Bioethics Forum Essay
Teaching Medical Ethics During the Pandemic
Despite the disruptive changes to my undergraduate medical ethics class this semester, my students have learned a lot about the paradox that the coronavirus presents: it is an unprecedented event, beyond the experience of nearly everyone alive today, and yet it puts on grim display the well-known problems of inequality that chronically plague the United States. Since week six of the semester, I have readjusted each unit on the syllabus to address some of the ethical issues that Covid-19 has brought to the fore, familiar challenges that have been stressed and distorted in astonishing ways by the pandemic.
Before the virus restrictions, the class met twice a week: the first time with me to discuss the readings and the next day at the hospital, with my co-teacher, a physician, who used to introduce us to his patients. Some of his patients were quite sick, and so we’d suit up in protective gowns before we entered their rooms. Then he would ask the patients (all of whom had agreed to talk to a group of 10 college students) to just tell us anything they wanted to talk about, and boy did we hear a lot! Much of what the patients revealed dovetailed nicely with what we had covered in class, including topics such as shared decision-making, the ethics of truth-telling, doctor-patient communication, and assessing capacity.
Now, of course, we meet virtually, and so the students talk with the doctor and some of his colleagues online, all of whom are dealing with Covid-19 patients. We’ve heard and read about hospital strategies for transferring patients to other places (I wonder if the patients we’d met earlier have had to move to different spaces or were discharged); we’ve heard and read about national shortages of personal protective equipment; and we’ve heard and read agonizing stories of young doctors leaving their worried small children to care for the many patients entering New York City’s hospitals each day.
Learning about how doctors across the country were dealing with dwindling supplies was particularly heartbreaking. They are committed to their patients, and they are working long and demanding shifts under very difficult circumstances. For our class, it raised the questions: What are the limits of physician responsibility? Are health care workers obligated to treat patients when that means putting their own lives at risk for lack of proper supplies? Is this what they signed up for?
It’s somewhat understandable, though lamentable, that hospitals would be short on ventilators and beds. These are unprecedented times, and under normal circumstances there are not hundreds upon hundreds of very sick patients entering the hospitals on a daily basis. We talked about allocating ventilators and other scarce resources, including human resources. Some of my students personally felt the brunt of the drastic measures taken to increase hospital capacity as CUNY dorms were repurposed for hospital overflow or to house exposed health care workers who needed to remain isolated from their families.
One thing has become clear to these students: decisions in medical ethics are embedded in our broader social and cultural fabric. All the ethical questions that come up normally are exacerbated in a pandemic. At the worst moment, doctors’ attention is focused especially on vulnerable populations, who show up in the greatest numbers needing care, and as they address immediate medical problems, they simultaneously face systemic ones. Our unit on health care inequalities related to race, gender, and ethnicity originally concentrated on the startling statistics regarding maternal mortality among black women and similar inequities among black cardiac patients. It wasn’t difficult to pivot when the virus hit to include an analysis of why the virus is affecting African Americans at three times the rate of white patients and killing them at six times the rate of white patients. Health disparities have always existed for people of color, but in this crisis their socioeconomic status quite starkly contributes to their underlying medical conditions (which also stem from poverty) in determining negative outcomes. Many of my students’ families suffer in this regard, as their parents are considered essential workers, some in health care settings. They have to leave their apartments to go to work using public transportation, and some have gotten sick. Two of my students have had the virus in the past month.
We’ve talked in class about the difficulty of end-of-life decisions under normal circumstances. We discussed the importance of advance planning, the meanings of “do not resuscitate” and “do not intubate,” and how people decide what they would want and who would make those decisions for them if they were unable to make their own decisions. Never could we have imagined, in the beginning of the semester, that people would be dying, separated from their families, or that patients would be flooding the hospitals and put on ventilators in emergent settings where they have been too sick to consider the possibilities. With the volume of patients that some hospitals saw in the last few weeks, how is it even possible to have these difficult conversations with patients on the verge of dying, with hospital staff desperately trying to connect with families using iPads and FaceTime?
Many of my students are pre-med, and so they understand the science of viruses. Some of the questions they ask my physician co-teacher are far beyond my expertise, but I love to see how they’re connecting what they’ve learned in biochemistry with larger ethical concerns. After a unit that covered the history of unethical research experiments and the protocols of clinical trials in ordinary times, for example, students thought deeply about the wisdom of challenge trials, which would involve intentionally giving the virus to healthy volunteers. With all that’s still unknown about this particular virus (we’re finding new symptoms and strange outcomes almost daily, it seems), would historians in 50 years look back at this time and say incredulously, “They gave healthy people the virus on purpose? What were they thinking?” But again, ethics decisions are made in context: we have to devise ways to return to our normal pre-pandemic lives, and a vaccine would go a long way toward mitigating the harms of that return. Are the risks worth it?
As the semester ends, we will be talking about the crisis of health care access in our country, specifically as it affects homeless patients. We’re told to stay home to avoid contracting or spreading the virus, but this advice is impossible for people living on the street, who have no way to wash their hands frequently or even to separate from others if they’re staying in a shelter. Many homeless people use emergency rooms for routine health care needs, or sometimes even for a sandwich and a warm bed. But Covid-19 has emptied emergency rooms because people are afraid to go to hospitals for fear of catching the virus. What else can we do to help this particular population?
The problems seem overwhelming and intractable. So many ethical concerns have become visible and urgent all at the same time. As aspiring medical students and physicians, my students will never forget their spring semester of 2020. I hope, first, that they survive it well, and then that they find ways to use the personal and educational experience of this pandemic to inform their future work, addressing especially the disparities and inequalities that the virus has put in such stark relief.
Elizabeth Reis is a professor of gender and bioethics at the Macaulay Honors College at the City University of New York. She is the author of Bodies in Doubt: An American History of Intersex. Twitter: @lzreis