Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma in patient care, you vote, and then we present an expert's judgment.
Last week, you voted on what to do when an older woman with multiple comorbidities wants to visit her critically ill husband with COVID-19. Here are the results:
How strongly do you discourage her from visiting?
Not at all: 37.36%
Some: 44.52%
Strongly: 16.09%
Absolutely forbid it: 2.03%
What if PPE is scarce in your hospital? How much would you then try to discourage visiting?
Not at all: 17.7%
Some: 36.93%
Strongly: 32.95%
Absolutely forbid it: 12.42%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
Some risk tolerance is widely accepted in our society: we drive, we give birth to children, we eat runny eggs and canned fish despite the dangers of salmonella and botulism. Medicine has long permitted competent patients to consent to elective and cosmetic medical procedures -- from liposuction to breast augmentation -- that entail rare but real threats to life. To what extent patients truly appreciate these risks is unclear. After all, nobody expects to die during rhinoplasty, like in the high-profile case of Maria Chiara Mete, or during a routine endoscopy as with comedienne Joan Rivers. As the risk increases, physicians tend to feel less comfortable with patients making certain choices -- whether because doctors do not believe that patients fully appreciate the dangers or because they simply view some risks as too high to tolerate. ("First," as it is said, "do not harm.") Phase I drug testing is considered ethically acceptable, and human challenge tests for a COVID-19 vaccine may be as well, but the potentially major contribution to the collective good probably plays into that calculus. Live liver donation poses a mortality rate of approximately 1 in 200 for the donor, and may represent the tipping point for the level of risk many providers are willing to accept.
In this scenario, the wife is seeking to risk her own life to comfort her husband on what may prove to be his deathbed. Whether or not adequate PPE is available, the underlying ethical question remains the same: How much risk should she be permitted to endure? And how to balance that risk against the value of saying farewell to a life partner of many years? One might also take the wife's age into account here. She could reasonably argue that she has led a full life, that death is inevitable, and that she wants to live and die on her own terms. In contrast, an 18-year-old who wishes to risk her life to say a final farewell to her prom date might give us more pause. An additional concern (not fully elaborated in the scenario) is the state of healthcare resources in the hospital and surrounding areas: If the wife develops COVID-19, could she require scarce resources (such as a ventilator) that will cost other patients their lives? Or are such resources now plentiful? In addition, even one more sick patient will pose some additional risk to healthcare workers, and unless her quarantine is airtight, also risks spreading the disease in the larger community as well.
Despite the risks of allowing the wife to visit, a particular consequence of prohibiting such visits may be far more concerning: Patients fearful that they will be forced to die alone may avoid hospital care entirely, or until the last minute, leading to increased community exposure. This has occurred in past epidemics, such as Ebola, and may already have occurred with COVID-19 in New York City as well. Rather than encouraging or discouraging a visit, the soundest approach would be to explain all of these risks and concerns to the wife. Some hazards, such as that to the community, may be mitigated with careful prior preparation. The care team should also screen the wife to make sure that she is acting of her own free will, rather than under duress, such as fear of her husband's later response if she doesn't visit and he recovers, or pressure to visit from other relatives. Once the wife fully understands the dangers, the wisest approach is for letting her decide what is in the best interests of herself and her husband. After all, they are the people most impacted by the consequences.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College. Appel is the author of the recent book, .
And check out some of our past Ethics Consult cases: Surprise Finding in Organ Donation Match Test; Compel Woman to Have C-Section?; Give COVID-19 Vax to Yourself Before Patients?