News and Commentary To Navigate Ethical Dilemmas, Craft Strong Policy and Nurture Strong Character

In the months following the launch of Knowing Better, Doing Better, the Macy Foundation’s new strategic plan, I have been busy sharing details with partners and gathering valuable feedback about our three core priorities:

  • Promoting Diversity, Equity, and Belonging
  • Increasing Collaboration Among Future Health Professionals
  • Preparing Future Health Professionals to Navigate Ethical Dilemmas

The inclusion of that final priority, navigating ethical dilemmas, has generated the most questions from friends and colleagues, and even a little pushback. They readily acknowledge that ethical dilemmas exist in clinical learning environments, but some have asked if they occur frequently enough to merit a top-three position.

I will address that question in this blog post, drawing on my personal experiences as a young physician and later as a residency program director and dean. I will also describe how the COVID-19 pandemic has surfaced many ethical dilemmas for health professionals and learning institutions.

Learning to navigate ethical challenges is a critical skill that helps forge a professional identity. Without a strong ethics-based foundation, young professionals can feel overwhelmed when encountering tough dilemmas. Cognitive overload can evolve into cynicism and ultimately turn into burnout that may cut short promising health careers.

By teaching future health professionals how to navigate ethical dilemmas, learning environments can help avoid that outcome, bringing professional success to their students, better care to their patients, and improved health in their communities.

Ethical Dilemmas Surface Every Day

As a physician and educator, I know that health professionals are confronted with challenging ethical dilemmas on an almost daily basis.

One of the first papers I ever published shared the story of a 37-year-old man with a history of drug use and alcoholism, who needed a costly artificial heart valve. He had been admitted to a private hospital, and surgeons there were reluctant to operate, in part because his Medicaid coverage would not cover costs for the expensive procedure and recovery.

In this case, the care team wrestled with two competing ethical principles: the imperative to provide quality care and the need to maintain economic sustainability, to protect the institution’s ability to provide community care. After much debate, the patient was transferred to a nearby public hospital where he underwent valve replacement surgery and was discharged eight weeks later.

My coauthors and I advocated for policy and process changes to address cases like these. For example, we suggested creating standing hospital ethics committees to assist clinical decision-making and increasing government funding for Medicaid and other health programs.

These kinds of policy and practice changes are important, but process improvements are only part of the solution. Ethical decision-making ultimately depends on the strong values, integrity, and confidence of individuals throughout the care team.

Through our new strategic plan, the Macy Foundation aims to help clinical learning environments model professional behaviors, craft wise policies, and teach learners how to approach ethical dilemmas in clinical practice, so they can navigate their own way forward. We will elevate promising models, bring leaders in the field together, and share the best approaches with learning environments throughout the nation.

COVID-19 Raises Ethical Questions for Learning Environments

The COVID-19 pandemic has presented many difficult ethical dilemmas for health professionals and learners. It started early in the pandemic, as health professions schools cancelled rotations for medical and nursing students, in part to protect limited supplies of personal protective equipment (PPE).

As equipment shortages reached critical levels, health leaders also grappled with the ethics of requiring doctors, nurses, and other health professionals to provide care for potentially infectious patients when the most appropriate PPE was unavailable. In some cases, nurses planned to substitute garbage bags for protective gowns, and hospitals reused masks intended for single use.

Providers understand that during health emergencies, we must accept more risk than usual. But ethical practice also requires providers to protect the health care workforce to ensure continued access to care.  

There is no single “right answer” to ethical dilemmas like these, but engaging in tough discussions is critical now, because the issues will only get harder in the months ahead.

When a COVID Vaccine Becomes Available, Who Should Be First in Line?

Although it is not my personal area of expertise, preliminary reports suggest cause for optimism that a COVID vaccine could be successfully developed and ready to begin distribution either late this year or early next.

Although pharmaceutical manufacturers will scale production at unprecedented speed, it will take months to produce billions of doses and distribute them around the world. In the first weeks of vaccine availability, when supplies will be very limited, governments, health systems, and individual providers will have to make ethically challenging decisions about prioritization and allocation.

Allocating scarce resources during pandemics has been studied by The Centers for Disease Control and Prevention and many others. Everyone agrees that health care providers, first responders, and professionals supporting vaccine manufacturing are important targets for prioritization.

After first responders, high-risk populations should receive priority. However, determining which populations are highest risk is a difficult task, and one that requires a strong ethical core. As trusted experts in their communities, leaders of clinical learning environments can help guide those discussions.

For example, incarcerated populations face high risk for COVID-19 primarily because of overcrowding in prisons and high prevalence of chronic disease. Although the science is clear, it is easy to imagine public and policymaker backlash to the idea that convicted criminals should be prioritized ahead of non-incarcerated community members.

Despite the pressure, leaders of health care learning environments are well-positioned to help craft prioritization policies in their communities and communicate why these decisions are appropriate and ethically centered. Surveys show that public trust in government and media is near historic lows, but confidence in scientists, particularly health care practitioners, remains comparatively high.

Leaders at health learning institutions are often hesitant to engage in public debates like these. Some worry about “staying in their lane” as educators, and others may fear the aggressive public backlash that can result from advocating for controversial policies, even when those policies are strongly evidence-based. In recent months, several public health leaders have been threatened with violence or forced from their jobs for advocating mask use and other COVID-related interventions.

Despite the risk, speaking out now is critical, for three reasons:

  • The stakes have never been higher. During this pandemic, strong science-based guidance is desperately needed, and health leaders are well-positioned to offer it. This is both a moment of truth for health leaders and an unprecedented learning opportunity for students.
  • Advocacy is a core professional responsibility for health professionals and their learners. Crafting policies that benefit public health and welfare is just as important as providing quality health care.
  • Engaging in policy debates now will set an example for today’s health care learners that   may inspire them to engage in the process throughout their careers.

Plans and Policies Matter. Character Matters Most.

General Dwight D. Eisenhower is sometimes credited with the famous quote, “Even the best battle plan does not survive contact with the enemy.” With this aphorism, military leaders are taught to lean on their training, while understanding that in the heat of battle, they will have to make difficult decisions on their own.

Health care learning environments must teach the same lesson to their students. Wise public policies and sound institutional practices will inform ethical decision-making, but nothing can replace the good judgment of prepared health care providers acting with strong integrity.

Thinking again toward the day when a COVID vaccine becomes available, health care learning environments are certain to face difficult decisions when VIPs seek to cut to the front of the line. Even in normal times, ensuring equal treatment for all patients while addressing VIP requests is a common ethical dilemma for health professionals and leaders of learning institutions. These requests are certain to occur with greater frequency during a crisis like COVID-19.

Nurses and allied health professionals face related dilemmas when asked to implement ethically questionable orders made on behalf of VIPs. Many are reluctant to speak out, fearing professional and social repercussions. This can lead to the moral distress that often precedes burnout.

Learning environments can help prepare future health professionals to navigate situations like these in clinical settings by teaching the core principles of ethical practice and providing frameworks for approaching difficult dilemmas. Guided by these foundational lessons, learners can practice applying them through simulations and collaborative project-based learning exercises, ideally involving students in medicine, nursing, social work, and other disciplines.

These simulations cannot anticipate every dilemma, but they can familiarize health care learners with the pillars of ethical decision-making and the value of working through challenges as a collaborative team. Having this strong foundation in place toward the beginning of a health career will reduce risk for cognitive overload and mitigate the risk of burnout that might otherwise shorten promising futures in health.

Collaboration, Equity, and Ethical Dilemmas: They’re All Connected

I began this blog by explaining why ethical dilemmas were important enough to be included among the Macy Foundation’s three core priorities. I close by noting how these priorities are closely interrelated.

  • Establishing vaccine distribution protocols presents difficult ethical dilemmas and requires a strong focus on equity. Historically, learning environments have not done enough to dismantle health inequities in the communities they serve. Hopefully, a combined focus on ethical practice and promoting equity and belonging can put us on the right track.  
  • Similarly, empowering all members of the care team to speak up when they have ethical questions requires an emphasis on collaboration in psychologically safe environments. The evidence is clear that collaborating across disciplines leads to better functioning teams and fewer medical errors.

We will get the best results when all three areas of our strategic plan work together: equity, collaboration, and navigating ethical dilemmas. By advancing all three priorities, we can improve outcomes for patients, future health care professionals, and the communities they serve.

If you have ideas about how learning environments can prepare future health professionals to navigate ethical dilemmas, I invite you to share your ideas with me at president@macyfoundation.org.

Help us know better, so we can do better!

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