Advocate or Allocate (or both)? What are the ethical responsibilities of the medical profession during and after the COVID-19 pandemic?
The COVID-19 crisis has pushed Canadian society into uncharted waters, both politically and economically. The Canadian health care system, however, is well acquainted with this kind of crisis – the difficult balancing of the two arms of health, acute care and social determinants, in an environment of increasing fiscal pressures. The pandemic has created significant anxiety about the ability of the acute care system, overtaxed before the pandemic, to provide care. It has also created unprecedented challenges to the maintenance of the social determinants of health: employment, economic and housing security, education and socialization.
Early on in the pandemic, the focus was principally on the acute end of the spectrum. Hospitals cancelled surgeries, physician practices closed and nurses were redeployed in anticipation of a coming wave. The nursing home crisis brought to light many deficiencies in the acute care provided outside the hospital setting1. As the pandemic wore on, however, the broader implications of societal disruption have come to the fore. The summer of 2020 has been notable for the broad social movements to recognize social inequality – resulting in, among other things, an unequal burden of COVID-19 on the marginalized2. Discussion on re-opening schools has highlighted the preeminent importance of education as a determinant of health in children.
Of unique interest is the role of economic security as a determinant of health. The economic security of Canadians is inescapably linked to the fiscal health of their governments. Provincial governments in Canada have begun to signal that they will face significant deficits and that they expect these to result in cuts to services3 – in many cases, services that directly impact on the social determinants of health. An appeal to the federal government for relief is unlikely to yield much fruit, as the federal coffers are likewise in dire condition. Any government that wished to make political hay out of economic largesse in these trying times is faced with the grim reality of empty pockets.
In these increasingly fraught circumstances, the medical profession will inevitably be forced to ask itself what kind of leadership role it wants to exercise in this scenario. With governments under increasing stress and having little political or practical room to maneuver, the medical profession will be positioned to be a prominent stakeholder in shaping the debate and decisions that will be critical to maximizing the overall social welfare of Canadians.
The COVID-19 crisis has highlighted the important role physicians can play as opinion-shapers and decision influencers. The current situation in Alberta is an example of how actions by both the government and the medical profession early on could have a dramatic impact on whether this is a constructive working relationship, or an acrimonious and potentially harmful one4.
The Canadian Medical Association’s Code of Ethics highlights the centrality of a strong commitment to patients in health advocacy. While many clinicians see this as an imperative to advocate for expanded provision of acute health services, it may be less intuitive that this responsibility extends to the management of all the social determinants of health. In an environment of scarcity, clinicians may find that in order to expand the social programs which support broader population health, they will have to accept a smaller piece of the pie for clinician-provided services.
It is an open question whether the medical profession will accept that clinical resources (including compensation) may need to be limited in order to provide better education, housing, or food security to a population struggling under the burdens of the pandemic. Clinicians will need to see the bigger picture of health, rather than simply be advocates for the acute health side of the equation.
Conversely, it can be argued that the role of acute care providers is to advocate for “the patient in front of them”, and that policy decisions about overall system allocation should be left to those vested with the authority to do so – elected officials and the public service. As professionals, however, can front-line clinicians really escape the reality that their patients’ overall health landscape is much larger than the acute care they receive from the “formal” health care system? Does this really fit the ethos of medicine, to pursue the holistic health of the patient? This is particularly relevant to the Canadian example, as there is evidence that comparative overinvestment in acute care may have had the effect of reducing overall societal health and well-being5.
In any case, the question of who ought to make the decisions is moot when policy makers in the COVID age are anxious to be seen as acting “on the side of the science”. It is inevitable that decision-makers will continue to turn to the clinical professions for guidance and endorsement of their proposals. Physicians and other front-line staff will continue to have a central role in policy-making. For this reason, it is an ethical imperative that they develop a broad perspective of the impacts of policy on the socioeconomic and political landscape. It is not enough to stay in our lane.
This is uniquely challenging in that health professionals, by and large, do not have training or experience in policy-making. Opinions about optimal priority-setting in an environment of scarcity will likely be wide-ranging (from socialism to free-market capitalism, and everything in between). In addition, the ever-present temptation to squabble over turf – a lamentable but frequent feature of contract negotiations – will present an obstacle to policy-makers seeking to obtain good insights from clinicians. In particular, contrasting positions on longstanding inequities within the profession, including those between high value primary care and expensive subspecialty care, are likely to flare, further impacting the ability of the profession to provide cogent, effective and clear advice to governments.
There is no sure answer to where the balance should be between investment in the health care system and in the social determinants of health. The focus should instead be on ensuring physicians have the virtues necessary to make ethical recommendations: humility, to understand that we do not have all the answers; honesty, to speak clearly on what we know; and solidarity, to put the needs of the society over our own interest and to present a cohesive voice as a profession. Above all, we will need courage, the “form of every virtue at the testing point6.”
Dr Travis Carpenter is an Assistant Professor at the University of Toronto and a general internist at Unity Health Toronto (St. Joseph’s Health Centre). He completed his medical degree at the University of Alberta, residency at the University of Toronto, and his graduate degree in public health at the Harvard Chan School. Dr. Carpenter currently serves as faculty with the University of Toronto Department of Medicine, focusing on health quality and health policy.
Dr Lucas Vivas practices General Internal Medicine at William Osler Health System in Brampton, Ontario. He has a background in bioethics, completing an interdisciplinary Masters degree from the University of Toronto at the Joint Centre for Bioethics. He is a member of the Corporate Ethics Committee and the Research Ethics Board at William Osler, has led seminars in the Ethics and Professionalism Curriculum at the University of Toronto Faculty of Medicine, and additionally teaches residents at McMaster University’s Osler site. His interests include the ethics of clinical decision-making in acute illness and the application of virtue ethics to medical practice.
References
1. Carpenter TD and Vivas L. Military help lays bare how misplaced health care priorities have harmed our seniors [Internet]. thestar.com. 2020 [cited 2020 Oct 4]. Available from: https://www.thestar.com/opinion/contributors/2020/05/28/military-help-lays-bare-how-misplaced-health-care-priorities-have-harmed-our-seniors.html
2. Public Health Ontario. COVID-19 in Ontario – A Focus on Diversity. 2020. Available from: https://www.publichealthontario.ca/-/media/documents/ncov/epi/2020/06/covid-19-epi-diversity.pdf?la=en
3. Sammy Hudas. Alberta’s deficit projection at $24.2 billion due to COVID-19 pandemic | Calgary Herald [Internet]. Calgary Herald. 2020 [cited 2020 Oct 4]. Available from: https://calgaryherald.com/news/politics/albertas-deficit-could-balloon-to-24-2-billion-finance-minister-warns-of-future-cuts-to-services
4. Alanna Smith. “It’s a storm”: Tensions rise between Alberta physicians and provincial government [Internet]. Calgary Herald. 2020 [cited 2020 Oct 4]. Available from: https://calgaryherald.com/news/local-news/its-a-storm-tensions-rise-between-alberta-physicians-and-provincial-government
5. Dutton DJ, Forest P-G, Kneebone RD, Zwicker JD. Effect of provincial spending on social services and health care on health outcomes in Canada: an observational longitudinal study. CMAJ. 2018 Jan 22;190(3):E66–71.
6. Lewis, CS (1942) The Screwtape Letters. In C.S. Lewis: The Signature Classics [2007]. HarperCollins (New York, USA). p. 270.
Collections
