Times of crisis generate extreme moral dilemmas: situations we can’t begin to imagine, unthinkable choices emerging between options that all seem bad, each with harms and negative outcomes. During the COVID-19 pandemic, these moral dilemmas are experienced across the healthcare landscape — from bedside encounters to executive suites of hospitals and health systems. Who gets put on a ventilator? Who transitions to comfort care? What does end of life care look like when high flow oxygen can’t be used because of viral spread? Who gets a hospital bed? How do we choose which sick person, with or without COVID-19, gets treated? Which patients should be enrolled in research? How do we support patients when their families cannot visit them? We will turn away people who, in any other circumstance in a U.S. medical facility, we would have been obliged to treat. We will second guess these decisions, and perhaps be haunted by them forever. We only know one thing for sure: people will suffer and die regardless of which decisions we make.

How should we confront these intense challenges? Many institutions are doing what they can to provide guidance. But “guidelines” by design are intended to provide broad parameters to aid in decision making, and therefore rarely address the exact situations clinicians face. Certainly no guidelines can reduce the pain of having to actually carry out recommendations that affect an individual patient.  For other decisions, front line providers will have no guidance at all, or will have ill-informed, or even potentially harmful guidance. In perhaps the worst case scenario, they may even be encouraged to keep quiet about their concerns or observations rather than raise them to others’ attention.

As bioethicists, we know that moral dilemmas require personal moral courage, that is, the ability to take action for moral reasons, despite the risk of adverse consequences. We have already seen several stark examples of moral courage from doctors, nurses, and researchers in this outbreak. In late December in Wuhan, China, a 34 year-old ophthalmologist, Dr. Li Wenliang, raised the alarm in a chat group of doctors about a new virus he was seeing. He was subsequently punished by the Chinese government. He continued to share his story via social media, even from his hospital bed, and was repeatedly censored. Dr. Wenliang died of the virus on February 7. Many credit this young medical professional with making the world aware of the approaching disease pandemic.

In Seattle, epidemiologist Dr. Helen Chu demonstrated great moral courage by reporting critical data to health officials despite instructions from federal officials to remain silent. As Director of the Seattle Flu Study, she wanted to test samples from her study participants for COVID-19 to determine whether the virus had already arrived in Washington state. When she made the request to do so, she was denied authorization. Feeling an ethical obligation to help in a way only she could, she proceeded without approval on February 25. Her team quickly identified a teenager with a positive test who had no travel or contact history, demonstrating community spread. They reported this information to the local public health service, just before the teen returned to his crowded school. Even then, the federal government reportedly served her with a cease and desist order. Dr. Eric Ding from the Harvard Chan School of Public Health has called her “an American hero” for her courage.

On March 5 in California, an anonymous Kaiser medical facility nurse released a statement outlining concerns about testing delays for infected frontline healthcare providers. Despite her illness and quarantine, the CDC initially denied her the test because she had worn basic protective gear as recommended, despite evidence that such equipment is not 100% effective at preventing transmission. Even after she was tested, the results were delayed by backlogs and prioritization in the testing process. In a letter shared with the media she wrote, “This is not the ticket dispenser at the deli counter; it’s a public health emergency!” and “I am a registered nurse, and I need to know if I am positive before going back to care for patients.” By speaking out, she called attention to the public health imperative to test healthcare workers promptly, and to the critical bottlenecks in the testing pipeline.

What Medical Providers Can Do

As bioethicists, we teach medical students, residents and fellows that every clinical encounter involves moral and ethical decision-making. As these three stories illustrate, the pandemic sharply focuses this paradigm and raises the stakes. What can clinicians do when faced with these kinds of moral dilemmas?

The answers are both undeniably simple and frighteningly difficult. Ask questions and speak up. Be brave. Stick your neck out.

These actions are especially urgent when you worry that no one else sees what you see. People around you may be too afraid to speak up and some will thank you for saying what they couldn’t. Organizations of all kinds are poorly designed for receiving, processing, and responding to front line concerns, especially when they challenge the status quo or conventional wisdom. These are extraordinary times, and with them come an extraordinary moral imperative to speak up, to ensure that the structures of normalcy do not silence the urgent needs of the crisis. In speaking up, even when it risks one’s job, providers can help changes happen before it may be too late to save lives.

As a clinician, if you find yourself in need of support in these exceedingly challenging times, look to the resources, and particularly ethics consultants, at your institution. Ethics consultants are well versed in thinking through trade offs in cases of conflicting values in the application of utilitarian perspectives in disaster resource allocation, and in the navigation of professional moral duties. They can also help raise emerging front line issues to senior leadership for consideration, and can provide guidance in situations of moral distress. For providers facing moral dilemmas at the bedside, they can be an advisory resource in real time, available remotely, for thinking through options with moral courage.

Unfortunately, not every institution has trained ethics consultants who are available for this kind of guidance and support. In their absence, some providers may find ethics expertise elsewhere, either through their professional societies or through resources that are being made publicly available.

What Leaders of Healthcare Institutions Can Do

 If you are a leader at a healthcare institution, what can you do to facilitate moral agency and moral courage by healthcare providers? First, institute mechanisms to solicit front line perspectives and concerns. For example, institute a 24/7 hotline or email account to field direct concerns from any front line provider. Such efforts can provide open channels of communication, providing eyes and ears on the ground, and allowing mechanisms for feedback and reasoned judgment.

These easy-to-create mechanisms can allow leaders, as President Barack Obama once said, to “break through the bubble” that may insulate them from critical information in a timely way. Equally important is fostering a non-punitive culture of transparency. Make it clear, ideally in writing, that individuals will not be punished for raising concerns, so that they are not inhibited by potential risks to their employment or job security.

The healthcare enterprise is working in the midst of deep uncertainty. As they must, our leaders are focused on fixing the parts that need the most attention. But we must create systems for them to monitor the important ideas from the bedside.

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We need to make it easier for heroes like those described above to raise alarm bells and ask tough questions. And we need to encourage and support our providers and leaders in demonstrating moral courage in each clinical encounter, policy and decision. In a time of crisis, moral courage must be as obvious, and as omnipresent, as the sanitizer at each examination room’s door.