As the world responds to the novel coronavirus public health crisis, the entire medical community across the Commonwealth, composed of numerous hospitals and countless providers, is working hard to develop and refine plans to support our patients, providers, and staff for the evolving and possibly unprecedented situations related to COVID-19. Many of our plans are well grounded in years of thoughtful ethical work and real-world experiences, like the Sept. 11 and Boston Marathon attacks, previous flu epidemics, as well as disaster preparedness drills. Recent lessons from China and Italy suggest that the public needs to be fully aware, as hard as this may be to hear, that typical medical options may soon not be available to everyone.
It was immediately clear weeks ago that we needed to do everything possible to prevent, or at least delay as long as possible, situations where the needs of our patients exceed our available resources, including hospital and ICU beds; ventilators and other equipment; and above all, staffing.
We have been coordinating with public health officials to support steps to minimize the spread of the coronavirus, while also working diligently and with great urgency to optimize use of the resources we have, and to secure even more. This has included canceling elective surgeries, transitioning to telehealth visits whenever possible, keeping care providers safe by limiting in-person meetings, and restricting visitors in order to protect our most vulnerable patients. It’s essential that the public heed all advice to practice physical distancing.
If we slow this pandemic down and flatten the curve, the medical community may have a fighting chance to meet everyone’s health care needs.
How the curve of the #coronavirus outbreak could be flattened. Important read from @HelenBranswell https://t.co/qF35LxplRR pic.twitter.com/yh0pEI1UEJ— Rick Berke (@rickberke) March 11, 2020
While you may or may not be at the highest risk for severe illness, the virus can cause critical illness and even death in all age groups. Moreover, you could easily pass the virus along to people who are more vulnerable. Given just how contagious the coronavirus is, it is essential that all of us do everything we can to avoid infecting others.
Should efforts to maximize our current medical resources fall short, we are making preparations for what may become an overwhelming demand for health care services in the coming days, especially critical care. While we will strive daily to identify strategies that are proportional to the challenges we face, we may be forced to transition to “Crisis Standards of Care.” In accordance with these standards, developed over many years of national and global planning for possible pandemic crises, health care systems must shift their focus from optimizing care for each individual patient to a population-wide approach. It’s the only way we can ensure that we ethically fulfill our responsibilities to all patients.
In taking this action, our commitment to principles of beneficence, justice, and respect requires us to practice evidence-based, equitable, fair, and transparent procedures to ensure that we achieve the maximal overall benefits for our entire community. Such situations might include, being unable to offer, or continue, ICU treatment and/or ventilator support for patients who, based on the most objective and evidence-based criteria available, have a prognosis too poor to justify using those limited resources in ways that deprive care to other patients for whom there is greater likelihood of benefit.
If we face those tragic situations, policies and procedures that are in effect will ensure that, no matter what choices need to be made, we will continue to provide the best possible care to every patient with compassion and respect, even if some forms of medical intervention cannot be offered.
As medical professionals dedicated to the best possible care and outcomes for all patients, making these decisions will be wrenching for everyone involved. None of us want to be in the position of choosing who will live and who will die because our capacity to treat is overwhelmed by the number of people in need of treatment. It’s why we beseech the public to do everything possible to help avoid such an outcome: Stay at home.
If Massachusetts follows a transmission rate similar to areas like Northern Italy, where medical personnel are forced to triage patients, we will strive to earn and deserve the confidence and trust of everyone involved or affected — our patients, their families, our staff, and the public. We seek input from all affected as we work to be as transparent and ethical as possible, most especially in these challenging and uncertain times.
Signatories are affiliates of the Harvard Medical School Center for Bioethics and its affiliates and have signed as individuals, not as representatives of their respective institutions.
Dr. George Q. Daley is dean of faculty of Medicine at Harvard Medical School. Robert D. Truog is director of the Center for Bioethics and practices pediatric intensive care at Boston Children’s Hospital. Dr. Scot Bateman is division chief of Pediatric Critical Care at UMass Memorial Medical Center. Dr. Rebecca Brendel is associate director of the Center for Bioethics. Dr. Charles Cook is chief of Acute Care Surgery, Trauma, and Surgical Critical Care at Beth Israel Deaconess Medical Center. Dr. B. Lachlan Forrow practices at Beth Israel Deaconess Medical Center. Dr. Margaret Hayes practices at Beth Israel Deaconess Medical Center. Dr. Kaarkuzhali Babu Krishnamurthy practices at St. Elizabeth’s Medical Center and Steward Medical Group. Aimee Milliken is a nurse scientist and clinical ethicist. Christine Mitchell is executive director of the Center for Bioethics. Dr. Elizabeth Nilson practices at Lahey Hospital and Medical Center. Dr. Kristin Ellen Raven practices at Beth Israel Deaconess Medical Center. Dr. James Russell practices at Lahey Hospital and Medical Center. Dr. Nicholas Sadovnikoffis practices at Brigham & Women’s Hospital. Dr. Todd Sarge practices at Beth Israel Deaconess Medical Center. David Sontag is co-chair of the Ethics Advisory Committee of Beth Israel Deaconess Medical Center. Dr. David Urion practices at Boston Children’s Hospital. Dr. Sally Ann Huntoon Vitali practices at Boston Children’s Hospital.