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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“Can you turn the iPad the other way to face him?” the patient’s wife said. “I know it’s grotesque, but I think I want to watch him die.”
During this, my first ICU shift early in the pandemic, knowing almost nothing of what would become so horribly familiar and trying to keep straight twenty nearly identical patients – the sickest I had ever seen – I stood at the bedside of a patient with severe multiple organ dysfunction syndrome as the result of COVID-19. His ventilator support and vasopressors were maxed out, and he was on at least 20 anti-this and pro-that medications; tethered in a cubicle but adrift on the extra-dimensional Sea of Pharmacology, unaware of his dire circumstances or his wife’s digital ubiety.
I was buoyed by the presence of two attending acute care surgeons, as this was unfolding (of course) at change of shift. We had spoken just moments before and agreed there was nothing left to offer except emotional support and our deepest condolences. Our patient was ashen and cachectic, with blood seeping through and around dressings on his neck and chest from his systemic anticoagulation. Bilateral chest tubes bubbled away, as pneumothoraces sustained from high airway pressures begat empyemas and a bronchopleural fistula. He looked nothing like his smiling visage peering in from 4”x 6” windows on his wall – beaming while sitting at a picnic table holding his grandchildren. In front of us, tonight, he was dying. There was nothing subtle about it. In a way, perhaps, he was fortunate where others were not, as he had received skilled critical care and his family loved him deeply.
When it was “time,” I re-donned all of my PPE and held an iPad close so that his family could be with him. After listening to me struggle through two masks to voice coherently his progression toward death, I turned the iPad to face my patient–her husband, their father, and grandfather–at his wife’s request, relieved that I finally had a moment to hide the tears that were welling up behind my face shield, feeling as though I had failed them all. There was grief to offer, too, supporting them in deafening silence, punctuated by artificial sounds of pseudo-existence.
This experience was not unique; is not unique. Who can be sure when the pandemic will truly be “over?” We have faced interminable ethical and moral issues, each in its own way grabbing our throats, muddling our minds, and tearing through our hearts. What was unique was that the pandemic arrived as I was completing a two-year clinical ethics fellowship. I pursued this training during surgical residency to complement my interests in acute care surgery, understanding that often, complex clinical decision-making occurs at the nexus of medicine, philosophy, morality, and the law. Never did I expect that a global pandemic would be part of my ethics education–alongside my moonlighting responsibilities working in the COVID ICU, or that my role as a clinician-ethicist would become so real, so soon.
My expansive interest and modest experience in ethics was well known to my surgical colleagues. Numerous calls and texts bled into formal ethics consultations. There was panic in so many voices, and so many questions that I was unable to answer given legal constraints and the unfamiliar ethical trails blazed by COVID-19. Collegial conversations resulted in resentment or frustration; others were steeped in ambiguity and despair. Awkward silence, among friends and colleagues, became part of our new normal.
Ethicists become accustomed to silence; I understand it quite differently now than I used to. Silence is the accompanist of uncertainty, angst, and the stomach-churning sensation which, more often than not, embodies the ethical dilemma of the moment. There were too many. When we ran short of oxygen, or blood, or medications, or dialysate. When we were forced to allocate ventilators, or hemodialysis machines, or operating rooms.
I listened recently as two of my fellow residents discussed their experiences with the first wave of COVID-19 during one of our rotations in Queens, New York. One described finding patients deceased on rounds, having exhausted their allocated single oxygen tank. On one Tuesday when she was on call, almost 20% of patients admitted to the hospital died. The other described the moment he considered removing a patient’s dialysis catheter post-mortem to give it to another critically ill patient. “How did we function?” they asked each other. Brief, shuddering silence, and the moment was gone. Bearing witness can often be as challenging as the dilemmas themselves.
Another of my attending surgeons, a person of few, well-chosen words, embodies a new pandemic ethos: “Keep your head down. Do your work. And wear a mask.” Surgeons often work in near silence, punctuated by the soft snap of instruments being passed and the “whoosh” of the anesthesia ventilator; planning intently, working carefully, knowing that in the operating room, it is easier to stay out of trouble than to get out of trouble. Surgeons are a particularly resilient breed of physician. The hours are long and the stress is ever-present. Shouldering responsibility is requisite; shouldering culpability shouldn’t be, but often is. We inflict injury in order to heal. And when we “fail,” or shoulder too much, who heals us?
Did my surgical colleagues know what kind of help they were asking for when they called, or texted, or chased me down in the hallways of the ICU? Perhaps they sought an ethical framework to practice within, or reassurance that they were, indeed, equal to their Sisyphean task. More likely, I think we all needed an outlet for our emotional and moral distress – a place to cry or yell to escape the moments of stomach-churning silence. How, then, can we help each other recover from all we have witnessed? How do we move forward? For now, we must allow ourselves to grieve, to celebrate the good we did, and to remind each other that we did not fail – we persevered.