Thinking about ethics during the COVID-19 pandemic: Insights and practical approaches for interventional radiologists

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ethics
Michelle Shnayder-Adams (L), Eric Keller, and Mina Makary (R)

“Practicing ethical inquiry and reflection may mitigate the moral distress that can arise from ethical dilemmas,” write Michelle Shnayder-Adams, Eric J Keller, and Mina S Makary—and there have certainly been a number of emotionally-challenging ethical dilemmas for healthcare providers treating patients against the backdrop of the COVID-19 pandemic. The authors discuss the intersection of medical ethics and interventional radiology (IR) amidst this crisis, and propose a framework interventionalists can use to enable decision-making when faced with multiple, conflicting moral obligations, which they say can cause stress and uncertainty.

In stressful times, challenges associated with making ethical and honourable decisions become more apparent. The COVID-19 pandemic has placed an immense amount of strain on the medical community, and interventional radiologists are not exempt from this pressure. When ethical norms are disrupted, we have an even greater responsibility as a specialty to bring ethical decision-making to the forefront. This article will highlight: 1) how ethics and IR intersect, 2) how ethical issues have been heightened during the COVID-19 pandemic, and 3) how to apply a framework to ethical decisions pertaining to IR care.

The discipline of ethics helps us to decide how we ought to behave as a standard of behaviour.1 To some, it may not seem obvious to discuss and practice ethical decision-making in medicine as it appears innate. After all, physicians pledge the Hippocratic Oath and vow to “do no harm”. However, conflict arises when ethical principles clash. The COVID-19 pandemic has challenged a number of ethical values, including duty to care, equity, autonomy, and individual liberty. As we continue to practice in a new societal norm filled with personal risk, limited resources, and limited physical contact, we must continue to reflect on our ideals and ethical identities during patient care delivery.

The Society of Interventional Radiology (SIR) Code of Ethics offers guiding principles for IR physicians on societal ethical expectations.2 Respect for human dignity, respect for human rights, and respect for the law are all included. However, these guidelines are not always sufficient when faced with practical matters. Are you obligated to place a central venous catheter in a patient with COVID-19 at a time when personal protective equipment is limited, and other departments have the means to perform this service? Some may argue that a pandemic qualifies as a state of emergency in which physicians must act on the best interest of society. However, in practice, it is much more challenging to jeopardise your own health and the health of your family and colleagues for the sake of professional duty. Physicians have a responsibility to care for patients, but this responsibility must be balanced with a duty to one’s health and one’s family.3,4  We must also resist the urge to deflect risk onto others and should view patient care as a collective responsibility. With thoughtful reflection and support from institutions to ease the moral burden of these difficult choices, IR physicians can weigh their competing responsibilities and come to a solution that balances all the ethical and practical issues at play.5

With the development of the COVID-19 vaccine, resource allocation concerns have shifted from intensive care unit (ICU) bed provision to vaccination distribution priority. How do we decide on a fair system of vaccine distribution? Whether you are a healthcare leader responsible for the development of a vaccine rollout plan or a frustrated IR practitioner awaiting a vaccine, resource allocation and equity affects all healthcare providers. The Center for Disease Control (CDC) has advocated to minimise morbidity and mortality and preserve societal functions.6 With these priorities in mind, some vaccination algorithms have prioritised age over exposure frequency. Without transparency from leaders about their chosen ethical approach, it is reasonable for younger practitioners with frequent exposures to feel betrayed when they observe vaccine prioritisation of older practitioners with lesser patient interaction. There is no absolute right answer when it comes to prioritisation in the setting of scarce resources, but as these ethical dilemmas unfold, it is crucial for healthcare leaders to maintain transparency and robust discussion with their communities to reach more optimal solutions.

Imagine you are running a busy consult service and you are tasked with acquiring consent for a gastrostomy tube placement in a non-English speaking patient with COVID-19 who has been delirious the last few nights. Her son is her power of attorney. Would you risk exposure, call a translator, and attempt to assess the patient’s decision-making capacity, or just call the patient’s son to get consent? From an ethical standpoint, many IR physicians may agree that they would advocate for explaining the procedure and its risks to the patient despite the extra risk, time, and logistic challenges. From a practical standpoint, respecting a patient’s autonomy, while paramount, can be often inconvenient, especially during a pandemic. Despite the challenges, we must keep in mind that assessing a patient’s decision-making capacity is one of our responsibilities as IR physicians, and if needed, there are resources and other departments in the hospital to help with capacity assessments.

Despite being accountable to our individual patients, IR physicians also have a responsibility to the general public. These two obligations may lead to internal turmoil and conflict. Visitor restrictions limit disease exposure for patients, providers, and hospital staff but at the expense of some individual liberty. Limiting a patient’s number of visitors may support a public effort to reduce spread of disease, but the social isolation of patients can lead to psychological distress and worse patient outcomes. 7–9 In balancing these opposing priorities and accepting the restriction of some individual liberties for the betterment of society, interventional radiologists may find that going beyond their usual levels of communication with patients and families may be necessary to preserve the patient-doctor-family relationship during a pandemic.

The COVID-19 pandemic has forced medical professionals, including interventional radiologists, to deal with ethically-ambivalent decisions every day. Many frameworks have been developed to aid in the ethical decision-making process. 1,5,10–12  One such approach is as follows: 1) recognise an ethical dilemma, 2) gather relevant information from all parties involved, 3) scrutinise possible options using various ethical theories, 4) decide how to act, and 5) reflect on the outcome. For example, this framework may be applied to triaging patients. First, we recognise that triaging with limited resources is an ethical issue. Second, we may gather information about the acuity of all patients involved and consider occupancy capacity at nearby facilities. Third, question the correct course of action under a utilitarian, rights, justice, common good, and virtue approach. For instance, under the justice approach, consider which options treats people equally—making sure not to succumb to bias and favouritism. Fourth, decide which patient to treat, and, fifth, consider how your decision impacted those involved. Practicing ethical inquiry and reflection may mitigate the moral distress that can arise from ethical dilemmas.13

Interventional radiologists have started to recognise the importance of ethical discussion in our field. We have an Applied Ethics Committee supported by the Society of Interventional Oncology (SIO) and SIR, and we have growing literature on ethical topics in IR including: complications,14 conflicts of interest,15 research ethics,16 and futility.17–19 The COVID-19 pandemic has highlighted the need for these discussions, and we must continue to provide platforms to discuss how best to act in ethically challenging situations.

Michelle M Shnayder-Adams is an interventional radiology resident at the University of Michigan Hospital, Ann Arbor, USA. @MMShnayderMD on Twitter.

Eric J Keller is an interventional radiology resident at the Stanford University Medical Center, Stanford, USA. @IR_Ethics on Twitter.

Mina S Makary is an assistant professor, interventional radiologist, and the director of scholarly activity and research at the Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, USA. @MinaMakaryMD on Twitter.

References

  1. Markkula Center for Applied Ethics. Accessed January 21, 2021. https://www.scu.edu/ethics/
  2. SIR Code of Ethics. Published online 2018. Accessed June 21, 2020. https://www.sirweb.org/globalassets/aasociety-of-interventional-radiology-home-page/about-us/governance/sir-code-of-ethics_approved-november-2018.pdf
  3. Shnayder MM, Keller EJ, Makary MS. COVID-19 Ethics: What Interventional Radiologists Need to Know. J Vasc Interv Radiol. 2020;31(10):1720-1723. doi:10.1016/j.jvir.2020.07.003
  4. Bakewell F, Pauls MA, Migneault D. Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic. Cjem.:1-4. doi:10.1017/cem.2020.376
  5. Thompson AK, Faith K, Gibson JL, Upshur RE. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006;7(1):1-11. doi:10.1186/1472-6939-7-12
  6. CDC. COVID-19 and Your Health. Centers for Disease Control and Prevention. Published February 11, 2020. Accessed January 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html
  7. Jago CA, Singh SS, Moretti F. Coronavirus Disease 2019 (COVID-19) and Pregnancy: Combating Isolation to Improve Outcomes. Obstet Gynecol. 2020;136(1):33-36. doi:10.1097/AOG.0000000000003946
  8. Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalised patients: a systematic review. J Hosp Infect. 2010;76(2):97-102. doi:10.1016/j.jhin.2010.04.027
  9. Hao F, Tam W, Hu X, et al. A quantitative and qualitative study on the neuropsychiatric sequelae of acutely ill COVID-19 inpatients in isolation facilities. Transl Psychiatry. 2020;10(1):1-14. doi:10.1038/s41398-020-01039-2
  10. Berlinger N, Wynia M, Powell T, et al. Ethical framework for health care institutions responding to novel Coronavirus SARS-CoV-2 (COVID-19) guidelines for institutional ethics services responding to COVID-19. Safeguarding Communities Guid Pract. 2020;2.
  11. A Framework for Making Ethical Decisions | Science and Technology Studies. Accessed January 21, 2021. https://www.brown.edu/academics/science-and-technology-studies/framework-making-ethical-decisions
  12. Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic. The Hastings Center. Accessed June 18, 2020. https://www.thehastingscenter.org/ethicalframeworkcovid19/
  13. Rushton CH, Kaszniak AW, Halifax JS. Addressing Moral Distress: Application of a Framework to Palliative Care Practice. :9.
  14. Keller EJ. Reflect and Remember: The Ethics of Complications in Interventional Radiology. Semin Interv Radiol. 2019;36(2):104-107. doi:10.1055/s-0039-1688423
  15. Clark JM, Anderson D, Makary MS, Keller EJ. Understanding Bias: A Look at Conflicts of Interest in IR. J Vasc Interv Radiol. 2019;30(5):765-766. doi:10.1016/j.jvir.2019.01.002
  16. Bozorghadad S, Newton IG, Perez AW, Makary MS, Keller EJ. Research Ethics in IR: The Intersection Between Care and Progress. J Vasc Interv Radiol. 2020;31(5):846-848. doi:10.1016/j.jvir.2020.02.014
  17. Clark JM, Keller EJ. Reconsidering Requests—Futility in IR. J Vasc Interv Radiol. 2019;30(6):961-962. doi:10.1016/j.jvir.2019.01.025
  18. Keller EJ, Perez AW, Makary MS. Informed Consent: Beating a Dead Horse or an Opportunity for Quality Improvement? J Vasc Interv Radiol. 2020;31(1):139-140. doi:10.1016/j.jvir.2019.08.010
  19. Keller EJ, Rabei R, Heller M, Kothary N. Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis. Cardiovasc Intervent Radiol. 2021;44(1):127-133. doi:10.1007/s00270-020-02675-3

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