Challenges and Ethical Considerations for Trainees and Attending Physicians During the COVID-19 Pandemic

We read with great interest the article by Kramer and colleagues, “Ethics in the time of Coronavirus: Recommendations in the COVID-19 Pandemic.”¹ It is a well-written synopsis of ethical issues from this pandemic. However, we have some concerns.

First, the use of the HIV/AIDS epidemic as a reference point for ethical consideration is not entirely appropriate because there are differences in the 2 disease processes. Even in the inchoate days of the AIDS epidemic, it was known that the main transmission was by bodily secretions and that one could not contract the disease simply by being near the infected person. Although HIV can result in no/mild symptoms in reservoir hosts, similar to the coronavirus,² comparison to the 1918 H1N1 Spanish flu pandemic seems more appropriate for mode of transmission and infectivity. Obligatory notification of suspected cases, hygienic practices, and quarantine were used to curb the spread of the Spanish flu³ and are more applicable to the novel coronavirus (COVID-19) pandemic. Although ethical considerations at the time were not extensively documented, the Spanish flu and following H1N1 pandemics have taught us lessons on pandemic preparation and public health.^{3 , 4}

Second, we do not agree that medical trainees, such as residents or medical students, be fully involved in the care of COVID-19 patients. Junior residents and medical students may not have the skill set and knowledge to fully protect themselves from this pandemic. This element of uncertainty and risk is unnecessary, especially when finite resources like personal protective equipment (PPE) may be in short supply. The justification that residents have inevitably signed up for some degree of risk and therefore are required to take on the same risk as attending physicians is not entirely equivalent. Residents do not assume the same level of responsibility as attending physicians do, and should not be required to assume the same level of risk. At our institution, we have established rules that minimize resident contact with COVID-19. These include alternate day schedules, reduced number per shift, and no medical students rotating on the service, among others. The Association of American Medical Colleges (AAMC) and the ACGME have guidelines for this, keeping in view trainees' personal safety balanced with their educational requirements and ethical considerations.^{5 , 6}

Third, the authors recommend that non-FDA approved therapies not be used for these patients. There is currently no established treatment/cure for COVID-19. If therapies like retroviral drugs are administered in a safe fashion, under the guidance of disease experts, with transparency, involving the patient in the decision-making process, then these drugs should not be withheld. Providers are currently using potential therapies, with no ulterior motive, and this should not be considered a violation of the Helsinki declaration. The government should also provide certain legal safeguards to providers using pharmacologic treatments appropriately, so they are not held liable in the future.7, 8, 9

Nevertheless, we congratulate the authors for proposing some very valid recommendations. As our clinical experience with these patients' progresses and more data accumulate, we will be able offer evidence-based care and recommendations to these patients.