Pragmatism vs. ethical choices

[bixaorellana]

Just throwing this out for discussion. We all like to think that we'd unquestioningly do the right, selfless thing, but ....

In New Orleans, fully half of the EMS workers are now out sick. This brings up the uncomfortable question of how many medical workers might be staying home because they don't want to contract a disease with no cure.

The story of the woman in Peckham makes the paramedic who responded to her emergency call sound incompetent and heartless. But if paramedics are not sufficiently trained for this pandemic, if they lack needed protection and backup, what can they do?

Some doctors in the US are hoarding unproven drugs.

Really, it is hard to judge any of these people harshly when some of them are surely thinking, "Why should I make a pointless sacrifice and leave my family to suffer?"

[Kimby]

Nursing home staff in Spain have apparently abandoned elderly residents to their own devices among the dead corpses of their deceased fellow residents. This was discovered by members of Spain’s army brought in to disinfect the facilities.

The only excuse for this would be if the entire staff’s dead bodies were found amongst those of the residents...

[bixaorellana]

Oh lord, Kimby! I read what you posted elsewhere about this, but had not understood that the living residents had been abandoned there along with the dead. Obviously the staff was able to call for assistance, proven by the fact that the army has been pressed into service for civil duty. But apparently they just went running on home, probably taking the virus along with them.

In terms of debate, I think we can all agree that this was overwhelmingly the wrong thing to do.

[Kimby]

Here’s a link:
www.bbc.com/news/world-europe-52014023

The nursing home staff could’ve at least telephoned for help as they were heading for the door....


But what happens when there IS no one left to help?

[Kimby]

Here’s another similar dilemma.

One of the loving caring caregivers who tended to my mother as she was aging and dying is in her twenties and has type one diabetes. She now works at a nursing home, and is stressing out about her elevated personal risk of working in her field as the pandemic worsens.

What should she do?

[bixaorellana]

That is a sad dilemma. She sounds as though she has a true vocation for that work, making it doubly hard to think about giving it up. I would think, though, that her diabetes plus elevated stress level puts her at extra risk, meaning she could be putting her elderly charges in harm's way.

[kerouac2]

I have found the varied reactions of the broadcast industry to be quite interesting.

Of course there are the news channels which have all become 24/7 Covid-19 channels, feeding people's anxieties even when there is nothing new to report for hours, just repeat repeat repeat. And then there are the extremes of the 'normal' channels. One of them is showing nothing but those dreadful made-for-TV Christmas movies. Yet that is the channel that I would probably choose to put on if I were caring for the elderly. Other channels are showing reruns of their usual game shows or talk shows with a crawl at the bottom of the screen: "recorded before the outbreak of coronovirus" so that no one will be shocked by the sight of a studio audience or people shaking hands. Three of the government channels and more particularly the one that has always been aimed at youth have been broadcasting school courses for the various age groups while trying to make them entertaining. I'm sure that in olden times all of us glimpsed at least briefly a show in black and white with a man (always a man) scribbling equations on a blackboard -- that sort of presentation is out of the question in 2020. Some of the principal channels continue live broadcasts with interventions by celebrities filming themselves in confinement at home. There was even a variety show the other night to raise medical money with a mosaic of all of the top stars performing something or other in their living room with grainy definition and flat colours. This was particularly depressing because they basically looked as miserable as the people watching them in spite of their professional fake smiles.

That leaves all of the movie channels, classic or otherwise -- business as usual.

At least there is something for everybody.

[bixaorellana]

Whereas that is interesting, I am apparently missing where the ethical choice element is in it.

[kerouac2]

I was concentrating on the pragmatism of the title of the original post. So if I was off topic.

[Kimby]

Mar 25, 2020 23:15:10 GMT bixaorellana said:

That is a sad dilemma. She sounds as though she has a true vocation for that work, making it doubly hard to think about giving it up. I would think, though, that her diabetes plus elevated stress level puts her at extra risk, meaning she could be putting her elderly charges in harm's way.

Though she is good at her job and loves her clients (and their family members, if our experience was typical), I don’t believe she loves her job. She often complains on Facebook about being tired and how she can’t WAIT for the weekend, etc.

I don’t fear for her clients though, I fear for her own personal health and well-being. She’s young and in love with a great guy and could be jeopardizing her future. Yet she needs the money. Sad.

[bixaorellana]

I think we're at the point that we have to automatically consider ourselves as risk factors for other people, just as they might be risk factors for us.

There were two stories in the Washington Post this morning that point up the hard choices people are being forced to make right now. Apologies for quoting from a paywall source, but the stories can probably also be found elsewhere.

First ~
Some health-care workers resist orders to work without adequate protection
After 21 years in military medicine, there isn’t much that rattles Richard Barnett. He was part of the Marine force that invaded Baghdad in 2003, where he intermittently came under enemy fire.
But during a 12-hour overnight nursing shift at West Hills Hospital and Medical Center in Los Angeles, the working conditions became more than he could accept. Ill-fitting masks. Poor sterilization technique. Worst of all, two patients with covid-19 slipped through the screening procedures, exposing health-care workers who treated them without knowing they were infected, he said.
At the end of the shift, at 7 a.m. March 15, Barnett quit and turned in his badge.
“It was a real obvious choice,” he said. “I either leave before I get sick and possibly get my family sick. Or I leave after I get sick. It was a simple risk versus benefit challenge.”
[The article goes on to say that] some health-care workers have begun to resist pressure to work with inadequate protection ... [and] A MedStar nurse, who said she is working without N95 masks, shoe covers and occasionally without eye shields, said her unit is employing a different kind of pressure. At morning huddles, the nurse, who spoke on the condition of anonymity because she fears she will lose her job, said supervisors have singled out nurses who are insisting on a higher level of protection, telling others “they’re not following our guidelines and they’re using up resources. source

To me it seems clear that those refusing to work under conditions that would spread sickness to themselves and others are making the right decision.
I don't know if others here will agree.

Second ~
Hospitals consider universal do-not-resuscitate orders for coronavirus patients
Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation [about] how to weigh the “save at all costs” approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.
The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient “codes,” and their heart or breathing stops.     ...
Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country’s major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

Several large hospital systems — Atrium Health in the Carolinas, Geisinger in Pennsylvania and regional Kaiser Permanente networks — are looking at guidelines that would allow doctors to override the wishes of the coronavirus patient or family members on a case-by-case basis due to the risk to doctors and nurses, or a shortage of protective equipment, say ethicists and doctors involved in those conversations. But they would stop short of imposing a do-not-resuscitate order on every coronavirus patient. The companies declined to comment. source

Please note that the second article goes far beyond the brief bits I've quoted. Regardless, it's terrifying to think that the US is so unprepared that doctors are already worrying about who might have to be left to die because of equipment shortages. This article again deals with dangers to medical personnel, whom I doubt seriously would willy-nilly just start deciding to let people die. The big fear is that the financial bottom-line people are going to be part of this decision making process.

[Kimby]

That’s horrifying, bixa. But something we have to come to terms with in a time of limited supplies and personnel.

I can’t imagine the anguish of being a physician or nurse in this crisis.

[bixaorellana]

And I can't imagine the anguish of watching someone being taken off for care and wondering if some bean counter or administrator is deciding that person cannot be saved.

What I'm getting out of those articles is that many of the medical people are being hushed or threatened with job loss or at least career stalling if they don't ignore the very reason they went into medicine.

[Kimby]

My impression (from an admittedly hasty read) is that it is the health care professionals themselves that are trying to figure out how to keep whole staffs from being infected - and their services lost - as well as how to avoid running through all the protective gear in last ditch efforts to save dying patients. The staff see the writing on the walls.

[bixaorellana]

Kimby, look at the last quoted paragraph in the first article cited in reply #10.

[onlyMark]

Mar 27, 2020 2:59:13 GMT bixaorellana said:

To me it seems clear that those refusing to work under conditions that would spread sickness to themselves and others are making the right decision.
I don't know if others here will agree.

All too often medical personnel are treated like cannon fodder and are taken advantage of.
To have some stand up and say they are being treated badly seems to be a rare occurrence. To enter that profession you generally have to have some form/degree of empathy, a willingness to help, to alleviate suffering and so on - so just think how difficult it is for someone in that position to then refuse to do what they trained for - and either consciously or subconsciously, those in authority know this and realise it takes a lot less pressure to get them to back down (because they already feel bad about it) than a steel worker downing tools because he hasn't got the right safety equipment.
Note that I bet those in authority are managers who aren't doctors/nurses, they are and always have been, managers - hence they only look to targets and not patients.

Imagine you have the bestest equipment in the universe and beyond but in limited supply. Who do you give it to? The bloody medical staff you stupid people. Give it a VIP and it only protects them, give it to a nurse/doctor and the help they'll give is multiplied time and time again because they can keep on helping and not dropping dead or infecting others.
The very best, no expense spared equipment goes to them and they have priority for anything. It's common sense and it seems that phrase may be getting out of touch, because common sense means the sense is widespread and common - yet there are all too often example where it isn't.

[bjd]

I have a friend in the States (haven't been in touch for a while, I confess) who is a doctor. He is from New York but did his residency in Buffalo where we went to see him a couple of times when I still lived in Canada.

He told us already then, 1970s, that doctors have to make rapid decisions in emergency rooms about who to save when there is a rush. There have always been choices to be made. This is nothing new. Perhaps what is different now, particularly in the States, is that it becomes a financial consideration and not just an ethical one.

[questa]

Two things...I listen to ABC radio (like BBC) This morning the two announcers had set up an interview with the Head of the SA General Practitioners...the boss of all the action. He arrived about 5 minutes late and as he made his apologies he burst into tears and sobbed, "It is like hell out there." It took a little while to gather his composure during which time the female announcer was soothing him and sounding choked up herself. He went on with the interview but I'm sure no matter how enlightening his words were the listeners got the message in the first 10 minutes.

Secondly...(ABC radio last night.) Someone in UK, noting the time taken by trained staff to run errands (Take these swabs to pathology, or give this mail to the Doctor) suggested that they should call for volunteers to do this level of care. Pointing out that the volunteers would be in the danger zone the officials expected maybe 250,000 applicants. They got 500,000. The Dunkirk spirit lives on.

[mossie]

They haven't quite reached the 500,000 yet but that is the revised target, which is well on the way to being met.

Talking of spirit, I was very encouraged last night when i stood at my door at 8pm to join in the applause for our health workers, that the whole close joined in.

[kerouac2]

I don't understand why people are so shocked that it is necessary to decide who is to live and who is to die. It's been that way for at least 5000 years. Even on battlefields, soldiers have finished off their wounded comrades when necessary.

The fact that we have nice hospital rooms now does not change the fact that somebody has to decide who gets them in cases such as we now have. And the "somebody" doesn't always make the same decision that we might have preferred. Would you like to choose whom to cull in their place?

[mossie]

I had " do not resuscitate" written into one of my documents some time ago. If it came had to be a choice I would far prefer a younger, healthier person was preferred over me.

[Kimby]

My DNR order in my health care directive specifies that if my condition is “terminal” I do not wish heroic measures to be taken to prolong my life. Not sure how that would be interpreted now.

Has anyone read about the harrowing conditions in New Orleans hospitals after Hurricane Katrina? Some staff members actually went further than letting patients die to HELPING them die, when they were evacuating and couldn’t take everyone...

en.wikipedia.org/wiki/Five_Days_at_Memorial

[onlyMark]

Triage - (in medical use) the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.
The process of determining the most important people or things from amongst a large number that require attention.
To decide the order of treatment of (patients or casualties).

[bixaorellana]

Mar 27, 2020 6:55:18 GMT onlyMark said:

I bet those in authority are managers who aren't doctors/nurses, they are and always have been, managers - hence they only look to targets and not patients.

Quoting Mark in order to answer everyone at one time, since the quote sums up what is what I suspect and fear.

It's obvious that the US is so totally unprepared that doctors are going to have to make snap decisions about how far to go to save critically ill patients. This is unfair to the doctors and other medical staff in terms of the relentless pressure it will put on them. If the virus doesn't get them, the stress will.

[questa]

Let the non-medical staff make the decisions on who dies and who gets another chance. Medical and
nursing people took on that career because they care for other people. Added to that is the training where the values are instilled...the patient comes first. Someone who has some hands-on involvement with a patient as a person should not be put in the position of making that decision. Give the facts of the situation to the non medical staff and only include the bean counters if that is relevant to the decision.

Just hope it never comes to this.