COVID-19 and ethics in the ICU
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EDITORIAL
Open Access
COVID-19 and ethics in the ICU Sarah E. Nelson The COVID-19 pandemic has brought into focus many medical ethics questions; several have burdened intensive care unit physicians in particular (Fig. 1). The aim of this article is to provide a frank yet thoughtful discussion of the many facets of these ethical dilemmas. We intensivists potentially put ourselves at risk each time we report to work. This is scary and unsettling. Hundreds of years ago, physicians had no professional or ethical obligation to take care of sick patients during disease outbreaks, some purposely fleeing from plagueridden areas [1]. However, times have changed. Most medical students now recite the Hippocratic Oath, which states that: “I will apply, for the benefit of the sick, all measures [that] are required,” though nowhere does it state that physicians must work in settings that could put their own health at risk [2]. Following the events of September 11, 2001, the American Medical Association (AMA) reaffirmed their stance that “it is a responsibility of health professionals to continue caring for patients even if doing so presents some danger to them” [1]. This includes an “obligation to provide urgent medical care during disasters … even in the face of greater than usual risks to physicians’ own safety, health, or life.” Given the large scope of the pandemic and the deadliness of SARS-CoV-2, these statements may not adequately address this ethical quandary. For instance, it is not entirely clear how much of a hazard is actually acceptable. And risk to healthcare workers is real: > 3300 were infected in China as of early March 2020 as were 20% of healthcare workers in Italy [3]; hundreds of these workers around the world have died since the pandemic began [4]. Healthcare providers may feel they did not sign up for their jobs knowing that they may need to sacrifice themselves for others [5]. In addition, hospitals have periodically suffered from shortages of personal Correspondence: [email protected] Departments of Neurology and Anesthesiology & Critical Care Medicine, Johns Hopkins University, 600 N Wolfe Street, Phipps 455, Baltimore, MD 21287, USA
protective equipment (PPE). Is it ethical to ask intensivists and other healthcare providers to counter this contagious threat with inadequate battle gear? One of the most upsetting issues of the pandemic is the limited number of critical care resources, including ventilators and intensive care unit beds, available to COVID-19 patients and other critically ill patients. In countries such as Italy, healthcare providers have had to make difficult decisions about who is provided a ventilator and who is not and thus forced to dictate life and death [6], and other countries have prepared to face similar difficult decisions. In what almost seems a foreshadowing, distribution of limited resources was explored recently by a Johns Hopkins intensivist and her team. Participants in the study felt that, in times of crisis, shortand long-term outcomes should be primarily considere
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