Amid the spread of the novel coronavirus and the disease COVID-19 across the country and the world, Ruth Faden, bioethicist, professor and founder of the Johns Hopkins Berman Institute of Bioethics, spoke with the Times in a telephone interview to talk about medical ethics during such a crisis.
Faden splits her time between Washington D.C. and Martha’s Vineyard.
Brian Dowd: Could you explain what a bioethicist is?
Ruth Faden: Sure, it’s pretty straightforward. People in bioethics study and work on ethical challenges in medicine, biomedical science, and public health. Then you need to follow that — what is an ethical issue? It’s an issue about what the morally right thing is to do, or not to do. It’s also about what kind of conduct and way of being in the world is appropriate for people who work in the fields of science, public health and medicine.
BD: We have one hospital here. If you’re in a hospital that can only accommodate so many people, how do you determine who can get treatment? Is it determined by who’s sicker?
RF: It depends on whether a hospital is operating under normal standard of care procedures, or if a hospital is in a situation where the demand for medical services is either expected to exceed the capacity of that hospital to meet that demand, or that excess demand is already happening. Under normal conditions, we rely on the incredibly talented and committed people at our hospital to make judgements about who needs to be hospitalized, who is so ill that they need to be transported to Partners-related facilities, [Massachusetts General Hospital] or otherwise. Now we need to rely on them to make much more difficult decisions. Currently, the hospital is taking steps to prepare for increased demand by, for example, canceling elective surgeries. The hospital is also taking infection control steps to protect both patients and staff by instituting policies like limiting visitors. If things get bad enough, the hospital will move to what is sometimes called crisis standard of care, where the toughest decisions will need to be made and health care staff will need to be working at the upper reaches or even beyond their training.
Allocating scarce resources in a crisis is ethically and humanly wrenching. I helped develop one framework for ICU beds and ventilators; other frameworks exist. These decisions should not and do not turn on one criterion, like who is the sickest. You have to think about who is most likely to survive with ICU care, in what ways pre-existing conditions should be allowed to count, and same with age. The most important thing people should be doing now is everything they can to reduce the likelihood that our hospital will face these awful, life and death decisions by staying home as much as possible. Social distancing is key.
BD: I was listening to the New York Times Daily podcast, and they had been talking about how China is now being praised by [the World Health Organization] for its efforts in containing the virus and lowering the spread. Is it ethical for the government to be allowed to take even draconian measures if it’s for the greater good?
RF: The ethics question is, to a certain extent, restricted to what’s legally possible; what’s legally possible to do in the U.S. even with emergency powers, both federally and in individual states.
When governors, for example, declare states of emergency, they get powers that they don’t otherwise have to do things like close schools, or limit the size of crowds, or of events, or just declare that certain events will not be allowed to be held. The powers that the federal, state, and local governments legally have in the United States are not as broad, even under emergency provisions, as the powers that the Chinese government has, period. So some of what the Chinese government was able to do is not to be legally permissible in this country.
But I’m not the legal expert. Get lawyers, read their stuff all over the internet; a great person to read is Larry Gostin at Georgetown University. Another very good person in Boston, is Wendy Mariner at Boston University. She had a nice article on quarantine in the Boston Globe.
When you do something like closing schools, you’re doing that in order to flatten the curve, and that is the most important concept, I think, for people to get and understand. The idea here is that by extending the period of time over which the disease spreads through a population, you reduce the burden on the healthcare system. You may not reduce the total number of cases overall, but if those cases extend over a longer period of time that scenario we were talking about earlier — that demand for hospital beds could exceed supply — that scenario is less likely to happen if instead of having all the cases bunched up at once, a very steep curve, the curve of infections is flatter.
Right now, the whole end-game is flattening the curve. Trying to figure out how to get the number of infections we’re going to experience in the U.S. to spread out over the longest period of time, so that the hospitals and medical professionals can keep up. And that’s difficult.
So from an ethics point of view, what is ethical for governments to do, within the confines of the law, is to get us to as flat a curve as we can get.
BD: Because we live on an Island, is it ethical or even practical for us to consider cutting off trips to the Island? Because you know we have a lot of seasonal people who live here, they have a second home … Is it okay for those people who do — to come to this rural community, if they are potentially dangerous?
RF: It’s a really great question, and I’ve had to think about that a lot more — I’m one of those people. I split my time between the Washington-Baltimore area , and the Vineyard where I also live. Right now, I’m in D.C., where we already have cases, and you’re asking me, do I have an ethical responsibility to stay away from the Vineyard as an individual?
On the one hand, my dear and wonderful friends are entreating me to come home to the Vineyard, and I struggle with that everyday. In some respects, I think it’s better if everybody stays put. The less movement, the better, and that’s because it’s just unclear, right, kind of what’s happening. And in part, we’re in this incredibly awful state of uncertainty because of the testing disaster, which we haven’t talked about.
So the question you’re asking is whether people have an ethical obligation to try not to facilitate the transmission of viruses. And the answer is yes. We should be careful. And there’s everything from washing your hands, to not leaving your house, that you could do on a spectrum, to try not to contribute to the problem.
This question of whether people who are not full-time residents should come to the Vineyard, depends a lot on what they could or couldn’t know about the chances or likelihood that they might be the person who brings COVID-19 to the Vineyard.
Now, there’s ways to do this. If I’m going to do this, I’ve got to do it in the safest way possible. For me and for others, I wouldn’t fly right now. I wouldn’t fly because of the process; I could both pick up something and also I could transmit. I would drive up, and I would sit in the car on the ferry, and I would sit in my car all the way to my house, and I would stay in my house for two weeks, not because I’ve had any exposures, but just because I’m coming from somewhere else.
BD: So maybe it wouldn’t be ethical to come from New York and go to the grocery store?
RF: Look, I would be careful. I don’t want to say people are acting unethically. What I want to say is it’s really hard in general in life to always act in an ethically pristine way, in ordinary life. It’s really a hard bar to sit there and interrogate every product I buy — does it come from no animal cruelty, does it not involve any child labor, you see where I’m going. It’s tough to live like this and to live an ethically pristine life is impossible.
So did these people do something ethically wrong? You know, they did something that’s not maybe ethically ideal, but it’s hard to fault people, I mean this is their home too and they love it. I wouldn’t be out there in Cronig’s saying “How dare you, this is terrible, you are an immoral person.”
BD: What about the financial hit?
RF: The financial hit is going to be enormous. And this is going to be a real challenge for our Island. If congress doesn’t do something about federally funded sick leave and income replacement, we’re in real trouble. The poverty rate, [the] low-income rate on the Island, you don’t need me to tell you, is not trivial. There are a lot of people who are living without a cushion on Martha’s Vineyard, whether it’s paycheck to paycheck, or it’s close. And you know, fortunately, this is not our season; this is not happening during the season. Right? Yet.
At this point, however, it seems increasingly possible that Memorial Day may be affected; and it’s not clear whether we will be OK by wedding and summer seasons.
Maybe it will all go really well, and things will have become secure enough from a health point of view that the summer season and even the early wedding season, the special events season will not be affected. But we can’t be sure.
As a consequence, now is the time to be thinking about what we can be doing to help each other on that score as well. We haven’t talked about food and medicine and so on. But I think it really is important that people have in their homes two or three weeks’ worth. This is not hoarding, this is being appropriate and responsible. Right now, and hopefully throughout this crisis, the food supply chain seems to be holding up, but anything we can do to help ease demand over time is helpful. Not everyone can afford to buy ahead for two weeks; if those of us who can, do buy, that will leave more later for those who can’t. Also, buying a bit more each trip (when possible) can help reduce the number of trips to the grocery store each of us has to do, which is great for everyone. And there is a related point as well. Obviously for grocery stores to have stuff to sell, groceries have to get there. So that’s a network problem. The ferries are not unique; it’s part of public transport, and goods and services of an essential nature have to move. We’re going to have to make sure that we really respect and honor the people who are going to continue to do that work even if the rest of us are told to stay home.
Then there’s the importance of recognizing that our doctors and our nurses, and the six health departments on the Island, the leaders of our schools, and public transport, are now under extreme pressure. They’re having to make decisions constantly and do a lot of preparedness planning and we should cut them some slack, give them support, give them some love. Because it’s not easy. It’s not easy to be in positions of civic responsibility right now. These are going to be tough calls, there’s a lot of tough planning that’s going to have to happen; I’m sure people are working many longer hours than they normally would in certain positions on the Vineyard.
BD: At the grocery store last night, I was in line and all the TP was gone, hand sanitizer, alcohol. Stores have been trying to restock; after all the announcements, people got anxious. I was in line, talking to the cashier, she was very flustered, and the guy behind me offered to buy her a soda.
RF: That’s exactly what we need. We need an epidemic of kindness. I can’t remember where I heard that phrase, but it’s exactly right. If you think about the ethics of everyday life, now’s the time to do things exactly like that. If there are elderly, anyone over 60, older Americans, it’s about kindness. For anyone with a serious illness, to say to them, I’m going to do your grocery shopping for you, you don’t need to go, you don’t need to be in a crowded grocery or Cronig’s. Not a good place for you to be, even though we don’t have a single presumptive case yet, you never know. You know what, stay in the house, tell me what you need, I’m going to get it for you, I’m going to bring it to you, and then we’ll visit from a safe distance in your backyard. It’ll be fun.
Most of us tend to have, if you have kids or younger relatives on Island, someone who will just naturally think to do that. Great. But there are a lot of people who don’t, or whose friends are all also over 60. It’s important to be thinking that little acts like this are going to go a huge way. I love that story.
Was the cashier wearing gloves?
BD: She was.