The Good of the One v. The Good of the Many

The Good of the One v. The Good of the Many

Some medical centers have been considering policies to withhold resuscitation of COVID-19 patients who stop breathing or whose hearts stop beating—even if the patients or their families request it.1 Typically, resuscitation attempts are assumed to pose no substantial risks to health care providers (HCPs) or other patients. However, “crisis standards during a major surge in Covid-19 patients challenge typical assumptions regarding resuscitation and default provision of CPR”.2 For example, patients with airborne infectious diseases are often placed in negative pressure rooms (which keep room air from escaping into the larger setting); but many hospitals do not have such rooms, and hospitals that do typically have only one or two.

As hospitals are being inundated with patients infected with the COVID-19 virus, many are facing a severe shortage of personal protective equipment (PPE)—e.g., masks, gowns, gloves—for hospital personnel. HCPs are bound by oath—and sometimes by law—to do everything they can to try to save a patient’s life. When patients stop breathing or when their hearts stop beating, typically all available HCPs—usually 6-8, but sometimes dozens—rush to the bedside to begin life-saving procedures. These procedures typically include the often-bloody exercise of inserting more intravenous lines; inserting a tube (to attach to a ventilator) into the patient’s windpipe—which sprays virus-laden sputum throughout the room; and providing external heart massage that requires close contact with the patient’s body. As of August 11, 2020, 922 U.S. HCPs caring for COVID-19 patients have died.3 Furthermore, during resuscitation HCPs use dozens of gloves, gowns, and masks that could be used to care for more patients and save more lives.

The American Medical Association’s basic Code of Ethics requires that:

... A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. [...] A physician shall, while caring for a patient, regard responsibility to the patient as paramount.4

Similarly, “The Code of Ethics for Nurses with Interpretive Statements" is the social contract that nurses have with the U.S. public. It exemplifies our profession's promise to and advocate for safe, quality care for all patients and communities.”5 In particular, The Code requires:

Provision 1.The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (emphasis added).

1.1 Respect for human dignity - A fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual.

[...]

1.3 The nature of health problems -The nurse respects the worth, dignity and rights of all human beings irrespective of the nature of the health problem. The worth of the person is not affected by disease, disability, functional status, or proximity to death.

1.4 The right to self-determination - Respect for human dignity requires the recognition of specific patient rights, particularly, the right of self-determination.

One factor complicating this issue is that survival rates for COVID-19 patients who experience cardiac or pulmonary arrests is uncertain. One study in Wuhan, China, reported a very low survival rate of 2.9%; but whether this same rate holds for patients in the U.S. is unclear.6 Common clinical practice and professional codes of ethics do not require HCPs to provide “futile” care—for example, care that has no chance of restoring the patient’s life. What, then, to do with COVID patients who suffer cardiac or pulmonary failure, but whose outcomes cannot be reliably predicted?

  1. Cha, A. E. (March 25, 2020). “Hospitals consider universal do-not-resuscitate orders for coronavirus patients” The Washington Post https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-d…
  2. CPR in the Covid-19 Era — An Ethical Framework. N Engl J Med 2020; 383: e6 DOI: 10.1056/NEJMp2010758
  3. “Lost on the frontline: Hundreds of US healthcare workers have died fighting Covid-19.” The Guardian.https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-…
  4. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/pr… Emphasis added.
  5. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/ Emphasis added.
  6. Shao, F., Xu, S., Ma, X., Xu, Z., Lyu, J., Ng, M., Cui, H., Yu, C., Zhang, Q., Sun, P., & Tang, Z. (2020). In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China. Resuscitation, 151, 18–23. https://doi.org/10.1016/j.resuscitation.2020.04.005

From the 2020 Regional Ethics Bowl. Prepared by

Michael Funke
Rhiannon Dodds Funke
Gretchen A. Myers
Greg Shafer
Becky Cox-White