We’re a married couple, both doctors, originally drawn to medicine because we want to be of value at times of need. But as Chicago approaches its projected surge, and with infections likely continuing for months, we’re debating what we can and should do.
If we’re asked to treat Covid-19 patients, we want to help, in part because we don’t want the burden to fall on residents and other trainees. But Veena is an ophthalmologist. Manish is a pediatric surgeon. Until now, being effective has meant honing very specialized skills in those areas. Veena has not practiced in an intensive care unit in years. Manish is pulling out his old textbooks before bed. We worry about practicing outside of our specialties, trying to solve life-threatening problems when we’re not really the experts.
Our ophthalmology and surgical patients need us, too, but treating them carries some risk of infection as well. We worry, every time we enter the house, about spreading the disease to our family.
How do we balance between protecting our patients, our trainees, our family, ourselves and our moral sense of why we do what we do?
VEENA and MANISH RAIJI, Chicago
Dear Veena and Manish,
When I asked other physicians, as well as medical ethicists, about your quandary, the first thing they said was: They’re glad you spoke up. As health workers in New York essentially rush into the equivalent of burning buildings, and earn nightly standing ovations for it, many doctors have felt it is taboo to express any reservations about lending a hand.
But with private practices shuttered and elective procedures canceled, there are doctors around the country watching edgily from home, feeling guilty that they haven’t done more, and weighing whether and to what extent they are willing to risk infection — or spread it — by treating either Covid-19 patients or others. Hospitals are reconfiguring staff and preparing for a long slog, relying not just on emergency and critical care physicians, but also on doctors like you who work in other specialties.
In New York, the conflict over who should work is rising: So many staff members at public hospitals have called in sick that administrators, suspecting that not all the absences were valid, began requiring doctor’s notes. That change in policy outraged some nurses: “Don’t blame us for the government’s lack of preparation,” one told The New York Post.
At many institutions, protective personal equipment is still in short supply. At least 9,000 medical workers responding to the outbreak in the United States have been infected and dozens have died.
Sitting out the pandemic could mean letting the burden fall on colleagues, missing a defining hour for medicine and defying the precept that, whatever your specialty, you’re a healer first.
“There’s a feeling of, ‘Oh my god, I’m not going in, I’m not working,’” said Dr. Stephen Goldstone, a surgeon in New York who is mulling whether to volunteer. “I feel totally guilty about not being there,” he said, especially because he has taught medical students that doctors are obligated to treat patients even when it means putting themselves at risk.
But that idea has not been tested in our lifetimes the way it is now. Even medical ethicists are divided about the degree to which medical professionals are required to put themselves in harm’s way. This is a question many of them have studied only in much more limited situations, or in the abstract. Now it’s pervasive and urgent, and everyone’s well-being rests on the answer.
“There are certain duties that go with your position in life,” said Dr. Steven Miles, an emeritus professor of medicine and bioethics at the University of Minnesota, adding that he had contracted tuberculosis, staphylococcal pneumonia, hepatitis and dysentery while treating patients in developing countries. “If we’re going to give doctors the monopolies on these tools, and compensate them, there comes a time when we say, ‘We’re going to need you for this work.’”
If firefighters refused danger, he said, “we couldn’t have a fire department.”
But firefighters at least wear full protective armor. They risk their own lives, typically without fear of inadvertently transmitting the danger to someone else. “The No. 1 rule is: You don’t create two victims,” said Dr. Douglas Diekema of the University of Washington, who argued that the continuing shortage of adequate protective gear somewhat lessened the moral obligation for health care workers.
No one I spoke with thinks it would be irresponsible of you to treat Covid-19 patients despite coming from other areas of medicine. Doctors with varied specialties are doing so — many working under supervision, handling tasks like monitoring oxygen and blood pressure or collating lab results.
Almost everyone feels unprepared, because the disease is so new and the treatments are still so uncertain, doctors said. “Would they still call us heroes if they knew we felt so helpless?” Dr. Craig Spencer, director of global health in emergency medicine at NewYork-Presbyterian/Columbia University Medical Center, recently wrote. That’s an unsettling change for ultra-specialized doctors like you, accustomed to working with more order and control. Dr. Megan Ranney, an emergency physician in Providence, R.I., said the chaos of treating conditions like gunshot wounds had been the best emotional training for the coronavirus. “We’re used to working at the liminal edge of the health care system,” she said.
The key to volunteering, other doctors said, is to find your own toehold. Several weeks ago, as the crisis climbed in New York, Dr. Judith Salerno faced a quandary similar to yours. For years, she had been running nonprofit organizations, seeing only a few geriatric patients on the side. “I was sitting doing Zoom conference calls, and all I heard were the sirens and the ambulances,” she said. Although she hadn’t worked in hospital medicine for many years, she volunteered at Bellevue. On her first day, she felt like an intern all over again.
But she found her place in palliative care. Her counterparts in the I.C.U. had no time for the delicate work of talking patients’ families through end-of-life care — remotely, no less — so her team is doing it. Once she began working, she said, her sadness increased, but her anxiety and feelings of helplessness abated.
In the coming weeks you, too, may decide to plunge into the Covid-19 emergency. But ethicists say that your obligation is not the same as that of the emergency room doctors, respiratory therapists, and others on the front lines. They have the relevant core skills. The obligation to volunteer is lower than the duty of essential workers not to abandon their stations. A rule of thumb for everyone in medicine right now is to “find a role to serve that matches your training and abilities and is specific to the conditions of today,” said D. Micah Hester of the University of Arkansas for Medical Sciences. By continuing to see patients at risk of losing their vision, and performing emergency pediatric surgeries, you’re already doing that.
For years to come, Dr. Hester fears, medical workers may ruminate about the trade-offs they are making during this period for their patients, their families and their own health. “It’s the story you tell yourself” about this time, he said.
He offered a gentle warning that you and your colleagues are likely to face moral residue — the lingering discomfort, he said, of “choosing between or among our moral convictions, letting some go in order to fulfill others.”
Lauren Messman contributed research.
Dilemmas is a new column about dealing with the human quandaries presented by the coronavirus pandemic. Please send yours to firstname.lastname@example.org.