Endocrinology, Epidemics and Ethics

INTRODUCTION

The ongoing COVID-19 pandemic has created major challenges for the healthcare professionals.[1] Workers have had to adapt to a novel disease, with myriad presentations and complications. The risk of exposure to a potentially fatal virus, along with the possibility of furthering community transmission, has added to the gravity of the situation. With the entire healthcare ecosystem, including public health and clinical care establishments, under strain, there is limited support from fellow professionals as well.

SAFETY FIRST

In this situation, many healthcare professionals have raised concern about the need to discontinue working temporarily, or curtail their services. In Bulgaria, for example, doctors have resigned en masse from hospitals that have been designated as quarantine centers.[2]

Various medical and surgical specialties have differing roles and responsibilities toward the general public. Because of the nature of their work, they also have varied exposure, and therefore, risk, of contracting the COVID-19 virus. This has influenced discourse and discussion regarding the response of health care professionals towards their role in the current scenario. Policy makers understand this issue: The government of Haryana, for example, has shut down regular services of most medical and surgical specialties from 22 March 2020 to 31 March 2020, keeping only Pediatrics, Gynecology, and Medicine/Chest clinics open.[3]

ENDOCRINOLOGY IN EQUIPOISE

Endocrinologists face a peculiar dilemma in this scenario. As we handle predominantly chronic care, we do not necessarily need to take care of emergency medicine. At the same time, it is well documented that people in our care, such as the elderly, those with diabetes, and those with concomitant conditions like hypertension and cardiovascular disease, are at greater risk of falling ill.[4] This means that such patients, who should maintain optimal glycemic and vasculo-metabolic health, need us more than at any other time.

This creates a situation of emotional equipoise in the mind of clinical endocrinologist. It becomes difficult to balance the call of duty with the need for preservation of self-health and family well-being. In turn, this leads to a sense of confusion and guilt.

ETHICAL ADVICE: ACTION

To resolve this issue, a review of medical ethics may be helpful. Most discussions on ethics focus on patient- physician relationships, and the responsibility of physicians towards persons in their care. There is relatively scant guidance to help health care professionals decide whether to attend to work or not. The Indian Medical Council, in its Regulations for Professional Conduct, Etiquette and Ethics (2002) clearly states (chapter 5.2) that “when an epidemic occurs a physician should not abandon his duty for fear of contracting the disease himself.”[5] The Declaration of Geneva is supported by the World Medical Association International Code of Medical Ethics (WMA ICME), which enjoins us to “respect the local and national code of ethics”[6] Thus, the Indian Medical Council regulations become sacrosanct for us.

Similar words were mentioned in the original American Medical Association (AMA) Code of Ethics, published in 1847:”When pestilence strikes, it is duty to face the danger, and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives”. This code has been revised and shortened considerably over the decades. It now states that “a physician may choose whom he will serve.” The omission of reference to pestilence or epidemics is thought to be due to the notion that infectious disease was a part of medical history, and would not occur again.[7]

At the same time AMA states: “In an emergency, however, he should render services to the best of his ability”.[8] Whether the word emergency can be used to define only an individual clinical situation, or can be extrapolated to the public health emergency of COVID-19 a debatable issue. The current AMA code clearly states that “a physician shall be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care,” “except in emergency.” This implies that the endocrinologist should continue to offer endocrine and metabolic care during an emergency (such as the COVID-19 outbreak) irrespective of the environmental conditions.

AMA goes on to add: “Having undertaken the care of a patient, he may not neglect him, and unless he has been discharged, he may discontinue his service only after giving adequate notice.” At superficial reading, this sentence seems to describe the relationship and responsibility of a treating physician towards an indoor patient, i.e., one admitted in hospital. Endocrinology, however, is a predominantly outdoor practice. Can this statement be read to imply that we continue to care for a patient on regular follow-up, avoid neglecting him or her, and offer adequate notice for discontinuation if necessary?

AMA clarifies its opinion, stating that: “Because of their commitment …, individual physicians have an obligation to provide urgent medical care during disasters”“even in the face of greater than usual risks to physicians’ own safety, health, or life.”…physician workforce is not an unlimited resource. Therefore,… physicians also have an obligation to evaluate the risks of providing care to individual patients versus the need to be available to provide care in the future.”[9]

ETHICAL ADVICE: CAUTION

The WMA ICME[6] also tells us to “give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care.” This, reinforces the responsibility of endocrinologists to support their fellow medical colleagues.

At the same time, the Geneva Declaration reminds us to “attend to my own health, well-being, and ability in order to provide care of the highest standard.”[10] Should this be interpreted as a blanket recommendation to avoid exposure to one’s community, in case of a communicable disease outbreak?

PRAGMATIC ADVICE

While managing one’s duties, the endocrinologist may choose to reduce his or her workload, in order to attend to other responsibilities. Two approaches have been suggested to help make choices and triage patients. An egalitarian philosophy suggests that all lives are equal, and we serve all who come basis, irrespective of the chances of their survival.[11] A utilitarian approach calls for assessment of the “utility” of a particular patient before taking a decision on whether to treat or not. An elderly person with diabetic nephropathy, in end stage renal disease, for example, may get less priority than a younger, previously healthy patient, if both develop symptomatic COVID-19 infection.

A prioritarian style has been proposed, which combines elements of both legality and utility in decision-making.[11] The endocrinologist may wish to follow a pragmatic attitude, combining the Indian teachings of Sarvodaya (benefit to all) and Antyodaya (benefit to the neediest).

Persons whose endocrinopathy, if uncontrolled, may lead to life-threatening, organ-threatening, or offspring-threatening complications, should be prioritized. These will include persons with gestational diabetes mellitus, type 1 diabetes, brittle diabetes, and other forms of diabetes which we feel will not be managed appropriately by community doctors. At the same time, a positive triage can be done for persons with endocrinopathies that are associated with immune compromise. These include Cushing’s syndrome and Addison’s disease. COVID-19 is associated with higher mortality in persons with diabetes. Therefore, aggressive glucovigilance is required to maintain optimal glucose control and immunity. This means that persons with uncontrolled diabetes also need to be given priority in endocrine clinics.

PRACTICAL ADVICE

In today’s world, there are multiple ways of providing emergency care, especially in endocrinology.

One can use the power of technology to provide telemedicine services to persons and healthcare systems in need. Modern communication allows one to offer accurate endocrine advice without exposing oneself to, and more importantly, without spreading communicable disease. Online consultations can be used, with informed and implied consent, to bridge the limitations and challenges posed by face-to face consultations. Through there are no legal statutes which allow online prescription, the current situation calls for out-of –the-box thinking. TheMadhya Pradesh Medical Council, Maharashtra Medical Council and Punjab Medical Council have supported the call for online consultation during the COVID-19 epidemic.

One must remember to ensure legal and ethical[12] safeguards while practicing telemedicine. Any patient with refractory or recurrent symptoms or laboratory abnormalities, and those presenting a diagnostic or therapeutic challenge, should be called for face-to-face consultations. In case this is not possible, remote general practitioner-based endocrinology is an option that can be considered. If face-to-face consultations are offered, they must be conducted with optimal personal prophylaxis.

PERSONALIZED ADVICE

There are no simple answers to the ethical dilemma of whether to continue endocrine care services in the setting of the COVID-19 pandemic.[13] Each endocrinologist should take an informed and rational decision regarding this. We suggest a 6A algorithm to help make this decision. One’s Ability to offer meaningful services, the Availability (or otherwise) of alternative sources of endocrine care, the degree of Assistance needed by the health care system, the Accountability toward the community/employers, and an Assessment of one’s own vulnerability, along with Assurance of medical support for oneself, if needed, all contribute to this decision [Table 1].

Table 1.

The 6A’s Algorithm

Strengths

Ability to offer meaningful help

Assurance of preventive/curative services, as needed

Needs

Assistance needed by health care system and professionals

Availability of other sources of endocrine care

Limitations

Assessment of one’s risk of contracting disease/vulnerability

Accountability towards employer/community

As responsible health care professionals, we must work together to fight COVID-19. We should maximize our usefulness to society by using novel means of communication to remain in touch with fellow health care professionals and patients, while keeping ourselves healthy.

As responsible health care professionals, we must work together to fight COVID-19. We should maximize our usefulness to society by using novel means of communication to remain in touch with fellow health care professionals and patients, while keeping ourselves healthy.