Coronavirus in Context: COVID Is a Perfect Storm for Ethical Challenges

[MUSIC PLAYING] Hi, everyone. You're watching Coronavirus in Context. I'm Dr. John Whyte, Chief Medical Officer at WebMD.

Today I'm delighted to be joined by one of the world's foremost authority on ethics, Dr. Arthur Caplan, Professor of Bioethics at NYU Langone Medical Center. Dr. Caplan, thanks for joining me.

Thank you for having me.

I have so many questions for you. So I'm going to start off with something that you wrote for Medscape. You talked about if you refuse to distance, you should bypass care. Not that you don't get care, but you're not first in line.

So you're a bioethicist. Some people may say, Dr. Caplan, that doesn't sound ethical. You treat who comes in the door. So walk us through your thinking.

So it's obvious that medicine prides itself on treating everybody, sinners, saints, whoever it is, we teach, and appropriately so, that you shouldn't discriminate against anybody, even if they brought their injury on themselves. We try to treat suicides. We try to treat people who are shot in the commission of a crime. We're not judges.

But what I was trying to do was provoke by saying, well, maybe if you didn't mask, if you didn't distance, if you didn't take precautions and you got infected, then you choose to go to the end of the line. Not the doctor triaging you, but the individual who was irresponsible.

Now, do I really think that's going to happen? No. But what I was trying to do is point out that freedom has consequences. You don't just get to do what you want normally. So you ought to think hard, if you aren't careful, if you don't try to be cautious, and you infect yourself and you get very sick, well, maybe you aren't as deserving, not so much from the doctor's point of view, but from a morality point of view, if there's a crunch for resources, maybe you should forego them. You made a choice. You should bear the consequences.

But in all honesty, that's provocative.

It is. Because I'm going to push on it a little, if I may. That's a slippery slope. We used to say that about alcoholics and liver disease, early on recognizing that substance abuse is a disease. We don't say to people, if you don't take your hypertensive medicines and you develop kidney disease and need dialysis, you should take yourself off the option for a kidney transplant.

So how is it different here? Is it because you might be infecting other people as well? It that the component?

Well, there is a bigger danger that you're going to put others at risk by your irresponsible behavior. There's also the idea that every once in a while, we do do what you said we don't do, meaning there are occasionally people who get their valve infected in their heart from drug abuse. And people start to say, you know what, you don't stop doing that, we can't keep replacing this valve. Now partly, it's a technical issue, but partly it's a threat to the patient to say, you've got to stop the IV drug abuse that continues to damage your heart. We can't fix it.

There are occasionally situations, too, where we, if you will, say, we're going to make a contract. You do this. I do that. You do this. I do that. And occasionally, a physician has been known to dismiss a patient, not because they didn't try to take care of them but because the patient just was totally not cooperative, unwilling, didn't go along. But again, to be frank, I don't think we're going to make that a policy and I don't think we should.

But it's a reminder, look, if you don't take precautions about protecting yourself and others, and we're really in a rationing situation, you've got to think about what you're doing in terms of not taking those precautions. That was really the point of that threat.

Because I could say, two people come in, both with severe COVID. We have limited monoclonal antibodies. Someone doesn't wear a mask, didn't believe it. The other person did everything that they could. Masks aren't 100%. So they still somehow got infected. Do we treat them equally?

Well, you're suggesting you might look at that situation, if they'd literally arrived at the same time, and still flip a coin.

It could happen.

It could happen. So I'll turn around and push you. Would you, flip a coin?

You know, as a physician, we want to try to take people's own individual behavior out of the equation at times, so we're not the judge. And in some ways, you're the expert. Do we flip a coin? In some ways, there's some fairness to that. But you're right, in real practice we don't do that. In some ways, it's a first come, first serve too.

Yeah. Let me put it this way. Here's a situation. The robber and the victim come in exactly the same time, series wounds. One ICU bed. You gotta make a choice. I think most people are taking the victim before they're taking the robber, although they'll treat the robber. But it would play on the minds of many that they wouldn't just flip a coin.

All right, Dr. Caplan. Let's turn to vaccines. Lots of controversy there. But let's take for granted and stipulate we'll have a vaccine at some point. But it's not going to be available for everyone. So is it ethically sound to say, we'll prioritize? And we'll prioritize first responders go first. Make sense? And then we have a system in terms of prioritization. Is that ethically sound?

It's ethically sound. And we're going to do it. I'm going to tell you that that's going to happen. It won't be a lottery. It will be a random use of vaccine. We're going to get vaccine, but we're going to get it slowly. So limited supply will be there and we're going to have to ration it. There won't be enough for everyone. And I know there are many people who are saying, I'm not going to take a vaccine. A trust issue is there, and there may be many refuses. But still, there'll be a lot of people who want it.

The first thing that's going to count in distributing vaccine is practical issues. Some of these vaccines, not all, but some require a lot of refrigeration, serious refrigeration.

Already right now do.

Special handling. You know, you're going to get a vaccine if you're near where the refrigerator is. That's simple. If you're in rural Montana, I don't think you're going to have the refrigeration capability and you won't be first.

So it's more likely that a practical variable, where did the vaccine ship to. We're hearing that each state is going to get an allotment. And I'm not sure that's going to work out, because some states are going to have bigger needs than others. Are we just going to give the same number of doses to Oklahoma as we give to New York and their big population? I don't know. So we have to work that out.

But to the core of your question, after we get through the practicalities, I think we will see people at greater risk probably lined up first to accept or get vaccination before others. That may be the elderly. It may be health care workers who are exposed more. We've seen a lot of breakouts in meatpacking plants. Got to have food. Looks like the conditions that they work under are pretty tough for controlling viral spread. We've even seen it in some poor African-American neighborhoods, seen it on some poor Indian, Native American reservations.

So I think there may be decisions made based upon who's most at risk of dying. And even if we say health care workers first, I don't think there's going to be enough for them. One thing to remember is, and you know this, a health care worker is a doctor, is a nurse, but it's also who cleans the room, who does the laundry, who provides the food, where's the security. Somebody jokingly said to me, aren't you going to vaccinate billing?

So you know, you've got to have the place work. And it turns out that that number of Americans employed in health care service delivery, it's a large number, at least 10 million or more.

That's a good point. Let's talk about the physician-patient relationship. Many people consider communication sacrosanct, like you would with your priest or rabbi. But there's been many people that have been talking that we deserve to know the health of the president of the United States and that the president's physician needs to tell us what we want to know.

So is it different if you're the president? Because that's still his physician. So are people right? Is it ethical to disclose more information about the president than he might want disclosed?

I'm going to surprise you and say the ethics are on the side of the president. The president is a patient. The president has all the rights that patients get, doesn't forgo any of them or waive any of them because he became, or she became, president. All the codes of ethics say privacy first, AMA, ACP, you name it. I've looked at them all. They're all clear. HIPAA says, don't share information unless you're caring for the person, so they need to know, or unless you're billing the person, which is a peculiarly American addition.

So I think everything lines up legally and ethically on protecting the privacy of the president. I don't agree with that. I think we should build some exceptions into the law and say, if you're a president or vice president, you have an obligation to give out more information. The public has a right to know more about your ability to function in the office. If there's any reason to think you're impaired, if there's any reason to think you can't do the job, I don't think we actually care whether the president has athlete's foot. The president had a stroke and they didn't want to tell us and decision making was going into other hands, I think the public should know.

So I favor--

Technically, is it ethically wrong? Because are we really treating the president as an individual? Are we really treating the office of the president and the person who occupies it? That could be different, couldn't it, in terms of--

It should be different. But I think unless we make-- we built in exceptions, for example, for privacy if it's child abuse, if it's elder abuse. There are certain reportable diseases that you're supposed to tell third parties about. And I think we should pass a law that says presidents and vice presidents, because of the office they hold, their doctors are obligated to tell more, even if they don't want that information shared.

But as of now, you think it's ethically appropriate and legally appropriate not to disclose anything that the president or whoever else doesn't want, and that's the end?

I do. I do. And I think the other problem we have is we're not requiring standard physicals of candidates for president and of people in office every year. I would like to see an independent board created not just to handle the president--

Like a life insurance board. Like a life insurance physical.

Well, something like that. Not just when the president gets COVID, but how is the president doing generally? Any cognitive decline? Anything that's impairing, again, the ability to do the office? Have it appointed by the National Academy of Medicine or some nonpartisan group. And let them give us a report every year on the health of the president.

But why doesn't it matter for the president or a senior official, if the doctor is being paid by taxpayers, there's a little bit of a difference there, or not. It doesn't matter?

Eh, I don't think so. Again, people get paid by the taxpayer who are generals. People get paid by the taxpayer who are, you know, other high government officials. I think we have to think this through in a way that doesn't give up the presumption of privacy unless you have a pretty powerful reason to override it. And I'm ready to do that.

Dr. Caplan, I want to ask you about the role of physicians. Because you've talked about-- I'm going to read from one of your articles-- whether do doctors have an obligation to fight COVID misinformation? Why is that my problem? I got 20 other things to do. I'm here to treat the patient in front of me, not to manage social media. So why do you say it's our job to help fight misinformation?

Well, I think it's because of the trust that people have in their doctors. They may say they don't like medicine generally or they don't like the pharmaceutical industry or-- but when you ask people, do you like your doctor? Do you trust your doctor? The answer is often yes. And I hear that all the time.

That means in a sea of misinformation, the best source, the best corrective is the personal physician to the patient. Now I'm not saying you have to spend all your time in the exam room or in the course of treatment talking about COVID misinformation. But I think I would try to put up some brochures in my waiting room saying, here's the real information from legitimate sources about COVID. Here's the situation that comes up in terms of whether you want to ask me questions, I'm happy to answer them.

And then physicians, like everybody else, spend time on social media. They spend time talking at Kiwanis Club or schools or churches, more of it online now than they might have done in person earlier. But they have venues. They have opportunities. There's a chance to go out there and speak up. And I think those chances should be taken. Because if not doctors, then who? If not doctors, then who's got the trust to correct ideas about taking bleach or other crazy stuff that circulates around that vitamins are going to be enough to defeat a virus?

You've been involved in bioethical issues 30 years. Are the issues that going on right now the biggest in terms of what you've been addressing over the past few decades?

I think this is the biggest, most intense period for ethics I've ever lived through. It's partly because when you don't have a cure, when diagnostics are underused, when everything that we try to do to fight the virus depends upon behavior change, masking, distancing, don't get in big groups, maybe don't eat indoors, it's all ethical choices. We don't have anything else. You're in one gigantic ethical tsunami.

So, vaccines, do we mandate them? Experimental drugs, should we make them available earlier? Should only the president get them? When we're looking at issues like behavior, how tough should you be in terms of saying you better wear a mask? Remember, we talked earlier about my provocative idea that you choose not to, maybe you self-punish yourself--

Back of the line.

--like that. Yeah. Everything is turning on ethical choices, ethical ideas. I've never seen anything like it. Never.

How do we know the right answer?

Well, there are three things that I think get us to some reassurance. One is, we try to be transparent and make sure that all the issues are pushed around. I took a stance that's a little bit surprising. Even presidents get privacy. I think a lot of people might argue, you know, the doctor should be overriding that. But I'm going to say until we legislate it, until we change the codes of ethics, no.

How do we know who's right? Well it does seem to me you have to go through the consequences. What could the slippery slope be? What's the implication that people who are just not presidents think? Oh, are they going to waive my privacy if I'm doing something that others want to know about? So you're trying to lay out the arguments and you're trying to be transparent about what the challenges are.

Secondly, you build consensus. We get agreement on things. You know, in medicine we hear about evidence. But it isn't enough to have evidence, because some amount of evidence will persuade people. More is necessary to persuade others. And then you want to know about who did it and how reliable is it and all the other measures we get into about the trustworthiness of evidence. And then we build consensus.

Ethics operates in much the same manner. It's not that there's some ironclad principle that we just say, OK, well, if you violate that, that's it. I think we get there by sort of mounting up what the consequences will be, what the likely fallout will be from following a particular action, and then say the risk of the benefit, it's worth it to do it or it's not worth it to do it, or the consequences are so great.

There are certain things that I think, for example, we might take more risk in a pandemic in allowing some emergency medicines to be used than we would normally do under ordinary circumstances where the world's economy isn't shutting down, kids can't go to school, and society is basically paralyzed.

And the last way you do it is by arguing from analogy from what we already agreed on. So if we agree x is going to be important, informed consent to being in an experiment, then if y is kind of like x, you argue by analogy and say, well, we've accepted this and this and this, so shouldn't we accept this? Those are the ways you sort of drive moral agreement.

Dr. Caplan, I want to thank you for providing your insights today. I want to thank you for being provocative, as well. Because it gets us all to think about how we address many of these complex biologic but also societal issues. Thanks for your time today.

Thank you so much.

And I want to thank you for watching Coronavirus in Context.