Posted on April 27, 2020 at 6:06 PM
by Annie Janvier, MD, PhD and John D. Lantos MD
The COVID-19 crisis has been compared to war. Providers are being drafted. Around the globe, retired clinicians are volunteering. Decisions about who should serve require complex moral choices. Older males are at highest risk. When high-risk providers get seriously ill, they too need hospital beds and/or ventilators.
Some high-risk providers insist that the only virtuous thing to do is to serve on the “COVID-front”; that is a misreading of what virtue requires. People are selected to be soldiers based on well-defined criteria. Those who are likely to be a liability are not chosen for active duty. In contrast, the COVID-19 drafting does not seem to be done in a rigorous fashion. We propose a scoring system to classify COVID-19 related activities using three criteria: the complexity of the intervention (competence of professional and risk to patient), the risk to professionals and the frequency of the intervention.
Jason is 68 years old. He is a retired family doctor who lives in Vermont. He worked in the emergency room, made home visits to complex patients and was responsible for organizing the home visit schedule for his hospital system. Mostly because of his work, he had neglected his lifestyle, became obese and started having angina at 64, which was a wake-up call. He decided to retire at 65 to take care of himself and his grandchildren who live close by. When the COVID-19 epidemic started, Jason felt lucky he was in his little farm, isolated from big cities. He became obsessed with the news. His emotions quickly changed as the pandemic grew. He started feeling powerless, useless and guilty. What was he doing, taking care of his hens, hiding with his wife, when his skills could be precious? He felt there was still something left in him. His family was asking his opinion. He was still a doctor at heart. When government officials started calling on healthcare workers to join the front, Jason felt obligated to join thousands of other clinicians who had answered the call. He did not have a choice. He could not continue to hide. He had no reason to. His children were older, his farm was paid. He was not a coward; he was brave and he could help. He left for New York city the next day.
Clinicians are being asked to volunteer during the COVID-19 pandemic. The New York Mayor called for a physician draft. Clinicians are bravely meeting their professional obligations to care but some, particularly those over 60 and those with other health risks, are at higher risk of getting seriously ill. Around the globe, retired clinicians are volunteering to help.
Decisions about who should serve in what roles require important and complex moral choices. We know that older males are at highest risk from COVID-19. If high-risk providers get seriously ill, they too need hospital beds and ventilators, which will increase the burdens on health care systems already stretched to the limit. The noble desire to serve might well be counterproductive.
The COVID-19 crisis has been compared to war. But it is an odd war. For most people, the virtuous thing to do is to sit at home and avoid contact with other people. That feels like doing nothing but requires determination and a strong sense of social solidarity. Clinicians, by contrast, put themselves at risk caring for others. They are the front-line soldiers in this battle; not all are equally good combatants.
People are selected to be soldiers based on well-defined criteria. Those who are likely to be a liability on the battlefield because they are old or sick or unfit are not chosen for active duty. In contrast, the COVID-19 drafting does not seem to be done in a rigorous nor uniform fashion. It is not clear who decides the rules. Clinicians are almost always asked to volunteer, irrespective of risk to them. For example, in Canada, a College of Physician is guided by the “principle of the most competent in the circumstances” to decide who should be deployed, only mentioning risk to patients as a relevant factor. Jason is compelled to help, he is competent, but he can also become a patient.
We suggest that a selection process should take place and be applied by professional societies, in a uniform fashion. Doctors should be assigned tasks based on their skills, their risk profiles, and self-assessment of any competing family duties which may compromise their work capacity, or place additional vulnerable community members at risk. We need doctors on the front lines. We also need doctors performing other crucial functions. There are ways to honor Jason’s admirable desire to serve while at the same time preventing an increased burden on the health care system. In our opinion, whenever possible, providers with low risk factors should be assigned to direct clinical duties. Providers with clearly higher risk factors should not work on the front line, even if they want to, unless there are no other clinicians available to serve.
Some high-risk providers insist that the only virtuous thing to do is to serve alongside their colleagues. But in this pandemic, that is a misreading of what virtue requires. It is also virtuous to act in a way that provides valuable services and that also decreases the burdens that fall on colleagues and society.
We propose a scoring system to classify the risk and the complexity of COVID-19 related activities. The first criterion would be the complexity of the intervention and thus which professionals are competent. The second criterion would be the risk associated with each intervention. The third would be how often the intervention occurs (Table). In our interdisciplinary healthcare system, there are many crucial roles for people with different skill sets. For example, medical students can serve in low complexity areas, such as staffing drive-through clinics or screening ER patients. There are other important tasks that does not place high-risk physicians at risk, such as the design and implementation of clinical trials, the development of diagnostic and treatment algorithms or advising community leaders who must make public health decisions. Jason has administrative knowledge and could also help organize and supervise a interdisciplinary screening clinic or virtual home visits. A 68-year-old physician such as Jason should not intubate a COVID positive patient when other clinicians can do so with less risk.
Given clinicians high levels of altruism, we suspect that many will insist on working on the front lines. The responsibility to deploy them where they may be safer while doing the most good should fall on administrators. Administrators in health care leadership positions are the officers in this war. They have the obligation to use their troops in the most effective manner maximizing benefit to society.
Accepting this change in thinking may challenge traditional gender roles. Older clinicians are more likely to be male physicians. They may feel the need to show their courage and commitment. It will be difficult for some clinicians to be denied the chance to live up to their own ideals of virtue. During the great wars, men were at the front while women played an essential role working in factories. Both were essential to the overall effort. From a public health and an ethical perspective, it is irresponsible to let those at higher risk sacrifice themselves when there are safer and equally important alternative activities through which these professionals contribute.
In Pat Barker’s WWI novel Regeneration, a psychiatrist who is caring for patients writes, “Taking unnecessary risks is one of the first signs of a war neurosis. Nightmares and hallucinations come later.” The same may be true in today’s horrific battle against COVID-19. The desire to take unnecessary risks may be both virtuous and pathological. There are enough necessary risks. We must avoid unnecessary ones. The fight against COVID-19 will be a long, tough slog that will require many sorts of expertise and many forms of heroism.
|Screening in drive-through clinics||1||1||4|
|Screening in ERs||2||3||4|
|Intubation of positive patient||3||4||1|
|Suctioning of positive patient||2||4||2|
|Tele-medicine for patients with COVID-19||3||0||2-3|
|Making policy for hospitals and systems||4||0||1|