Ethical Issues in Healthcare Practice During COVID-19

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2. The plan • Logistics 5 minutes • Brief outline of ethical issues --10 minutes • Part 1: Ethical issues for residents --45 minutes • 5 minute break • Part 2: Ethical issues for patients and practice --45 minutes • Wrap up --10 minutes • Summary • Remaining questions • Plan for next steps 2

3. Ethical issues For Practice For Practice For Practitioners For Practitioners • Resource allocation • Labor Justice • Moral distress & moral panic • Stigma and racial bias • Education vs. public health priorities • Essential vs. nonessential care • Resource allocation during scarcity • Telemedicine benefits/limits • Health disparities, stigma/bias • Counseling during uncertainty 3

4. Ethical issues For Practice For Practice For Practitioners For Practitioners • Labor Justice • Duty of care • Essential staff/activities • Allocating risks/burdens • Fair division of labor • Personal circumstances • Cohorting? • Stigma and racial bias • Education vs. public health priorities • Practical guidance for minimizing nonessential patient contact • Moral distress & moral panic • Role of social media • Essential vs. nonessential care • Practical guidance for minimizing nonessential patient contact • Prenatal care • Visits • Ultrasounds • Prenatal diagnostics • L&D, antepartum management • Ambulatory & ED visits • Gynecologic surgery • Oncology • Benign gyn • Family planning • Who decides? • Telemedicine benefits/limits • Health disparities, stigma/bias • Resource allocation during scarcity • Counseling during uncertainty 4

5. Ethical issues For Practice For Practice For Practitioners For Practitioners • Labor Justice • Duty of care • Essential staff/activities • Allocating risks/burdens • Fair division of labor • Personal circumstances • Cohorting? • Stigma and racial bias • Education vs. public health priorities • Practical guidance for minimizing nonessential patient contact • Moral distress & moral panic • Role of social media • Essential vs. nonessential care • Prenatal care • Visits • Ultrasounds • Prenatal diagnostics • Who is “high risk?” • L&D, antepartum management • Ambulatory & ED visits • Gynecologic surgery • Oncology • Benign gyn • Family planning • Who decides? • Telemedicine benefits/limits • Health disparities, stigma/bias • Resource allocation during scarcity • Counseling during uncertainty 5

6. Case Scenarios For Practitioners 6

7. CASE 1.1 Resident Z is pregnant Bayview. She is very concerned about potential exposure to COVID-19 as it represents disproportionate risk to her health compared to non-pregnant colleagues, especially in this clinical role where she expects to do ED consults and L&D triage. She requests to be moved to a rotation with minimal in- person patient contact. pregnant and is scheduled to be on L&D at 7

8. CASE 1.2 Alternatively… Resident Z has asthma Bayview. She is very concerned about potential exposure to COVID-19 as it represents disproportionate risk to her health compared to non-pregnant colleagues, especially in this clinical role where she expects to do ED consults and L&D triage. She requests to be moved to a rotation with minimal in- person patient contact. asthma and is scheduled to be on L&D at 8

9. CASE 1.3 Alternatively… Resident Z is scheduled to be on L&D at Bayview, where she expects to do ED consults and L&D triage. Johns Hopkins Health system is on a temporary backorder for facemasks and gowns and has limited use of certain PPE to ICU and OR settings only to conserve equipment. 9

10. CASE 2 25-year-old primiparous patient at 39wks in spontaneous labor, currently 8/90/-1. Dr. Betty Chou enters the delivery room to greet the laboring patient and her family in anticipation of the upcoming delivery. Dr. Chou introduces herself as the supervising physician at the beginning of her 12-hour shift. The patient looks uncomfortable and the patient’s mother blurts out, “I don’t want my daughter or grandchild exposed to the “Chinese virus!” Please find another doctor to take care of my daughter--there must be people on your team who are lower risk!” 10

11. CASE 3 • It’s June 2020 and 4 of 9 senior residents have not met their ACGME procedure minimums as a result of practice changes in response to COVID 19. • Should they graduate? • Does it matter which procedural minimums they fall short on? 11

12. CASE 4 Resident Y returned from maternity leave a few weeks ago. Resident X, now on vacation, is called in to cover L&D in place of Resident Y, a resident in the same year, because of concerns of increased risk of spreading COVID 19 to Baby Y and Husband Y. Resident X, just finished GYN ONC, JHH L&D and GYN blocks back to back, and was at a physical/mental breaking point, only staved off by the promise of the upcoming 2-week break, which is now cancelled. 12

13. Case Scenarios For Practice 13

14. Case 5 • 28 y/o G5P6 presents to your office for postpartum visit. She had wanted an immediate postpartum tubal while on L&D, but due to patient acuity on the unit during her admission, this was not possible. She was discharged for the plan of interval tubal ligation and is requesting to schedule the procedure ASAP because she has had short interval pregnancies in the past. You inform her that, unfortunately, all “non-emergent” procedures are currently on hold due to the health crisis. 14

15. Case 6 • You are doing a telemedicine prenatal visit for a patient at 20 weeks with uncomplicated second pregnancy. She works on the hematology service at JHH. She requests a doctors note to say she should stay home from work because of potential harm to her or her fetus from COVID-19. 15

16. Case 7 • 34 y/o P2002 with one prior cesarean delivery is being seen in the clinic at 34 weeks. She tells her provider that she now plans to have a home birth because she is concerned about prolonged exposure of herself, her neonate, her husband and other family members during the hospitalization. She has a friend who is a midwife who has volunteered to attend the home delivery. 16

17. Case 8 • 68 y/o patient with tissue diagnosis of uterine carcinoma from EMB is scheduled for TLH/BSO/staging later this week. She calls the office to say she’s cancelling her case because she can’t risk being in the hospital and getting COVID-19 since “older people are more likely to die.” She has HTN and prediabetes, but is otherwise healthy. 17

18. Ethical issues For Practice For Practice For Practitioners For Practitioners • Labor Justice • Duty of care • Essential staff/activities • Allocating risks/burdens • Fair division of labor • Personal circumstances • Cohorting? • Stigma and racial bias • Education vs. public health priorities • Practical guidance for minimizing nonessential patient contact • Moral distress & moral panic • Role of social media • Essential vs. nonessential care • Practical guidance for minimizing nonessential patient contact • Prenatal care • Visits • Ultrasounds • Prenatal diagnostics • L&D, antepartum management • Ambulatory & ED visits • Gynecologic surgery • Oncology • Benign gyn • Family planning • Who decides? • Telemedicine benefits/limits • Health disparities, stigma/bias • Resource allocation during scarcity • Counseling during uncertainty 18

19. Questions? mgross23@jhmi.edu 19