Most people have heard of the “trolley problem”– a thought experiment commonly discussed in ethics. In this fictional scenario, a trolley track splits into two paths. In the direction it is headed, the trolley would fatally hit five people; in the other direction, it would only hit one. It presents a few questions– is it morally permissible to redirect the trolley to take one in place of five lives? How can you determine who is allowed to live or die? Although this is just a hypothetical thought experiment, it’s a concept healthcare workers actually faced during the Covid-19 pandemic in 2020.
A ‘code blue’ means a patient has gone into cardiopulmonary arrest, and anywhere from eight to 30 people immediately respond [1]. They must rush into the room, performing a variety of procedures that are critical to saving the life of the patient. As there is a positive correlation between Covid-19 cases in a community and cardiac arrests, this intensive ‘code’ became frequent in 2020 [2]. However, as an ICU physician in the Midwest said, “[a ‘code blue’ is] extremely dangerous in terms of infection risk because it involves multiple bodily fluids” [1]. These life-saving measures ultimately place a lot of healthcare providers at risk if the patient has infections or illnesses, especially Covid-19.
Not only were exposures to Covid-19 especially deadly and dangerous in early 2020 due to the lack of a vaccine, but personal protective equipment (PPE) shortages also posed an additional danger. As the number of masks, gowns, and gloves dwindled in hospitals, it became apparent that the risk to staff “may be too great to justify the conventional response” for a code blue [1]. This idea poses an ethical question relating to the trolley problem- is it worth it to resuscitate one Covid-19 infected patient to save their life if it places many more healthcare providers in danger? If not, is it ethical for a do-not-resuscitate (DNR) order to be unilateral–without the permission of the patient or their decision-maker?
Healthcare providers are bound by oath to do everything in their power to save a patient’s life with modern technology, unless patients have previously discussed and decided on a DNR order [1]. However, as Covid-19 cases began to rise and the availability of PPE lessened, there were emergency measures implemented in hospitals. These had the power, in some cases, to completely halt certain procedures from being performed on Covid-positive patients [1]. For example, Northwestern Memorial Hospital in Chicago discussed a DNR policy for infected patients that was unilateral– it didn’t matter what the patient or their family members wished for [1]. Other large hospital systems like Atrium Health in the Carolinas chose to address coronavirus patients on a case-by-case basis, but still looked at policies allowing doctors to make unilateral decisions [1]. In 2020, all Covid-19 patients were placed on DNR status at hospitals in New York and New Jersey [3]. Ultimately, these measures and policies were formed to save and prioritize the lives of many over the one – but can this be ethically justified?
Robin Alta Charo, a bioethicist at the University of Wisconsin-Madison, justifies the DNR unilateral order by calling it “pragmatic” [1]. Despite describing the idea of withholding treatment as “unsettling,” Charo defends his stance, saying “it doesn’t help anybody if our doctors and nurses are… not able to care for us,” and that the code process is one that puts them “at an enhanced risk” [1].
Additionally, it’s important to note that the possibility of discharging an ICU patient after using CPR on them is about 17% [3]. Moreover, CPR is only effective within the first 4 to 7 minutes of cardiopulmonary arrest, so it’s likely that providers either will run out of time before reaching the patient or lack crucial PPE [3]. Furthermore, most patients who have been successfully resuscitated will require a ventilator, further contributing to the scarcity of resources in hospitals during the pandemic and potentially taking these resources away from patients with a better chance of recovery [3]. Patients with other conditions or those who require surgery might also suffer as a result of limited resources like ICU beds and ventilators. For example, in Northern Italy, about 50% of beds in the hospital were occupied by Covid-19 patients, leaving minimal spots left for other patients seeking help [3]. As a result, non-Covid patients suffered greatly. Within this population, there was a sudden drop in the amount of times they visited the emergency department or were hospitalized during the lockdown period [4]. Concurrently, there was an increase in out-of-hospital mortality for these non-Covid patients – mainly driven by deaths for neoplasms, cardiovascular, and endocrine diseases [4]. This reveals how overcrowded hospitals and dwindling resources made it difficult for non-Covid patients to receive potentially life-saving care.
Despite the practical reasons to support the implementation of unilateral DNR orders, there are still many ethical aspects that complicate these policies. Refusing CPR and allowing a patient to die – while knowing something could have been done – is very difficult for a physician to grapple with. Physicians have historically faced high rates of depression, burnout, suicide, but studies have shown that the pandemic has worsened these issues. In fact, physicians of Covid-19 hospitals were shown to be “more severely depressed, stressed, and anxious than physicians of non-Covid-19 hospitals” [5]. Forcing physicians to determine whether a patient should live or die could easily compound these existing issues.
Additionally, unilateral DNR orders seem to “violate the principle of autonomy, which honors the patients’ preferences and wishes regarding any decision for their medical care” [3]. As the different forms of consent are already discussed and learned by all healthcare providers, bypassing consent completely is radical and potentially unethical. Lastly, bioethicist Scott Halpern at the University of Pennsylvania said that a “blanket stop to resuscitations for infected patients is too ‘draconian’ and may end up sacrificing a young person who is in otherwise good health” [1]. This is why it is important for healthcare providers to look at individuals on a case-by-case basis, taking into factors such as age and pre-existing health conditions. However, these factors – potentially including race, age, gender, etc. – are subject to plenty of implicit bias, meaning that a physician’s unconscious feelings toward a certain patient could determine whether they live or die.
Although unilateral DNR orders might seem unethical and radical at first, it’s important to look at not only what is best for the patient, but what is best for the healthcare providers and society at large. Resuscitating a Covid-19 patient, even with full personal protective equipment, is not going to be successful most of the time and patients often do not fully recover. Moreover, it exposes a large number of healthcare workers – who are critical to the health and safety of many other patients – to illness and infection.
A pandemic like Covid-19 is unpredictable and dangerous, and its implications are difficult to address. In these unideal conditions, some people are bound to “lose.” This brings us back to the original trolley hypothetical – is it ethical to not resuscitate a patient, essentially directing the trolley at them, in order to protect more healthcare workers? There is truly not one right answer, and it’s also deeply affected by the case’s circumstances. Does this situation ethically change if the patient is a small child or 90-year-old? What if it were your loved one? This “back-and-forth” is just a glimpse into the moral and ethical battles that hospitals, healthcare workers, and patients have been facing during the Covid-19 pandemic. This understanding can hopefully result in more grace and empathy for the job they have done.
References
Cha, A. E. (2020, March 26). Hospitals consider universal do-not-resuscitate orders for coronavirus patients. The Washington Post. Retrieved February 8, 2023, from https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate/
Bharmal, M., DiGrande, K., Patel, A., Shavelle, D. M., & Bosson, N. (2022, August). Impact of coronavirus disease 2019 pandemic on cardiac arrest and emergency care. Cardiology Clinics. Retrieved February 25, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8960232/
Sultan, H., Mansour, R., Shamieh, O., Al-Tabba', A., & Al-Hussaini, M. (2021, May 12). DNR and Covid-19: The ethical dilemma and suggested solutions. Frontiers in public health. Retrieved February 8, 2023, from https://www.ncbi.nlm.nih.gov /pmc/articles/PMC8149588/
Santi, L., Golinelli, D., Tampieri, A., Farina, G., Greco, M., Rosa, S., Beleffi, M., Biavati, B., Campinoti, F., Guerrini, S., Ferrari, R., Rucci, P., Fantini, M. P., & Giostra, F. (2021, March 22). Non-covid-19 patients in times of pandemic: Emergency department visits, hospitalizations and cause-specific mortality in northern Italy. PloS one. Retrieved February 25, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984614/
Rahman, A., Deeba, F., Akhter, S., Bashar, F., Nomani, D., Koot, J., Koly, K. N., Salah, F. B., Haverlag, K., & Anwar, I. (2021, December 9). Mental health condition of physicians working frontline with COVID-19 patients in Bangladesh. BMC Psychiatry. Retrieved February 25, 2023, from https://bmcpsychiatry.biomedcentral. com/articles/10.1186/s12888-021-03629-w