Posted on August 10, 2020 at 2:32 PM
by Nolan M. Kavanagh, M.P.H., Rishi R. Goel, M.Sc.
The COVID-19 pandemic has sidelined many medical students from the “frontlines.” Our classes are now online, clinical responsibilities were delayed, and testing schedules for board examinations have been thrown into uncertainty. Many institutions have prohibited students at various levels from any clinical contact, even in a volunteer capacity. Although these measures protect students and patients, the pandemic has made us feel helpless. We see a world on fire and feel the urge to save it. This same instinct brought many of us into medicine.
In response, many students have rolled up their sleeves and gotten to work in their communities. They have gathered personal protective equipment (PPE) for hospitals, developed educational resources, participated in contact tracing, collected devices to connect isolated patients with loved ones, and more. We have also supported research on COVID-19 and advocated for policies and structural changes that would promote social justice. For many medical students, this experience is our first exposure to public health policymaking. After all, many relief efforts, such as PPE drives, were designed to supplement a lagging government response. We have grappled with decisions about where to send supplies or how to spend donations.
Even so, not all COVID-19 relief efforts are equally helpful. While many have been effective and innovative, some may have suboptimal or negative impacts on their communities.
A DUTY TO ACT
The professional duties of health care providers compel us to engage in relief efforts for COVID-19. Physicians take an oath to serve their patients, and the American Medical Association’s Code of Medical Ethics calls them to act even in times of disaster and crisis. As medical students, we bind ourselves to these professional duties when we accept our white coats. When we cannot participate in clinical care, we are still called to promote the well-being of our communities in other ways. The AMA Code states that “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health,” a commitment that extends beyond medical care to health promotion broadly. This duty does not cease when we are confined to our homes, as many of us have been during COVID-19. Despite these constraints, many students have valiantly risen to the challenge.
ETHICAL PRINCIPLES TO GUIDE RELIEF EFFORTS
We propose that relief efforts for COVID-19 be assessed by three ethical principles: procedural justice, maximization of benefit, and distributive justice. Consideration of these principles can help us serve our communities most effectively. Our framework draws on the principles of biomedical ethics and Bernheim’s framework for evaluating public health policy.
Procedural Justice. We should solicit needs from community members and involve community leaders in our efforts as much as possible. An open-minded, thorough needs assessment can help prevent our efforts from being out-of-touch or redundant with ongoing activities. Moreover, involving community members helps maximize buy-in as well as fairness in the process, whereby we promote their autonomy to decide what is best for themselves.
Maximization of Benefit. We should map our strengths onto identified needs and engage in efforts that maximize our (limited) time and resources. All relief efforts should be necessary and effective. Providing our community with something it does not need is a waste of resources. Similarly, it is inefficient to engage in one activity when our skills could make a greater impact in another. Relatedly, while many medical students are eager to advance professionally, we should check in often with our motivations. The drive to strengthen our resumes can distort the choices we make in ways that are suboptimal for our communities.
Distributive Justice. Since medical students do not have the resources to support all community members, we should focus on serving those in greatest need. The economic and emotional burdens of COVID-19 have not been evenly distributed. Our impact should be equitable, and we should strive that our efforts do not (further) concentrate wealth and privilege.
EXAMPLES WITH PRACTICAL CONSIDERATIONS
Let us explore these ethical principles using two examples: access to reliable information and economic hardship within communities.
During a pandemic, the public must have access to reliable, understandable information to protect itself. Many medical students have responded by producing online educational resources. But is this the most appropriate and effective response? Here are some questions we might consider: With respect to procedural justice, does our resource fulfill a need not already met by governments, public health agencies, hospital systems, and newspapers? And if communities have a need, do they trust medical students as a credible source? If not, can we partner with community leaders and organizations to help design and distribute the message? With respect to maximization of benefit, do we have the expertise to scrutinize the rapidly expanding literature in infectious disease, immunology, epidemiology, and economics? If not, can we seek active collaborators to compile information that is accurate and applicable? Can we commit to reliably updating the resource as new information becomes available? And how can we design the resource to complement other credible sources, amplifying them rather than crowding them out? Lastly, with respect to distributive justice, how can we ensure that the resource is accessible to community members who need it most, such as those with less formal education?
Many of our communities are also struggling with economic hardship, such as unemployment, food insecurity, and lack of childcare. With respect to procedural justice, we should ask community members what burdens them most, then work with them to design a response. If, for example, we collaboratively decide that fundraising maximizes our impact, we should both leverage our own access to resources and invite community leaders to broadcast our call. However, we should be mindful not to burden struggling community members with our call. And when choosing which organizations or relief efforts to fund, we should consider the equity of our impact. For example, low-income workers and less funded institutions in our communities may need our support more than well-resourced academic medical centers. There have been similar debates about the distribution of government relief funding, and we believe that the same principles should apply to grassroots organizing by students.
Medical students across the country have organized relief efforts for COVID-19. We applaud the compassion, commitment, and creativity of our classmates. However, we can elevate our impact by reflecting on three core ethical principles: procedural justice, maximization of benefit, and distributive justice. In doing so, we can use our platform to amplify good signals, rather than add unhelpful noise. Medical schools can also take an active role in supporting projects that promote these goals. More broadly, these principles may be applied to any health promotion activities of (future) clinicians; we might allow them to guide our priorities throughout our careers.