COVID Ethics: Should clinicians see patients without appropriate PPE?

Should a clinician see a patient with COVID symptoms if the appropriate PPE is not available?

People are already breaking standard protocol and reusing PPE designed for single patient encounters. What should we do if there is no PPE available at all? I sincerely hope that this question never becomes relevant, but with reports of an Italian doctor dying after being forced to work without gloves, it must be asked. I raise this difficult question not because I think I have an answer, but because I hope to start a (civil) discussion about ethics. I will start by offering a rather simplistic answer, but simple answers often fail in ethics. There are usually unseen layers of complexity, which I hope you might help me unpack. However, at first glance, I think the answer is clear: clinicians should not see patients without appropriate PPE.

My instinct is to treat sick patients. I have to admit, over the past 10 years I have rushed into many resuscitations without appropriate PPE. While I am focused on the airway, it is often a nurse who slips goggles over my eyes. I am starting to improve, but there is an instinct in medicine that always places the needs of a dying patient ahead of our own. Thus, even in the era of COVID, I think it would be very hard for me not to rush into the room to aid a dying patient.

However, if we take a moment to step back from the emotions of the situation, it will quickly become clear that seeing a patient without appropriate PPE results in tremendous harm in a pandemic situation. Without PPE, I am very likely to spread the infection to other patients, staff members, family, and friends. I am likely to make the pandemic worse. Furthermore, after treating a patient without PPE, I am very likely to become ill myself, and I will be unable to work. If everyone followed my actions, the emergency department would rapidly run out of staff, and our patients would suffer. Our efforts to save a single patient would end up harming thousands.

Although we don’t discuss it often in the hospital, the concept of scene safety is a core of paramedic training. You shouldn’t approach a patient until the scene is safe. The rescuer is no good to the patient if he or she also becomes injured. The last thing we want is more casualties. This is the very first thing paramedics consider when arriving on scene. (Surprisingly, I was unable to find any papers discussing the ethics of this principle. If you have something, send it my way.)

The calculus might be different in normal times. When there is only a single patient that needs treatment, it might be reasonable to take a personal risk in caring for that patient. In usual times, my colleagues would be able to cover for me when I become sick. Of course, in usual times, we would never have to make this decision, because PPE is available, but I think the decision might be different, because in usual times I would anticipate the healthcare system to survive. (I am not sure exactly how much personal risk we should expect emergency providers to assume, but there is clearly some risk inherent in this work.)

However, during a pandemic, when no PPE is available, I know my colleagues will face the same decision with their next patient. It is no longer a matter of me assuming a personal risk. We are risking the entire workforce. The consequences of the loss of an entire healthcare system are clearly catastrophic. Thus, at least during an epidemic or pandemic, I think it is pretty clear that clinicians should not see patients if appropriate PPE is not available.

I will admit, counterexamples to this position are not hard to come by. Imagine I show up to work, and my first patient is Dr. Anand Swaminathan. He is severely hypoxic. If I do nothing, he will probably die. However, if I intervene, he is young and healthy, and he will probably survive. If he survives, he will rejoin the workforce in a month or two, and will ultimately save many lives (not to mention the many thousands of lives he will save through his incredible medical education.) Not intervening puts those lives at risk. However, if I enter the room without PPE, I will almost certainly become infected. Instead of the system being down 1 emergency doctor, we will be down 2. But I am also relatively young and healthy, so hopefully I would also survive. We would have to weather a short term storm, but in the longer run, we would all be better off if I decided to risk my life to save Swami.

Of course, this math doesn’t just apply to Swami. Nurses, RTs, and other emergency staff are essential to running a department. I am useless without my team. And what if the patient was essential in the production of PPE or ventilators? What if the patient was a single mom with multiple dependants? I have shown this post to a handful of people, and each has come up with unique scenarios which expand the grey area tremendously.

There are many ways to formulate the scenario so that intervening seems appropriate, but does that make it the right thing to do? At this point, my limited philosophical reading brought me back to Kant. One formulation of Kant’s categorical imperative is the universalizability principle: “Act only according to that maxim which you can at the same time will that it should become a universal law without contradiction.” In other words, for an action to be moral, we have to to be happy with the consequences if everyone universally undertook that action. (For anyone who takes philosophy seriously, I am sorry if I butchered that).

So, my actions should be universal. If I run into the room to save Swami, I should expect all ED staff to act the same way. And when all of us return sick in a few days time, I should expect the staff working that day to also care for us without PPE.  Very quickly, in exponential fashion, the entire medical workforce is sick, and no one can receive care. Everyone gets sick and many people die. Therefore, treatment without PPE cannot be considered the morally correct action according to my crude Kantian assessment, nor does it appear to be the pragmatically correct action. 

Utilitarian ethics are often seen as the antithesis of Kantian. The general maxim is “the greatest good for the greatest number”. Without exploring it too deeply, I think it is also clear that depeteling the medical workforce by seeing 1 patient without PPE will clearly not result in the greatest good for the greatest number (although this assessment is much more likely to allow exceptions, like trading my life for Swami’s.)

My rather simplistic reasoning leads me to the conclusion that healthcare workers should not see COVID patients if appropriate PPE is not available. Of course, nothing is truly black and white. I have not fully explored the pragmatic and ethical consequences of not seeing the patient. Will the patient become even higher risk if they become angry or agitated? What happens when patients lose trust in healthcare providers because we are unable to help? Furthermore, there are options other than just not seeing the patient. If I can manage a patient without putting myself at risk, I should clearly do so. With the patient in the room, I can assess them by phone. I could advise them how to turn on the oxygen and apply their own mask. I may be able to temporize until PPE becomes available. But intervening in the usual fashion puts me, my patients, and the healthcare system at risk.

Interestingly, despite a relatively lengthy search, I couldn’t find a single paper that covered this topic. A few organizations have position statements (see below), but they don’t tend to explain their positions. Although I sincerely hope that no one reading this post has to face this problem in the real world, I think it is worth discussing here. Please leave our thoughts below. 

An aside: Altering PPE standards

The complete absence of PPE is probably too simplistic a scenario to consider. The broader question, which is informed by the same framework, is what should be done in response to the deterioration of our standard PPE protocols. Our protocols are designed to keep staff and patients safe. Changes to those protocols should not be undertaken lightly.

In general, PPE in the hospital is designed to be single use. Reusing PPE increases the chance of spreading infection from patient to patient, and also increases the risk to the provider. In the ideal scenario, we would not alter our standard protocols. 

Unfortunately, a pandemic is not a usual scenario. Disposing of PPE after every use may simply be impossible. Unlike the relatively simplistic scenario above, where I am required to see a patient without any PPE, ensuring increased exposure to myself and anyone I subsequently contact, reusing PPE probably only increases the chance of exposure by a small amount. That small risk may be justified, depending on the circumstances of the patient.

Of course, even a small increase in risk may not be justified if the exposure is not going to help the patient. Not every patient requires a physical exam. If the vital signs are already done and normal, I can probably take a history remotely (using a phone, for example), and safely disposition many patients without ever entering the room. Here, I would think that even the small risk of reused PPE is not acceptable. On the other hand, if a patient requires intubation, the small risk of reusing PPE is clearly justified by the much larger benefits for the patient.

I will ignore the incredibly important practical issue of ensuring that you have a way to clean PPE that doesn’t spread infection around the department or significantly degrade the equipment. Although I am ignoring it, this is not something that should be undertaken lightly. The department needs a strict protocol to ensure something that sounds fine in theory doesn’t become a disaster in practice.

Ultimately, there is a lot of grey area here without clear answers. I am hoping to gain from the perspectives of people smarter than me. Leave any comments below.

Conclusion

These musings must be taken in context: I am not an ethicist; I am not a lawyer. I have no special training in this area. I am really hoping to generate conversation that guides the ultimate answer. Please share the post widely and share any comments below. Unfortunately, I don’t think this is really a hypothetical situation. Although I phrased the question as an “if”, I think the question we really need to be tackling is: what should we do when appropriate PPE is not available.

Official organizational stances

• The American Medical Association: “Whether physicians can ethically decline to provide care if PPE is not available depends on several considerations, particularly the anticipated level of risk. In some instances, circumstances unique to the individual physician, or other health care professional, may justify such a refusal—for example, when a physician has underlying health conditions that put them at extremely high risk for a poor outcome should they become infected.” (Ie, vague legalese that doesn’t actually help us when trying to make a decision in the moment.)
• The Candian Medical Protective Association: “Physicians may be permitted in exceptional circumstances to refuse to practice if they reasonably believe that the work environment creates a legitimate unacceptable hazard that is not inherent to their ordinary work. A refusal to work due to inadequate protective gear, could put a physician at risk of a College or hospital complaint, the success of which will depend upon the context of the situation. The CMPA is aware that the Colleges are taking into account the current COVID-19 situation and would assess any College complaint in that context. Hospitals and clinics also generally have an obligation to provide a safe work environment for their staff pursuant to occupational health and safety legislation.” (Again, some not so helpful legalese.)
• The Ontario Medical Association (in an email to members): “If you have run out of PPE, and legitimately can no longer safely practice, you are not legally required to risk your life. Society needs health-care workers to try to protect themselves to ensure a healthy work force.”
• The National Academy of Medicine does not address this issue specifically, but provides some pragmatic advice about rationing PPE and altering standard PPE practices.
• The College of Nurses of Ontario: “You should only conduct clinical assessments and collect specimens from at-risk patients in compliance with PPE guidelines and the latest guidance from Public Health or the Ministry of Health.”

If you happen to be in the position to help with the PPE shortage, know that all hospitals are accepting monetary and PPE donations. Hopefully with the help of our communities, we can ensure that this ethical conundrum never comes to pass. Look up your local hospital for details.

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If you want more practice details on how to deal with COVID-19, check out the COVID-19 resources page.

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Other FOAMed

I don’t really have other FOAMed, but if you want a fun refresher on some of the basics of philosophy, the Crash Course series is pretty good.

Kant and Categorical Imperatives on Crash Course Philosophy:

Utilitarianism on Crash Course Philosophy: