Wave After Wave
Bioethics and Distress in the Pandemic Hospital Setting
The Loyola Marymount University Bioethics Institute hosted a webinar on issues at the forefront of medical care during the COVID-19 pandemic. Three panelists provided their stories, insight, and advice for navigating through unprecedented times.
Thomas V. Cunningham
PhD, MA, MS
Nicole Rae Van Buren
"No one will be the same after this"
Dr. Cunningham, a bioethicist working at Kaiser Permanente West Los Angeles recounts the nascent stages of the COVID-19 pandemic. In mid-March 2020, when word began spreading regarding a virus coming out of Asia, no one knew what this virus would develop into, that there would be massive numbers of hospitalizations. Nonetheless, news sparked interest, and conversations began in anticipation of worst-case scenarios with respect to the potential risks of the virus and how ethicists might respond. As circumstances of crisis arose, allocation decisions needed to be made. However, legal and ethical justifications were not always considered.
Around mid-April, as cases began to appear at his hospital, Dr. Cunningham recalls that the initial issue was not a surge of patients, but rather uncertainty, fear, and scarcity. There was a limit of reliable information regarding the virus. Hospital staff began to fear the severity of the virus, and the possibility of transmitting it to their loved ones. Finally, resources needed to be rationed in anticipation of an escalating crisis that could leave the hospital short on supplies without being able to predict what other disasters may ensue. During the next surges of COVID-19, plans were drafted with respect to how to allocate resources. Revisions were constantly made. During this time, hospitals were functioning at 200% capacity. Many resources were taken from other areas and allocated to the COVID-19 care. The lack of precedent made these situations difficult, however, as Dr. Cunningham states, "the best we could do during this difficult time was keep calm and carry on."
"From the armchair, to under fire"
Dr. Cohn describes how fear, distrust, and fatigue persisted and changed throughout the course of the pandemic. Initially, people were afraid of the uncertainties of COVID-19. As the virus progressed, society became more accustomed to the virus. As information spread so did misinformation, trust between patients and physicians became increasingly fragile. There were times when patients’ family members would sneak in medications, or not accept recommended treatments because of something they had read online. As the waves continued, visitations were denied and families were not only angered by this restriction, but some began approaching hospital staff with hostility stemming from the grief and shock that their loved ones were dying. The stress, long hours, the intensity of patient care became a source of extreme fatigue for hospital staff. There was little instruction on how to approach these new situations.
Fair Allocation of Scarce Resources During COVID-19
Dr. Cohn recalls how in graduate school they had “played the games”, the games of distributive justice, of “who gets the ventilator”. They approached these hypothetical situations with different views and constructs; however, it stopped there. The COVID-19 pandemic became the real-life situation. Dr. Cohn notes that bioethicists were generally tasked with providing advice, whereas the pandemic situation brought them into the position of making decisions. Decisions regarding who got care, how resources were allocated, of planning and implementing for situations of increasing crisis. This was no easy task. Bioethicists asked themselves if they had the authority to implement plans for crisis care. If physicians would follow their plans. If the data was enough to influence ethical decisions. Diversity became increasingly apparent. Some people were vaccinated, others not. Some agreed with mandated vaccinations, others thought it reprehensible. In the midst of this diversity, the role of health professionals and their approach to people with a vast array of views needed to be carefully considered. Every physician, organization, bioethicist wants to be on the right side, but as Dr. Cohn suggests, only time will tell which side that is.
"Into the thick of battle"
Dr. Van Buren, a palliative physician, describes frontline work at her hospital and how it changed during the pandemic. As the COVID-19 crisis worsened, physicians were required to step outside their established routines. Physicians from other fields were asked to assist in the ICU or in palliative care. Unlike anything before, Dr. Van Buren describes how she was flooded with phone calls. She would speak to the family members of dying patients, needing to tell them that their loved one were dying and that they would not be able to see them. Dr. Van Buren admits that the high volume of calls not only became robotic, but that it was mentally and emotionally fatiguing to the point of breakdown.
For the frontline, Dr. Van Buren describes the COVID-19 pandemic like war. There is the war against the virus; how to stop it. There is tension between physicians regarding which courses of action are best. The goal is to save as many lives as possible. However, if this is the goal, that means that treatment, namely ventilators, are not first come first serve. Those who have a chance of making it should be prioritized over those who do not. This in turn creates a sense of injustice for the families who see that their loved one are not being prioritized. In this case, how do you choose? Ethical dilemmas continued to arise with no simple resolutions. Throughout these challenges, Dr. Van Buren states that the hospital teams supported each other, adjusted wherever necessary, worked together, and established leadership for the goal of saving as many lives as possible.
For more, watch the full video here:
This page was created by Bioethics graduate student Flavius Rusu.
Flavius Rusu is a second-year graduate student at the Bioethics Institute. He is the Craves Scholar and manages the content for the Bioethics Hub.
Roberto Dell'Oro, PhD
Nicholas Brown, PhD
Joseph Raho, PhD
Gianna McMillan, DBe
Facing Disaster: Covid-19 & Ethics of Pandemic
Dr. Dell'Oro: An Introduction
Roberto Dell’Oro studied philosophy and theology at the Catholic University of Milan (Italy), and the Hochschule für Philosophie in Munich (Germany). From 1993-1995, he was a postdoctoral fellow in bioethics at the Kennedy Institute of Ethics, Georgetown University. Dr. Dell'Oro is now the director of the Bioethics Institute at Loyola Marymount University and teaches in the areas of bioethics, fundamental moral theology, and ethical theories, with a special interest in anthropological themes at the crossroad of theology and philosophy.
Dr. Dell'Oro begins his introduction with a statistical overview of the COVID-19 pandemic. According to official records, forty-five million people across the globe have been infected with over one million deaths. Given the pandemic's scale, the bioethics scholarly community rigorously reflects and engages with the various ethical issues arising from the pandemic; issues of public health policy, clinical ethics, research ethics and medical experimentation. Introducing the lecture's panelists, Dr. Dell'Oro asks, "What have we learned from this crisis?" Acknowledging the expansive global impact of the pandemic, and the realization it brings about with respect to our interdependence and fragility, Dr. Dell'Oro urges us to view the pandemic as an opportunity to denounce national self-interest, and instead strive towards a standards of ethics which promotes cooperative efforts and the balance of resources and distribution.
Dr. Brown: Health Inequity
Nicholas R. Brown is the Director of the Bioethics Minor and Clinical Faculty in the Bioethics Institute at Loyola Marymount University. He received his doctorate in Christian Ethics from the Center of Advanced Theological Studies at Fuller Theological Seminary. His work and research focuses on how philosophical and theological conceptions of justice inform political discourse on public health and the distribution of health care resources and the ethical implications of embodiment.
Dr. Brown's remarks are centered on John Rawls's egalitarian system of justice. As empirical research suggests, the color of one's skin plays a significant role in one's exposure to COVID-19 and likelihood of death. Dr. Brown argues that health should been seen as a communal and shared good. In order for a community to devise and implement a system which follows this maxim, Dr. Brown suggests that the most feasible approach is founded on principles of liberty and difference.
Dr. Raho: Physicians Duty to Treat
Joseph Raho is a clinical ethicist at the UCLA Health System Ethics Center in Los Angeles, where he also trained for his fellowship in clinical ethics (2014 - 2016). Prior to coming to L.A., Dr. Raho received his PhD in philosophy from the University of Pisa, Italy, in May 2014, concentrating in moral philosophy and bioethics.
Questions of physicians' duty to treat during pandemic become increasingly relevant as the COVID-19 outbreak intensifies. Given the high infectious rate, physicians put themselves, colleagues, and loved ones at higher risk. Dr. Raho asks whether the principle of beneficence as applied in the context of the pandemic is a matter of absolute ethical duty or rather a charitable act. Tracing back historical codes of ethics provided by the American Medical Association, it is common throughout its development that physicians have an obligation to provide urgent medical care even in the face of disaster. However, it must also be noted that the physician workforce is limited and that doctors have an obligation to address the needs of patients but also have the duty to treat future patients.
Bioethics Undergraduate Interns Scholarly Research
Dr. McMillan: Research
Gianna McMillan received her Master’s Degree in Bioethics from LMU and her Doctorate from Loyola Chicago. She has served on the board of the American Society for Bioethics and Humanities, and is currently a Board Member for PRIM&R (Public Responsibility in Medicine & Research) and the Director of Community Engagement for the academic journal, Narrative Inquiry in Bioethics. Her primary interests are consent issues in clinical research and the use of narrative as an educational tool in bioethics.
The COVID-19 pandemic spawns a multitude of issues within the field of research. Dr. McMillan states that drug development within a public health crisis faces pressure from various directions; e.g. governments, the public, stake holders, the scientific community, etc. Nevertheless, respect for persons, beneficence, and justice must be honored in the attempt to combat the virus. Information should be adequately disclosed to those who wish to participate in research. Further, Dr. McMillan argues for a single, centralized politically unaffiliated organization that would be responsible for gathering COVID-19 related data. Information could then be intelligently formulated and relayed accurately to the public with consistency and accessibility. Finally, Dr. McMillan suggests that innovative collaboration between research facilities would accelerate knowledge and best practices for addressing the COVID-19 virus.
VIEW ENTIRE LECTURE HERE:
This page was created by Bioethics graduate student Flavius Rusu.
Flavius Rusu is a first-year
graduate student at the Bioethics Institute. He is the Craves Scholar and manages the content for the Bioethics Hub.
LMU Magazine Off Press Podcast
EPISODE 21 • MARCH 30, 2020
Bioethics Institute Professor Thomas V. Cunningham, Bioethics Program Director with Kaiser Permanente West Los Angeles Medical Center, spoke with LMU Magazine in the second of their series on the pandemic about the impact of trauma and stress from the virus on medical professionals and staff people.