Medical Ethics Surrounding the COVID-19 Pandemic

Lorenzo Norris, MD


April 01, 2021

This transcript has been edited for clarity.

Lorenzo Norris, MD: This is Dr Lorenzo Norris, editor-in-chief of MDedge Psychiatry. I'm very pleased to have with us on the Psychcast today Dr Rebecca Brendel and Dr Allen Dyer. They will be engaged in the conversation regarding ethics and COVID-19, particularly as it relates to allocation of resources, which we have dealt with, and how we can start to think about ethics relating to taking the vaccine, distribution, and trustworthiness. Guiding this discussion today will be Dr Carol Bernstein. Please stay with us for what I'm sure will be a very informative discussion about ethics and COVID-19.

Carol A. Bernstein, MD: Thank you very much, Lorenzo. I'm Dr Carol Bernstein. I am a professor and vice chair for well-being and faculty development in the Department of Psychiatry and Behavioral Sciences and the Department of Obstetrics & Gynecology and Women's Health at Montefiore Medical Center and the Albert Einstein College of Medicine. I am also a past president of the American Psychiatric Association.

I'm delighted to be welcoming our guests today, as Dr Lorenzo Norris mentioned, and I will have them introduce themselves first before we get to our topic. First, Dr Rebecca Brendel.

Rebecca Brendel, MD, JD: Thank you, Dr Bernstein. It's my pleasure to be here with you, Dr Norris, and Dr Dyer today. I'm Rebecca Brendel. I'm the director of law and ethics at the Center for Law, Brain & Behavior at Massachusetts General Hospital, as well as the associate director and director of the Master of Bioethics Degree Program at Harvard Medical School.

Bernstein: Thank you. Now, Dr Allen Dyer.

Allen Dyer, MD: Hi. I'm Allen Dyer. I'm a professor of psychiatry and behavioral sciences and the vice chair for education at the George Washington University School of Medicine and Health Sciences in Washington, DC. It's my pleasure to be with this group.

Bernstein: Well, thank you very much. Clearly, there are many ethical considerations we have to talk about in regard to COVID-19. There have been many noted by the media and in the news, but I always like to start these conversations by hearing just a little bit about your own interests. Dr Brendel, I know you have a long and illustrious career, but could you just tell us a bit about your particular interest in ethics and why you got involved in this aspect of psychiatry?

Brendel: Well, let me try to put this in a nutshell. Otherwise, I'd eclipse our entire podcast talking about my interest in and love of ethics. Let me say that, from early on, before I even went to medical school, I was a philosophy major in college. I became really fascinated with the kinds of decisions that we make about health care, and then again later on in psychiatry.

Now as I've gone on in my psychiatry career as a forensic psychiatrist, and as a psychiatrist who practiced on the constant liaison service at Mass General, many of the issues that provided the most challenges in consultation and around patient care did not have to do with psychiatric care, per se, but with many of the surrounding issues and kinds of decisions we had to make.

That led me to spend a lot of time in ethics going forward. I've had some wonderful collaborations with colleagues in psychiatric ethics, including Dr Dyer, whom I'm delighted to be here with today. When COVID-19 came, as a teacher of ethics, I was being immersed in a living laboratory, so to speak, about how we can reframe and reshape our ethics to be responsive to the challenges that we're facing today. It was unfortunately one with grave consequences for human life and suffering.

Bernstein: Thank you so much. Dr Dyer, the same question goes to you.

Dyer: My interest in ethics also goes way back. When I was a resident in psychiatry at Duke, I was concurrently doing a PhD in medical ethics. This happened to be the time when the APA reformed its ethics committee and dealt with a number of important issues in terms of how you articulate a code of ethics for the psychiatric profession.

What the committee decided at that time was that because psychiatrists were physicians, it would be the AMA Code of Ethics with annotations applicable to psychiatry This is what we've been using for the last 40-some odd years, but it is updated as particular situations emerge. It was a great pleasure to get involved in the APA early on when I was a resident and see the importance of a professional organization in defining and articulating the standards of practice in terms of an ethical formulation.

Bernstein: Thank you both very much. I'm sure we could talk a lot more about your interest in ethics. I'm going to ask a broad question first, so I hope you'll forgive me. As the COVID-19 pandemic has emerged and erupted, there's been a lot of talk about ethics. I know there are so many topics for us to cover, so can you briefly talk about how the standards of care may be ethically different in the course of a pandemic like this than they are in the usual practice of medicine?

Dyer: One of the things we could say about the usual practice of medicine is that it's the doctor and patient in an individual relationship. Doctors, because of their commitments to their patients one-on-one, one after another, are very dubious about a mass disaster situation in which the decisions made are not only about the individual patient in front of us — they are about the well-being of society and the relationship of us and our patients to the larger community in the larger society.

Brendel: As a teacher of ethics, we used to start our academic year with what we called an ethics simulation. This was a case we gave to students working in groups to think about what ethical principles we'd apply if we were in a situation of scarcity. In doing so, students would sit there and think about what they would do. Come on, it's 2019. It's 2020. This is United States of America health care. We have so many resources. This is never going to happen here.

We were thrust into the spring of 2020 with real shortages that left us reading in the newspaper about getting ventilators from the local animal hospital to make sure we would have enough for people, and reallocating ventilators from neonatal ICUs to makeshift ICUs all over the country. All of a sudden, we were faced with the reality about how to think about allocation when there wasn't enough for everyone. That's something that really shook the system to focus immediately — as you'll see, if we can talk about the evolution of this — on how we do this work we've been imagining and use it to shape our ethical discussion for when we actually have to do it. That's when the ethics was really front and center.

I couldn't walk my dog in the morning without my neighbors, many of whom are physicians, saying, "OK, what are they going to decide today?" All of a sudden, I was the most popular person at 6 AM on my street.

I think that really reshapes how much this captivated everyone's interest and brought medical ethics front and center. It was fundamentally antithetical to our desire to save everyone, to push forward with medical technology, to save life at every cost. And really within the public spaces, and certainly in Massachusetts where I live, to think about access to health care and broadening access for many. I don't know if that helps give it a little bit of a context of why this was such a pivotal moment for medical ethics in the public sphere.

Bernstein: Basically, the shift in thinking was driven by the scarcity because you couldn't just look at an individual patient and say, "What are the ethical considerations for this particular patient?" We have to think about the ethical considerations, not only for this patient, but also for society at large because of the scarcity. Is that correct? Alan, go ahead.

Dyer: I was going to say we're wearing two hats when we talk about ethics. On one hand, we're talking about the decisions we make as individual physicians and as people in our day-to-day lives. On the other hand, the larger questions are policy questions, which aren't questions that we as physicians will make. We will become part of a larger conversation with society, and we're very concerned about how the decisions will unfold, but that's very different from the decisions that we make in our role as physicians with our patients.

Bernstein: From a layperson's perspective, we hear that the instructions to the EMS team are that if somebody is dying, they shouldn't even bother to bring them to the hospital. What can you say about that? Although it has societal implications, that's an individual decision that an EMT or a physician has to make.

Brendel: This was really a shift in the discussions we were having. In Boston in particular, we would have a meeting every week with leaders in ethics that involved how we were going to make these decisions. Of course, where you are in New York, Dr Bernstein, we were watching very closely what was happening and learning from our colleagues there since you were a bit ahead of us in terms of the peak of the pandemic.

Really, the notion that it could actually happen was something we always knew was possible — that an individual physician would be in a position to deny care to a patient and eclipse their possibility of rescue or survival because of a societal prioritization that came between the individual physician and individual patient, as Dr Dyer was talking about.

We always talked about things like crisis standards of care. We never really imagined the reality that this would face us front and center. That was really the place that caused not only a lot of distress but also reexamining and revisiting the ways in which we make these policy kinds of decisions.

Bernstein: What guidance did you decide to give people about that? I know it was hard, but what is the guidance?

Dyer: Maybe we could use Washington, DC, as a third pole in this discussion because we didn't quite get to the point of rationing health care. The whole idea was to avoid by preplanning as much as we could — and it wasn't clear that it would work out — so that the individual physician didn't have to make that decision. There were committees set up that would talk about the algorithms used in making the decision for who would be admitted to the ICUs. This is so the doctors actually caring for the patients would be directly involved. It didn't happen that they had to minimize care, but this is if it was minimized. Fortunately, we didn't get to that point.

Another thing that we did in Washington was that all of the hospitals got together. Everyone was using the same algorithms, so there wouldn't be any opportunity or temptation to jump from hospital to hospital or shop around for where you might get a better situation.

Brendel: Yes, and that's really the experience we had in Boston as well. The Department of Public Health really took leadership on crisis standards of care. We prepared, as I talked about earlier, and tried to gain and pool as many resources as possible, to avoid cherry picking, so to speak, about which hospital to go to.

Also, we had enough time and enough warning to be able to engage multiple voices from the community in how to establish these crisis standards of care, which were adopted but ultimately not implemented. We were able to avert the crisis but begin to have these really important conversations.

Bernstein: I know I keep pushing you on this, but I'm really glad that we were in a circumstance where it didn't have to be implemented. One important thing you both alluded to is the fact that the importance of common agreement about the process to be followed was really significant. This way, it didn't create a multitiered system where one hospital did one thing and another hospital did another, or that one doctor did one thing and another doctor did another.

I've also heard the "almost" cases in California. None of us are there right now, and I haven't heard it has come to this, but I am hearing about the discussions. Is there anything you can say about the principles, even with the great relief we have at the moment that we haven't had to go there yet — and hopefully we won't have to.

Brendel: Let me start us out, and I'll invite Dr Dyer to jump in. In a situation of urgency and exigency coupled with scarcity, we turn to what we would call a utilitarian approach initially to thinking about allocation. This mostly means we get the most bang for our buck, and we maximize our outcomes so we avoid situations in which we allocate scarce resources to those who could not benefit. We ultimately try to think about doing the most good for the most people, which might mean that in the process, there are certain individuals who get left out. We can come back to that and talk about why that becomes problematic. That's really where a lot of the concern came up.

That seems like an easy principle. Number one, however, we weren't sure early on who was going to survive, so survivability became a really important metric. Then we also had to think about survivability for what period of time. That's another place where there were big debates about how we would define who would come first, so to speak. That's really where a lot of this started. I'll ask Dr Dyer if he wants to jump in. This is something he's given a lot of thought to.

Dyer: I think the question you're asking, Dr Bernstein, is that we're in a pretty good place so far compared to where we might be as the curves escalate upward rapidly. Yet we may be facing the things that we haven't yet had to face.

As Dr Brendel said, it's a utilitarian calculus. One of the things about the utilitarian calculus, or the greatest good for the greatest number, is that it's hard to say exactly what good is, and it's hard to calculate how it's going to play out. It's really very challenging.

One of the principles we're talking about in the larger sense is justice, transparency, solidarity, and community engagement. Who decides these issues, and how are they going to be decided?

We can go back to some of the early decisions in renal dialysis when it was first available and before Medicare paid for it. There were committees set up that tried to make these decisions about who was worthy of getting the care available. They were called disparagingly, and I think the disparagement is rightly labeled "God committees." The committees involved physicians and nurses and members of the community and clergy of various denominations. There's no way to get it exactly right.

The way this was ultimately solved was by making it available in Medicare so more resources became available, and these hard decisions could be avoided or at least kept at a greater distance. Something similar happened in psychiatry with PTSD before it was a recognized diagnosis in DSM-III. People who had PTSD symptoms, usually Vietnam-era veterans, had to specifically sue the government for their care, and this changed very much when the resources became expanded.

In a sense, we're in a similar era right now in that resources have perhaps been artificially constrained over the last several months. Now we can hope, and I imagine it will be a major push, to make resources available in ways that they haven't been heretofore.

Bernstein: I'm going to switch gears slightly here and move from, if you will, the life and death ethical decisions to decisions about the vaccine rollout. This probably hints at the scarcity question, but more at the issue of who gets it when. What are the general ethical challenges now around the vaccine distribution? I think there's a fair amount of confidence that, ultimately, there will be enough vaccine. We can also talk about vaccine hesitancy ethically. Could you comment on this situation as well?

Dyer: One of the things to say is that it's also a question of who gets the vaccine in terms of who will benefit from having it. The other is what is the good going to be of forestalling the spread in the population? Part of it is balancing these two considerations against the resources available.

Brendel: In particular, I think it brings up a number of considerations we have about who we ought to be concerned about and take care of in particularly vulnerable populations. Individuals living in institutional settings from nursing homes all the way to correctional facilities really have very little ability, and in many cases no ability, to find an alternative that would be safer.

They bore a disproportionate impact of COVID-19 infection at the time of the shutdown when people were confined to their living spaces. We can also think about other individuals. This of course affects many chronically mentally ill individuals who live in group, semigroup, or semi-institutional kinds of settings or congregate living settings.

With the vaccine, there is this added question about what the risks are to different populations. Certainly, cohabiting individuals living in these group and institutional settings were at much, much higher risk. Then there's the question of healthcare workers. By the time the vaccine came out, we did have good data about risk stratification and who is at highest risk. In the setting of availability of PPE, the rate of transmission for those who were not necessarily doing aerosolizing procedures and having prolonged patient care contact was actually much lower.

On the one hand, we say we need to vaccinate healthcare workers so they don't spread COVID-19 to others and they are still available to care for patients. On the other hand, the data were a little more complicated for this because there were clearly levels of individuals whose clinical contact or care contact did not place them at the same kind of risk as persons with higher vulnerabilities. That was something really different.

It was also different in the in the setting of asymptomatic carriers and the lack of community testing to understand the second part of the conundrum that Dr Dyer brought before us — in vaccinating, who would we really be decreasing the spread and the toll of COVID-19 within the community?

There are so many different pieces. This drives home the point that we can come up with a lot of principles and a lot of ethical judgments and ideas, but that moral judgments very much turn on nonmoral facts. For example, the lack of availability of surveillance testing in many settings turned out to be something that limited our ability to implement the ethical choices or goals we set up for ourselves.

Bernstein: Similar to the question that I asked before — Dr Dyer, maybe you can answer this — what principles do you then espouse when you're trying to weigh all these different considerations about who has access, who needs it the most, where they are, et cetera?

Dyer: Right. When we identify principles, we generally identify them by a word or a phrase that connotes a very complex situation and tries to distill it into something much simpler. Take justice, for example. Justice is important, but justice is very complicated, and what does it mean?

In terms of these allocation decisions, one of the principles that becomes more important is transparency. What are the algorithms, and how are decisions being made? We can argue with the decisions. We can argue with the algorithms. We can argue with the principles. We can't do that unless we know how the decisions are being made. Transparency becomes a very important consideration, especially in a situation like this.

Another principle that's very important is community solidarity. The American philosopher Wendell Berry says the smallest unit of health is the community. If we stop and think what the smallest unit of health is, we might be tempted to say it's the individual. We might be tempted to say it's the cell. But Wendell Berry says it's the community. In a pandemic that affects everyone, community solidarity becomes very important in terms of each of us getting the care we hope for and need and also in that we recognize the needs of others as it unfolds.

Bernstein: I experienced a circumstance this morning that, in a way, gets to your community piece, Dr Dyer. I was in a small coffee shop that probably had safe spacing for four people. It's a coffee shop I go to every day. A woman approached the counter to give her order. I couldn't see her because she was in the back. The server said to her, "Do you have a mask?" She said, "Oh, no. I don't have my mask with me."

Another minute or so went by and he said, "Would you like a mask? I will give you one." She said, "No, my mask is in the car." I said, "Could you please give her the mask for the benefit of all of the rest of us?"

I felt a little weird about doing that. But we're talking also about the ethical responsibility, if you will — maybe I'm not using the term correctly — that we have about making decisions and principles like this as members of the community, not just as people. Would you say that this is a significant piece of this discussion?

Brendel: Clearly, a significant piece that has played out is how we reconcile this notion of American individualism and individual freedom with these notions that Dr Dyer has been talking to us about. These are community responsibility, our obligations to others, and even beyond that, as a physician, your responsibility in this scenario to public health and to advancing the public health.

How do we really start with the science and the conversation that says it's actually not all about me or one person, but that we actually do have at least reciprocal obligations, if not primary obligations, to the health of those around us. I think what you're bringing up is a really important part of one of the reason why, in the US, we're still having a conversation about face coverings when we know that masks work. How do we square the ethics with the legal principles and some of the values that our society is formed upon?

Dyer: That's the situation that leaves you, Dr Bernstein, and all of us scrambling when we're in a situation where people refuse to wear masks or decline to wear masks, or even when the wearing of masks has become politicized. I think that challenges the notions of the common good and responsibility that we have to one another.

I think in the broader sense that Dr Brendel just mentioned, everything we know about public health; everything that we've learned about infectious diseases since the time of cholera; all the infectious childhood diseases; and HIV, SARS, and H1N1, is absolutely applicable here. We haven't been able to do things like contact tracing because of the tension between individual freedoms and rights and public responsibilities and the common good.

Bernstein: That may easily segue into the question about what it means for the public health system to be trustworthy. Is part of the challenge we have that people are struggling to some extent with their individual rights vs the common good? Could you touch base on that a bit?

Brendel: Let me start, and then we can have a conversation about this. The question here starts really with the transparency that Dr Dyer was talking about. If you don't know what's happening, these are life and death decisions we're making, and they're happening in a black box. How can you trust the system if it's not predictable and doesn't include public engagement, community values, and the interests of persons and groups of persons, or communities or persons — using the word community, of course, in a broad sense.

Rather than just saying, "Trust the system, go along with what we're saying," how do we, as those in the medical profession, both show and prove that others can trust what we're doing? We start by making it clear the parameters we're using. And we have to hold ourselves to exercising these values and holding ourselves to them.

Then we really have to be clear about the science. We have to be clear about what the responsibilities will be. For example, in the vaccine trials, what happens if somebody gets ill. We would make sure there is access to treatment and medical care regardless of insurance status, where a person is living, or their background. We have to really bring forth in very clear terms, credible evidence about both the contagion and features of COVID-19, and also about the efficacy and side effects or experiences of those who go on to get vaccinated. That would be one of the first steps.

Dyer: One of the things that's very important in public health — and I think of my friends in ministries of health and other places — is that they spend a lot of time in communication, picking up on the theme of the importance of the science and the accuracy of the science. And to not only work with the health departments or the government agencies, but work closely with the media so the messages are very consistent. This is what you need to do.

Again, we might think of some of the other viral infections like HIV, H1N1, and SARS. A clear and consistent message is important and what needs to happen. We have as a federal kind of government, many different voices saying a lot of different things, which only complicates the challenge that we face.

Bernstein: That was part of a question that I was going to raise. Part of transparency is also accountability. When we talk about transparency, we're making an assumption that if we say something is transparent, it is truly transparent as opposed to fake news, as it were. Part of what's happened here is that the public in general has lost faith in understanding what's transparent or what it means to be transparent.

How do we, as a nation, as a country, and as public health officials and doctors, go about trying to restore faith in truth and transparency? This is central to what you're talking about with these ethical challenges.

Brendel: Yes, that is a big question. We'll see how it plays out, and we'll see what works. Another living laboratory, so to speak. Some of the things we can also do, in addition to working with communities and working to disseminate information, is to work with other trusted institutions and persons within the community to disseminate this information.

One thing that's been effective and needs to happen, for example, in predominantly Black communities where there's justifiable mistrust of the medical system for so many reasons, is to work with faith leaders and religious communities. We should work with those who are trusted and to establish a trust in the science and in the accountability and the responsibility for treating persons fairly and equitably, as well as provide care based on science.

That's another thing that sometimes we don't think about. As physicians, we are so used to thinking that if it's science, it must be trustworthy. We need to give people the opportunity to ask questions through other trusted leaders, and to show and model through relationships. In Philadelphia this weekend on public radio, Black physicians were going into the community to provide vaccinations — this is really, really important, not just to talk about and quote science but to show through relationships and actions.

Dyer: That's an important example. Another important thing in the discussion that may be counter-intuitive is that the message needs to be simple and consistent. We're used to thinking of the complexities. It's important to think of the complexities, but it needs to be a simple and consistent message.

I'm reminded historically of smallpox vaccination. One of the reasons we're even here to be able to talk about this, perhaps, is because George Washington vaccinated the troops, and Abigail Adams had to decide whether she was going to vaccinate her children and take the risk of that. Some of the children she vaccinated and they survived. I think she did not vaccinate one of the children, and that child did not survive.

It's kind of a daunting prospect to say they're going to put something in your arm and you don't know exactly what it is. We sort of have a sense of what mRNA is, but many people don't. Vaccinations are daunting prospects, really. Those of us who have faith in science and know how to look at the data to try to make sense of the data are privileged in a way that somebody who is more vulnerable to fears and uncertainties may not be.

Bernstein: I have two questions that may be related or may not be. One is how we know when people are being treated fairly and equitably. The other, which is a little bit of an aside, is how to ethically deal with the challenges of people who are anxious or resistant or don't want to take the vaccine.

Brendel: You gave us both pause in answering those questions, so they are obviously outstanding questions. One of the problems is that we need to collect better data, and we need to be really clear about what we're doing and how we're doing it. In the vaccination realm, we already had a fair amount of distrust about vaccination within our society. There is this mystery. There has been a lot of mixed-credibility science around it.

We need to be clear about how many vaccines have been administered and prepare people for what the side effects might be. This is so they are ready and not surprised, and do not say, "nobody told me." This also means keeping data and being clear about what the serious side effects are, what they look like, and what happens at that time. We need to keep demographic data, looking at the administration of the vaccine and measuring it against the policies and the prioritization of vaccines. This is to make sure the allocation is actually happening in the ways we said it was happening. If it is not, then correcting course and showing a real engagement in that we do what we say and we say what we do. Those two conversations together become really, really important. I'll stop there. I'll let my colleague take the second question or jump in on the first one.

Dyer: One thing I think is important to say again is whom do you trust and how do you develop trust? Maybe you think a little bit about psychiatry's contribution to ethics as well as the contribution of ethics to psychiatry. One of the things that we, as psychiatrists, take to be very important is dealing with people's feelings, fear, uncertainty, and anxiety. That's part of your question, Dr Bernstein.

Then, we need to recognize that when we say we think a medicine might be useful to somebody, it's a process of informed consent. It's informing them of the information with the recognition that they have a decision to make; it isn't a decision we make.

One of my patients said recently he didn't want a colonoscopy. I said to him, "You don't have to have a colonoscopy, but most people feel that the inconvenience of the colonoscopy is worth the benefit." He began to think of it that way.

I also had a patient who was on lithium for bipolar disorder. I said, "You don't have to take this. Of course, we know when we write the prescription, patients may not fill it. They may not take it." She said, "Oh, I didn't realize that. No one ever said that." I replied, "But to follow up, you realize the consequences of not taking it — but it isn't because I told you that you need to take it."

I think it is similar with vaccines in that you can't just tell people this is what they need to do. They have to see the benefit for themselves as well.

Brendel: To that point, on one hand, we've been talking about trusting the science, trusting the facts, and making a rational decision. On the other hand, especially as psychiatrists, we know that feelings, emotions, and experiences weigh heavily into these decisions.

One of the ways in which we can have the discussion about the benefit of vaccination, for example, is to use both. What if I told a patient it could prevent them from dying — the rational conversation — but then also engage the affective conversation. This means not just discussing the individual themselves but who they love most in the world. If it's a parent or somebody who is at high risk or vulnerable, I would ask the patient if they would be willing to get vaccinated to potentially save someone else's life or prevent somebody they love from getting sick. This means broadening the conversation just from the individual and a seemingly disembodied decision on the facts to one that really resonates with the circumstances and the important relationships in their lives.

Bernstein: I think you're both talking about how important communication is, what the communication is about, and the relationship. I heard from someone what I think is a very good way to start the conversation about the vaccines. They said to say, "What would make it possible for you to take the vaccine?" It's turning it around. It's like you're saying you don't have to take your lithium and you don't have to do the dialysis, but this is what will happen.

I think it's also about respect for each other, which has been a huge challenge here. Are there some other issues I haven't raised that either of you would like to mention before we have to wind this up?

Dyer: One of the things that troubles me greatly is an issue we haven't solved in decades in terms of the distribution and access to health care in this country. In this situation, we have a global pandemic that's affecting everyone in one way or another and a massive unemployment with health insurance being largely tied to people's employment and decisions their employers make. This is something we've got to figure out. It may be if there's any opportunity in the crisis, it will be the opportunity to think long and hard about how we can make a more just and equitable system and help everyone who needs it.

It isn't just that we need it for the health care we get. We need it for the benefit that everyone gets from having a healthy population, a healthy workforce, and a healthy military force, as in the case of the George Washington example with the colonial army. It's something that's very serious. It would be nice to say Medicare for all, but that's very complicated. Or, maybe the government does it or private insurance does it or the private sector does it in some way. How can we merge and recognize and reckon with all of these disparate concerns to come up with something that's better for everyone?

Brendel: One piece I would also add is the importance of mental health in overall health. There have been a couple good parts to the story around innovation, and access and delivery of mental health care. One in particular is the ability to implement telemedicine relatively quickly in ways that do help many patients access mental health care. Our suicide rates are up, our overdose rates are up, and our rates of violence are up.

We need to use this as an opportunity to treat physical and mental illness, but also to think about the ways we can reintegrate mental health care into overall health and treat the whole person. I do worry a little bit about this. On one hand, it's been great innovation. People show up for their psychiatric appointments. They have access to psychiatrists who are far away. On the other hand, we do not want to lose the importance of the personal connection and the availability of in-person psychiatric care — the same way we've prioritized in-person physical health care.

Bernstein: Thank you both very much. I'd like to thank my guests, Dr Rebecca Brendel and Dr Allen Dyer, for a very stimulating discussion. The last point you raised, Dr Brendel, is one that we could have another podcast on. Again, thank you all. I'm Dr Carol Bernstein.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: