Answering the tough questions

Who should receive respirators if there is a shortage? Should we save lives or the economy? Who should receive a newly developed vaccine first?

During a pandemic, ethical debates sparked by questions such as these often have life or death consequences. For answers, government agencies and hospitals turn to experts, including several at Carolina.

Jim Thomas, associate professor of epidemiology in the Gillings School of Global Public Health, was a member of the team asked to develop ethical guidelines during an expected influenza outbreak in the early 2000s that never materialized. When the COVID-19 pandemic swept the globe, Thomas knew policymakers would be looking for help again. He quickly created a pandemic ethics dashboard of answers to difficult ethical questions, determined by academic or international consensus.

Since March, there has been an explosion in material related to pandemic ethics, says Douglas MacKay, associate professor of public policy and core faculty member in the UNC Center for Bioethics. MacKay and his colleagues at the Center curated a collection of academic publications and research on how to address moral questions during the pandemic over the summer.

Arlene Davis, associate professor of social medicine and co-chair of the UNC Hospital Ethics Committee, and committee vice chair Benny Joyner, associate professor of pediatric critical care medicine, have been asked to address several issues surrounding allocation of critical resources and are currently examining the ethical balance of allowing visitors for critically ill patients with protecting everyone else in the hospital from COVID-19 exposure. They both cite the pandemic as presenting ethical challenges they never expected to face, even as committee members.

Through the use of the pandemic ethics dashboard, academic consensus and empathetic reasoning, these Carolina experts are helping solve the ethical quandaries caused by the pandemic. As members of the UNC Hospital Ethics Committee, Davis and Joyner regularly guide hospital staff, patients and families through difficult ethical decisions, and Davis teaches on ethics in the UNC Center for Bioethics and the department of social medicine. MacKay researches priority-setting in health care through the UNC Center for Bioethics, and Thomas researches the ethical practice of public health in pandemics through the department of epidemiology. The Well asked them for answers to six difficult questions.

1. Does it infringe on civil liberties for the government to mandate mask wearing or social distancing?

Despite the vocal protests of anti-maskers who claim that being forced to wear a mask to buy groceries infringes on their rights, MacKay said he believes the government and private businesses requiring masks or social distancing is ethically sound.

Douglas MacKay

“In a pandemic, the ordinary individual actions that pose no risk to anybody else suddenly are a risk to others’ lives,” said MacKay. “In a pandemic, I believe it’s justifiable for governments to begin to restrict people’s activity.”

The COVID-19 pandemic has been repeatedly cited as “extraordinary times,” and that characterization is what supports the controversial, yet logical requirement of wearing a face covering in public. Although MacKay does describe face covering requirements as encroaching on personal freedom, he points out that facial coverings cause no harm to the wearer, but the public could face serious harm if people don’t wear masks.

“The justification for the mask mandate is that, yes, it’s a way of infringing people’s liberty,” said MacKay. “But it not only ensures you aren’t hurting anybody else; it doesn’t harm you either.”

2. How should hospitals allocate scarce resources?

According to Thomas’ pandemic ethics dashboard, the guiding principle of resource allocation is “just distribution.” For any patients suffering from COVID-19 and complications from other diseases and conditions, the patients’ family and doctor should consider terminating treatment so that other patients can have access to scarce resources. But policymakers should ensure that any criteria for allocating resources does not discriminate against individuals based on gender, race, religion, political affiliation, nationality, or social or economic status.

When considering how treatments, personal protective equipment or a future vaccine are distributed, the preservation of the health care system and frontline workers should be prioritized, Thomas said. This will prevent a shortage of caregivers as the pandemic spreads and the need for health care workers increases.

And when and if there is a resource shortage, such as limited ventilators, health systems should document and publicize that limitation so potential patients can make an informed decision before beginning treatment.

3. Should families be allowed to visit sick loved ones in the hospital during the pandemic?

Davis and Joyner say one of the most difficult decisions the UNC Hospital Ethics Committee makes during this pandemic is whether a patient’s family should be allowed to visit. When helping families make difficult choices on behalf of their loved ones, the committee has met with them over the phone, Zoom or Skype, which Davis says often lacks the usual empathy of a human conversation and opportunity to read reactions to what they’re telling the family.

Arlene Davis

“We’ve been considering what it really means to limit visitors, because visits from family members under normal circumstances are helpful for making tough decisions and supporting the patients,” said Davis.

Joyner, the chief of pediatric critical care medicine, says limiting visitors is especially difficult for pediatric patients.

“Having an 8-year-old in the hospital is scary, but it’s even scarier for both the patient and parent if visits are limited or not allowed at all,” said Joyner.

Benny Joyner

Still, Davis and Joyner are finding the balance between keeping their patients safe from COVID-19 exposure, while also recognizing the importance of maintaining the patients’ mental health, which sometimes means allowing a socially distanced visit from a family member because communication with family members is often vital for decision-making with the health care team.

4. Do health care workers have an obligation to care for COVID-19 patients?

All doctors and nurses take an oath to always preserve life, but Thomas believes there are competing risks during a pandemic.

“Each health care worker needs to weigh all the obligations that they have, both personally and to the field they work in,” said Thomas. “People who have been trained to serve society as health care workers have an obligation to show up when they are needed, but if they have small children, sick parents or an ill spouse, their priorities may lie there.”

Essentially, health care workers have an obligation to care for COVID-19 patients, he said, but not if they have a greater responsibility to preserve the life of their loved ones. Many frontline health care workers have quarantined from their families to avoid infecting them, and some nurses are purposefully traveling to COVID-19 hotspots to supplement hospital staff.

Jim Thomas

Thomas also emphasizes that employers are responsible for any risk they ask their employees to take in the normal function of their jobs.

“Employers have an obligation to minimize any risk to health care workers and to compensate them for any increased risk, whether that be more insurance benefits in case they become ill or hazard pay,” says Thomas.

5. Should researchers conduct human challenge trials of a COVID-19 vaccine?

According to the World Health Organization, a human challenge trial is, “a trial in which participants are intentionally challenged (whether or not they have been vaccinated) with an infectious disease organism.” In the context of COVID-19, participants would receive the trial vaccine and then be purposefully exposed to COVID-19. The risk is greater in challenge trials because the exposure is purposeful, and there is no proven treatment for COVID-19 if the vaccine failed.

“The researchers would provide care to people who are members of these studies, but there’s just the risk that someone could, in the context of these studies, get very sick or possibly pass away,” said MacKay. “So, as we get closer to developing a vaccine, we have to decide if we would allow our fellow community members to take that great risk for society.”

The organizers behind the “1 Day Sooner” movement are not only willing to take the risk but are actively campaigning to participate in a COVID-19 human challenge trial. Mostly comprised of young, healthy volunteers who believe they would recover from COVID-19 if they became ill during a trial, they believe if human challenge trials help develop a vaccine even one day sooner, it’s worth the risk.

Thomas says that as of now, human challenge trials are so controversial that no consensus exists in the medical and ethical community on their use in developing a COVID-19 vaccine.

6. When a COVID-19 vaccine is developed, who should be vaccinated first?

“We need to ensure that health care workers are vaccinated first so we have a group of people who can administer the vaccine to everyone else,” said Thomas. “Then we need to vaccinate our vulnerable populations who are at a higher risk of serious complications, and then our essential workers because we’re putting them in harm’s way.”

To Thomas’ point, the World Health Organization also recommends that health care workers receive any future vaccine first to ensure that there is a population that is immune and can safely vaccinate the rest of their community. This also ensures that hospitals, doctors’ offices and care facilities continue to function through the pandemic and that there is not a shortage of health care workers to care for those who contract COVID-19 as it spreads.