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March 2020

COVID-19: Ethical Implications in Vermont

by Tim Lahey, MD, MMSc

Director of Ethics at UVMMC 

Professor of Medicine at Larner College of Medicine

The first case of COVID-19 has now been reported in Vermont. Epidemiologists believe it is just a matter of time before more COVID-19 cases are found. This raises interesting ethical questions.

Currently public health authorities are conducting surveillance for COVID-19 and encouraging people to self-quarantine if they have been exposed to a case or traveled to an epidemic hot spot. Each action to contain the epidemic can pit personal interests (privacy or bodily autonomy) against the greater good (i.e. prevention of community transmission).

These somewhat abstract-feeling ethical challenges may be joined by new and more personal-feeling challenges as the number of cases grows. About 80% of the time, COVID-19 is a safe illness to tolerate at home without any specific therapy. Older and medically vulnerable patients, however, are being hospitalized at alarming rates and in some locations outstripping ordinary health care system capacity. This can lead to health care infrastructure shortages, which in turn can trigger uncomfortable questions such as who should gain access to a finite supply of masks, or who gets to use a small number of private rooms, or which patients should be prioritized for a small number of mechanical ventilators in the state.

If such decisions arise, ethical lessons from battlefield triage will inform next steps. The ensuing conversations will focus primarily on utilitarian considerations such as which use of health care resources will save the greatest number of lives. It has not come to it yet, but public health authorities have pre-existing plans for triaging scarce medical resources in general (such as in Vermont ) or mechanical ventilators in particular (see this policy from New York ).

Prevention is the best way to avoid tough ethical challenges. Hopefully, Vermont will see success with the commonsense infection control measures we hope will slow the epidemic. We can each see our investments in handwashing, social distancing, and wise access of the health care system as our way of preventing the emergence of hard questions like which sick person gets access to a limited supply of mechanical ventilators. If luck is not with us and we have to face such questions, we are ready and talking about it and will do our very best to make the best of a hard situation.

Vermont Legislature Considers Stem Cell Bill

Legitimate research in the use of cellular based therapies remains a rapidly advancing and promising field. However, the proliferation of clinics marketing unregulated and unapproved stem cell products with claims of efficacy and safety that are not evidence-based is concerning. Particularly problematic is the growing practice of promoting unproven and expensive “treatments” of unknown benefit that may pose significant risks to the health and welfare of sick and vulnerable patients.

 

In October of 2018, the VEN Board had a presentation from a pulmonologist on the topic of stem cell medical tourism. This, along with a series of ads appearing in the Times Argus in November of 2018, prompted the organization to send letters to the Attorney General, The Board of Medical Practice and the Office of Professional Regulation requesting investigation into the advertising practices of these clinics. Specifically that the ads may:

VEN was concern that the advertisement and practice may constitute unauthorized medical or naturopathic practice; may constitute false advertising; may be offering false hope to vulnerable persons desperate for any treatment, regardless of proven effectiveness; and may, as has been previously reported , cause serious harm.

Since then, a coalition of stakeholders with similar concerns have coalesced to offer education and additional resources about stem cells. Presently, Vermont’s Senate Health & Welfare Committee is working on a bill that would require appropriate notice and disclosure about stem cell products from clinics and practitioners who administer them. 

Learn More:

Court Upholds Psychiatric Advance Directive

Per the Winter 2019 issue of Counterpoint (a newspaper published by Vermont Psychiatric Survivors):

In a unanimous ruling, Vermont's Supreme Court has upheld an advance directive that rejected all psychiatric medication. It said disagreeing with a psychiatrist about a diagnosis does not mean a person lacks capacity to make a health care decision.

The court found that the advance directive was valid, and it therefore vacated the Family Division's involuntary medication order. It said the state had failed to meet its burden of proof that the patient did not have capacity to make the decision at the time of signing the advance directive.

National Advance Care Planning Cases

The following cases that pertain to advance care planning across the country were brought to our attention through the Medical Futility Blog of Thaddeus Pope, JD, PhD, one of the speakers at our upcoming Spring Conference (details below):

Upcoming Events

National Healthcare Decisions Day

April 16, 2020

We're only 1 month away from National Healthcare Decisions Day 2020! A wide range of groups across the state are already planning to participate in a coordinated effort to raise awareness about the importance of advance care planning on this date by tabling, offering community presentations/screenings, etc. Won't you join us? For more information, please visit our website. To share what you're planning and be included in our promotional efforts, please complete this short form.

HEALTH DECISIONS is a publication of the Vermont Ethics Network.

The mission of the Vermont Ethics Network is to advance ethics in health care.