COMMENTARY

When to Restore Medical Services While We Still Fight COVID-19

Arthur L. Caplan, PhD

Disclosures

April 27, 2020

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This transcript has been edited for clarity.

Hi. I'm Art Caplan, normally at NYU's Division of Medical Ethics in New York City. Today I'm talking to you in social isolation from my home in Ridgefield, Connecticut. But plague or no plague, opinionating goes on. I want to talk to you today about something that keeps coming up.

As hospitals have tried to deal with the influx of coronavirus-infected patients and the ICU care and personnel required to take care of those patients, it's put a strain on resources and on personnel. Many people are being reassigned to cover either ICU care or other parts of the hospital where they normally wouldn't be. That applies to nurses and others as well.

We all understand the need to redeploy, and part of the issue is, what should a hospital be doing and what should it stop doing? That has been framed in terms of what's essential and what might be elective. This is going to be a very important distinction as we see hospitals hopefully start to return services and people back to where they work.

It's going to happen in an order. It's going to happen not all at once. The door won't just open and it's "Back to work, everybody." We'll wean out people slowly or titrate them, and then everybody will be back to business, but not at the same pace.

I know this is a hugely emotional issue. I'm getting people asking me at my own institution, "When can I go back and do X? When do you think it will be time to do Y?" People are also lobbying and saying, "We're essential; what we do in terms of treating a cancer patient or in terms of organ transplant, or what we do in different types of repair of orthopedic, knee and joint procedures, is very essential. We're very important; we think we're more important than X."

This idea of deciding what not to do in order to make sure that the hospitals can run, and then deciding what we should do first when it's time to start restoring services, has turned into a pretty emotional battle, with appeals and with people even talking about doing surveys of the public to see what they want to come back.

I work with a medical student, Shailin Thomas, here at NYU. We've been thinking hard about this and we think the whole thing is framed wrong. I want to suggest to you a way to think about this both for your own practices (or your administrators) and as you talk to colleagues.

I think the "essential" versus "elective" distinction is wrong. It leaves people wondering what falls under that, and it sometimes demeans very important services that are just, for the purposes of this debate, sometimes called elective, implying that they're not essential or important. They are if you're the patient—that's for sure.

I think the better way to go about this is to consider what we are trying to achieve. There are two goals: making sure that we maximize services to people in need, both COVID-19 patients and those who are acutely ill; and put our personnel and staff to work to do that, despite the strain on resources in many places.

Then, as an aside to what must we do, what can we do? What I mean by that is, what services can continue that don't strain resources? That seems to us, my student and myself, a much more reasonable way to think this through, both in shutting things down and in opening things up.

Rather than trying to decide what's more important than something else, if we still have resources that are burdened, what should we stop doing so that the personnel doing those things can help others or keep the facility going?

It may be that while orthopedic surgeons need to be shifted over somewhere, psychiatrists who are doing telemedicine can continue to do telemedicine because they're not getting moved into frontline delivery roles. Or at least until they might be, they can do their work without burdening anybody. They're not making the hospital worse off in terms of delivering service.

People wonder about things like in vitro fertilization. That seems to us to be a pretty resource-intense activity. Again, it's probably not one that you want to be diverting resources to, unless you get to a point where it doesn't really matter if you're diverting resources because the hospital's getting pretty stable.

Organ transplants are highly intensive. Transplants take many people, many people are in follow-up care, and they take up critical care space. That's probably going to be one that you almost have to stop—as almost everyone has already—and only restore toward the end of the line, even though patients' lives hang in the balance.

If you're tipping over or overburdening those ICU facilities, if you're pulling too many people away too soon from the provision of acute care, emergency-type care, docs, beds, recovery space, and so on, then that's the measure that you're trying to use.

I don't think it really matters whether it's Botox, elective abortion, or trying to treat a breast cancer that you're worried is growing. What matters is whether you have to stop doing these things because they're hurting what you can do to really acute emergency care because you've got all hands on deck.

Can you restore these services without creating too much turmoil for the emergency services that are starting to, if you will, wean away or drop off? I suggest we think about this without the emotional fights of whether dermatology is more important than ophthalmology is more important than doing colonoscopies.

That's not the right way to think about it. The way to think about it is, what do we have to do to keep maximum effort going to maximize the number of lives saved? How do we back out of that without jeopardizing that goal? That will tell us in terms of what the resources are that are required or not.

Continuing elective abortions early on—if they're pharmaceutical—those can be offered; that's not a resource burden. Maybe we can do outpatient Botox. That could be administered perhaps by someone who's not going to be moved to frontline ICU duties in the middle of a pandemic.

On the other hand, there may be services that we just can't bring back fast, including orthopedic surgery, because many of the skills involved there are transferred over to the frontline battle against the pandemic.

Let's not do the finger-pointing. Let's not do the emotional appeals. Let's try to think this through carefully and reasonably. The goal was to maximize our ability to fight the pandemic and then do other things that could continue if they don't jeopardize that mission. In restoring services, maximize things that help continue to fight the pandemic until it's gone, and bring back those services that are less likely to jeopardize the mission.

I'm Art Caplan. I'm at the Grossman School of Medicine at the New York University Division of Medical Ethics. Thanks for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and Grossman School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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