnel get be fair and equitable and transparent in the process.” Yet
sidelined due to actual or suspected disease, exhaustion, or the Washington State Health Department recently issued a
fear for themselves or their families. Some active and retired statement that “triage teams under crisis conditions should
personnel who initially stayed out of the fight or were sidelined consider transferring patients out of the hospital or to
due to illness or other circumstances may reassess their decision palliative care if the patient’s baseline functioning was marked
and join the battle. Employing senior medical students and by ‘loss of reserves in energy, physical ability, cognition and
extending advance practitioners’ scope of practice has been general health.’”36
suggested as one way to ameliorate this problem. Rationing plans must conform to general ethical principles
In England and Wales, the National Health Service has and to existing community moral standards. Community input
asked about 65,000 retired doctors and nurses to return to work. into these plans is vital for maintaining the public’s trust in
In Scotland, they are recalling those who retired within the past
three years. If these clinicians have been away from practice
for more than a short time, they will receive brief refresher
training.26 The Institute of Medicine, among others, have
described how to best manage resource scarcity in a widespread Table 2. Strategies for Scarce Resource Situations.27-30
disaster (Table 2). Many of these strategies are discussed in • Prepare—e.g., anticipate challenges, develop plans,
more detail elsewhere. 27 stockpile materials. Identify leaders who can source or
develop alternative supplies and equipment. Identify
and train risk communicators. Plan to mitigate personnel
ETHICS OF SCARCE RESOURCE ALLOCATION difficulties in responding.
During or after attempts at conservation, reutilization, • Conserve—implement conservation strategies for supplies
adaption, and substitution are performed maximally, rationing in shortage or anticipated shortage to ensure the minimum
will need to be implemented.31 The ethical principle that guides impact/compromise possible (e.g., determining “at-risk”
rationing is distributive justice, which requires that scarce groups with priority for therapies in shortage and overall
strategies to conserve use of oxygen delivery devices [i.e.,
resources be distributed fairly, providing them to those most ventilators] or PPE.
in need. Specifically, it requires impartial and neutral decision • Substitute—provide an equivalent or near-equivalent
makers to consistently apply rationing decisions across people medication or delivery device.
and time (treating like cases alike).32 This is based on Utilitarian • Adapt—use of equipment for alternative purposes (e.g.,
principles, including conservation of resources, fiduciary anesthesia machine as ventilator)
responsibility (stewardship), multiplier effect (does the person • Re-use—plan to re-use a wide variety of materials after
appropriate disinfection or sterilization (e.g., may include
have a job that will save other lives?), immediate usefulness, oxygen delivery devices).
medical success, and caretaker role.33,34 Most ethicists agree, • Re-allocate—if no alternatives exist, remove a resource
however, that such distribution should be equitable, although from one area/patient and allocate to another who has a
in some circumstances other distribution methods, such as first higher likelihood of benefit (i.e., greater chance of surviving
come, first served; equal distribution; and even, no distribution or more post-disease years to live).
may be more rational. Even with agreement about equitable PPE, personal protective equipment.

Volume 21, no. 3: May 2020 481 Western Journal of Emergency Medicine
Healthcare Ethics During a Pandemic Iserson

clinicians, the institutions, and the organizations involved Address for Correspondence: Kenneth V. Iserson, MD, MBA,
in disaster relief and resource allocation. A major ethical Department of Emergency Medicine, The University of Arizona, 4930
dilemma is that current rationing criteria may skew away from N Calle Faja, Tucson, AZ 85718. Email: kvi@email.arizona.edu.
normally disadvantaged populations. In the past, allocation Conflicts of Interest: By the WestJEM article submission agreement,
plans were developed by the healthcare community. In the all authors are required to disclose all affiliations, funding sources
current crisis, some planning groups have tried to address this and financial or management relationships that could be perceived
by asking disparate communities throughout their region to as potential sources of bias. No author has professional or financial
offer input into the plans. 36 relationships with any companies that are relevant to this study.
In all circumstances, rationing scarce medical resources is There are no conflicts of interest or sources of funding to declare.
difficult and stressful. Such distribution, rather than being based Copyright: © 2020 Iserson. This is an open access article distributed
on politics, money or power, must be based on an equitable in accordance with the terms of the Creative Commons Attribution
(fair), openly available, pre-existing plan. It may be beneficial (CC BY 4.0) License. See: http://creativecommons.org/licenses/
to have emergency physicians and intensivists take the lead by/4.0/
(under set protocols) in making these decisions, since they have
had more experience than others in doing this on a regular basis.
Ideally, they will have support from their institutions’ bioethics
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Volume 21, no. 3: May 2020 483 Western Journal of Emergency Medicine