The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!
Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director
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The COVID crisis has been difficult, to put the situation mildly. Nationally, we have made concessions in education and healthcare that will have consequences for future generations. Friends have lost jobs, homes, and family to the virus. Fortunately, my family has avoided the worst, but isolation has taken a toll on us mentally and emotionally.
As the crisis worsened, I recall how rapidly medical education changed. In weeks, we transitioned from donning to enter isolation areas and limiting patient interactions, to leaving wards all together. Clerkship directors struggled to construct lesson plans for quarantine. Zoom fatigue quickly set in. Some classmates were upset we left the wards at all; to them, it made no sense to leave the frontlines when we were training for this situation.
I had reservations about returning. We were pulled off the wards to preserve facemasks and gowns due to the national safety equipment shortage. Justice, a principle of bioethics, demands an equitable distribution of limited goods or services. If medical students were not necessary to deliver healthcare to patients, it would be unethical for students to take that equipment from essential workers and patients.
However, we need students to be well-trained and graduate on time. Students are the pipeline of interns and residents for many hospitals. If students fail to graduate on time, health systems dependent on residents would falter. Applying Kantian ethics, schools and students cannot delay training: if every other school or student were to delay graduating, there would be no new interns at hospitals as early as 2021. Therefore, it was unethical to wait out the pandemic before returning students to the wards.
That said, we still had to limit the risk of COVID infection to students, workers, and patients. This concept of risk raises several difficult problems despite the need to complete training students on time. How do we measure the harm associated with an increased risk of COVID infection? Does the kind of risk involved negate any benefits of returning students to wards? And does introducing risk where there was none automatically make a choice unethical? COVID infections can lead to life-threatening complications and, worse, outbreaks within a medical system. We can accept that what students learn working with these patients prepares them to become better doctors for future patients. However, we should prioritize our moral obligation to protect students and patients ahead of any societal good on Kantian grounds that both deserve to be safely trained and treated, respectively. Therefore, however we choose to proceed must first limit the risk of COVID infections and then meet the societal need to train our students.
I argue the most ethical way for students to participate in rotations is with restrictions on patient interactions. My school’s current policy that students should not participate in the direct care of patients who test positive or are suspected to be COVID-positive aligns with my ethics of continued training while preserving trainees’ safety. However, students can assist medical teams outside of direct care by obtaining medical records and consults. In this capacity, students can remain engaged with patient care, learning how to treat and manage each case assigned to their team. Students can also improve patient safety by ensuring medical providers have the correct health information to make informed care decisions.
With regards to COVID-negative patients, students can participate more actively and should take more initiative in providing direct care to these patients. With residents and attendings needing to direct more attention to COVID-positive patients, students can provide more attention to the needs of COVID-negative patients to ensure they are receiving appropriate medical treatment. As stated earlier, this improves patient safety, while also giving students more independence to learn from their patients and reducing residents’ and attendings’ workloads.
Restrictions must also extend beyond student-patient interactions. Schools should require students take the necessary precautions from spreading COVID when away from hospitals, such as social distancing when doing necessary activities or otherwise quarantining at home. Schools should also provide and require free and regular COVID tests, along with tools to report developing symptoms or confirmed diagnoses. COVID vaccines should also be required as they become available. Students must honor and self-enforce these restrictions to eliminate as much risk of a COVID outbreak as possible.
One may object that this policy unfairly limits the educational opportunities of students on rotations. In fact, students should be learning how to care for COVID-positive patients, as managing pandemics is part of the career they have chosen. However, the kind of risk associated with COVID is greater than other exposure risks. Infection puts students’ lives at risk and spreading COVID to other healthcare workers could collapse an overburdened health system. Given the danger of a COVID outbreak, it is unethical to introduce the risk of an outbreak when alternatives are available. The limitations to student-patient interaction reflect how attendings have adapted their practices to minimize COVID risks and maintain patient care alongside trainees’ education. For example, my family medicine attending would schedule telehealth visits whenever possible to protect himself and his patients. Medical student training remains an imperative for schools, and these restrictions will not prevent students from gaining exposure to a variety of medical fields and necessary education. However, we must prioritize students’ and patients’ safety while preserving the training pipeline of essential workers. How we reintegrate students into the workforce will help us protect and save lives in the short and long-term.