General COVID-19 Questions

What is the coronavirus?

Coronaviruses are a type of virus. The specific coronavirus causing the present pandemic is called SARS-CoV-2 (SARS = severe acute respiratory syndrome; CoV = coronavirus). It is also known as 2019-nCoV (2019 = year; n = novel; CoV = coronavirus).

What is COVID-19?

COVID-19 (CO = corona; VI = virus; D = disease; 19 = 2019) is the name of the disease caused by SARS-CoV-2. Find additional information from the Centers for Disease Control and Prevention (CDC) about COVID-19 here.

Isn’t this just basically the flu? What’s so different about SARS-CoV-19 and COVID-19?

SARS-CoV-19 is completely new to humans. So apart from those who have recovered from the virus, the population as a whole has not developed an immune response to it. It is also highly contagious, binding to respiratory cells ten to twenty times more powerfully than the first SARS-CoV, which hit in 2002–2004. Notably, it has a long incubation period, during which the disease is transmissible, or contagious: on average about five to six days, but up to fourteen days. By comparison, the seasonal flu has an incubation period of up to only four days, and on average only two days. This means that, compared to the flu, SARS-Cov-2 has more transmission opportunities when someone is asymptomatic and unaware of being a carrier. Its delayed symptom onset and delayed time until death also mean that more deadly strains of the virus can persist longer. Shorter symptom onset and time to death cause the more lethal strains to die out sooner.

Is there any progress on a treatment for COVID-19?

Yes. Efforts to develop a vaccine are underway. More importantly, given the urgent need, multiple pharmacological interventions are already in experimental use in various countries. As many as sixty drugs are being explored. Studies are still too early and experimental to be conclusive, but several are showing promise—whether alone or in conjunction with other interventions:

  • chloroquine—a common drug used against malaria
  • hydroxychloroquine—typically used in treating rheumatoid arthritis and lupus
  • remdesivir—used to combat Ebola
  • lopinavir and ritonavir—used against HIV
  • favipiravir—used against flu and many RNA viruses

Do any of the COVID-19 vaccines in development use cell lines derived from the tissue of aborted fetuses, like HEK-293 or PER-C6?

Unfortunately, yes. It is our understanding that several of the vaccines under development make use of these cell lines of illicit origin. See the NCBC statement on COVID-19 vaccines and the NCBC FAQ on the use of vaccines.

I’m hearing about “slashing red tape” for clinical trials of experimental drugs to treat COVID-19. Isn’t it unethical to bypass the processes intended to protect against human exploitation?

Clinical experimentation protocols are intended to safeguard human subjects of experimental research. In the face of serious need, such as responding to a global pandemic, the phases of experimental research can be accelerated and sometimes bypassed so long as the good of each individual patient is not sacrificed. For example, patients with minor or no symptoms should not be subjected to experimental treatments, whereas patients who have not responded well to existing, safer treatments and are at risk of dying could be good candidates for human trials of new drugs. Proper informed consent for the experimentation always remains necessary.

Can physician-assisted suicide by those who are elderly or disabled be a selfless act at this time, to reduce the impact of COVID-19 on health care providers?

Absolutely not. Those who are elderly, disabled, immunocompromised, or otherwise vulnerable should continue to be respected and should not feel pressured by anyone to end their lives. Suicide and its ideation are always cries for help, directed against life, that deeply wound communities; they are never selfless acts of generosity.

COVID-19 Critical Care Questions

For more information, see “Ethical Concerns with COVID-19 Triage Protocols” and “Triage Protocol Guidelines.”

Are triage protocols that allow hospitals and health care providers to limit the use of scarce resources (like ventilators) ethically sound?

In principle, such triage protocols can be ethically sound. The specific criteria used to determine use or limitation should be as objective as possible, avoiding categorical exclusions based on disability, age, or other nonclinical characteristics.

Various triage protocols identify “long-term survival” and “maximizing life-years saved” as their primary goal. This sounds utilitarian. Is utilitarianism an acceptable framework for determining how critical care resources should be directed? What criteria can legitimately be used for the allocation of scarce intensive care resources under a triage protocol?

Utilitarianism is not a sound moral framework. Triage and resource allocation protocols that prioritize cases based on clinical criteria such as organ function assessments and similar predictors of short-term survival are a solid ethical foundation and should always be primary. Clinical indicators of short-term readmission risk (i.e., the likelihood that a patient will need critical care resources again during the resource shortage) may also be valid. Long-term survival and quality of recovery are not ethically appropriate factors for treatment priority during a temporary resource shortage.

Nonclinical allocation criteria for deciding between patients in similar clinical situations (same clinical priority) can be morally sound as secondary criteria for determinations between patients with similar clinical priority. Any nonclinical criteria should avoid considerations of social utility or quality of life. Criteria can include considerations of justice and the ability to ensure the common good, such as prioritizing those who are essential to the health care delivery system itself and are at high risk of becoming infected in the line of duty (e.g., active health care workers or first responders receive higher priority than others in similar clinical situations). If no other justice considerations are applicable, criteria that involve no value judgments may be used, such as first-come/first-served, lottery-based, or other criteria that are randomized and unbiased.

Is it acceptable to prioritize health care professionals for receiving care in triage scoring?

Yes, it can be permissible to prioritize those who are actively engaged in roles that are essential to the delivery of health care in a crisis situation, and who face significantly elevated risks of contracting the virus in the line of duty. This should not extend unreasonably to all health care professionals or all people involved in some way with health care, but should be narrowly focused. For example, inactive or retired health care professionals should not be prioritized over others, while ICU nurses who are directly placing their lives and health at risk to treat others should be. The priority considerations here, as with all nonclinical criteria, are only secondary to the clinical criteria.

Should pregnant women be given higher priority in a triage protocol?

Assigning higher priority in a triage scoring system based on pregnancy can be morally appropriate since mother and child are two patients, and both are particularly vulnerable. However, clinical factors such as likelihood of short-term survival remain primary.

Is age a morally sound criterion for rationing limited medical resources?

No. A rationing decision based exclusively on age amounts to unjust discrimination and is immoral. Nonetheless, age may be correlated with poor clinical outcomes and could serve as one of several initial indicators for more carefully identifying patients whose actual clinical situation is rapidly and irreversibly worsening with no reasonable expectation of survival.

Is it okay if age is used only as a “tie breaker” for triage priority between patients in equivalent clinical situations? Some protocols say that tie-breaker criteria are not actually “exclusion criteria,” so it’s okay to use age.

No. Age may never be used as an independent criterion for determining priority level, even as a “tie breaker.” It should be clear, however, that clinical factors impacting short-term survival and readmission risk may be used, even if there is a known correlation between these factors and advanced age. This is not the same as making age itself the criterion on which resource allocation is determined.

Is it okay to assign a lower priority level to patients with dementia, Alzheimer’s, other mental health illnesses, or chronic but controlled conditions?

If a lower priority is assigned based solely on the presence of the condition, and not based on any known clinical impact of the comorbidity on short-term survival, this is not morally sound. This would be tantamount to determining priority based on non-clinical factors such as quality of life or the value of a certain number of months or years of additional life. It should be clear, however, that clinical factors with an impact on short-term survival (and possibly short-term readmission risk) that derive from the comorbidities may be used in determining triage priority for intensive care.

How do we uphold the patient–professional relationship in times of triage and rationing?

The principles of the patient–professional relationship should be upheld even in times of pandemic. Essential principles include, but are not limited to, informed consent and shared decision making. This means that the patient (or designated decision maker) must be properly informed of his or her medical condition to the extent this is possible under the circumstances. Decisions about level of care, including the decision to remove a ventilator or transition from aggressive interventions to palliative care, should be made in consultation with the patient (or designated decision maker).

Acting for the good of each patient and the common good requires respectful communication and efforts to enable voluntary patient consent, but it does not require acceding to unreasonable patient demands.

Is it ethical to give the responsibility for making triage decisions to “triage committees” or “triage officers”? Won’t this compromise the physician–patient relationship with an unfeeling, “top-down” approach?

While triage committees and officers may not be appropriate for every situation, there can be ethically sound reasons to use them. They can offer objectivity and help doctors focus on caring for their individual patients without having to be concerned with comparing patients or determining triage priority. They also provide front-line clinicians a buffer against moral distress, as these clinicians are not left entirely to their own devices in determining which patients receive scarce resources. Overall, the triage committee and/or officers help ensure that the triage process itself retains integrity, consistency, and transparency. A triage committee involved in decisions about triage priority and resource allocation should not, however, eliminate direct physician–patient communications and efforts to enable voluntary care decisions. If possible, an ethicist or ethics committee member should be a member of a triage team.

Some triage protocols allow physicians to unilaterally (i.e., no discussion with patient or decision maker) write DNR orders. Is this okay?

The notion of “unilateral” DNRs and “unilateral” withdrawing of critical care support, regardless of patient/surrogate wishes, is problematic. There may be scenarios where DNRs or withdrawal of critical support may be part of a particular care plan (e.g., a decision to pursue palliative or hospice care given the burdens of critical care support or given that death is expected even with critical care support). However, automatically applying them without any patient opportunity to voluntarily choose or at least discuss a DNR order seems a step too far in suppressing the role of informed consent. Even in times of crisis, clinicians must preserve appropriate communication with the patient and his or her designated decision maker. Patients can be presented with the clinical scenario and expected outcomes of cardiopulmonary resuscitation under particular circumstances, including limitation of resources, longer response times for staff to don proper personal protective equipment, dangers of infection for health care staff, and any other clinical considerations about burdens and benefits of CPR. If a patient demands resuscitation and refuses a DNR on unreasonable grounds (particularly if doing so puts the lives of others in jeopardy), these wishes could be overridden.

Said differently, in some cases physicians might have sufficient reason to override an unreasonable patient or surrogate demand to be resuscitated and could place the DNR order anyway, but this should only be done as a last resort.

The details of the situation are important. Generally, the answer is yes, it is immoral. However, it can be legitimate in situations where consent cannot be obtained and the patient is clearly deteriorating, such that survival is no longer a reasonable expectation. There may also be situations in which a patient can be removed from intensive care support by physician order in spite of unreasonable patient demands, such as when benefits to the current patient are minimal and a patient of higher triage priority level urgently needs—and would benefit from—the ventilator support.

In general, no. Patients with chronic conditions who are stable on ventilators that are ordinary and proportionate care for them should be allowed to continue until such ventilator use becomes extraordinary or disproportionate. If, however, these patients experience an acute event for which they need intensive care, circumstances tied to a very poor clinical prognosis for the patient might warrant removal of the ventilator to provide for another acute care need. The criteria in such a case, however, should be based not on the fact of the patient’s chronic illness or perceived quality of life, but rather on a substantive change in the patient’s clinical situation such that patient is no longer expected to receive a proportionate benefit from ventilator support. In other words, the ventilator should not be removed if the acute event can be resolved with ventilator support, but it might be removed if the acute event is reasonably expected to result in short-term mortality regardless of ventilator support.

Can a patient choose to have a ventilator withdrawn in order to allow someone else access to limited treatment resources?

Yes, this can be a morally good or even heroic act. However, no patient has a general moral obligation to decline continued ventilator support simply because others may benefit more, and no patient should be coerced or otherwise unduly pressured by others to make this choice. Similar to the principles applicable to organ donation, the act must be truly selfless and not imposed by force.

[April 15, 2020]