A New CME: Continuing Moral Education

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“This [COVID-19] was all brought on by the Chinese in order to get back at Trump for imposing the tariffs on China,” said a patient during a psychiatric consultation focused on her anxieties, those of a mother of young children who was struggling to cope with several serious medical concerns. A shrewd businesswoman, she owned several successful businesses that were floundering in the wake of the coronavirus 2019 (COVID-19) lockdowns, while she was facing her own failing health. Her frustrations and apprehensions turned out to be a fertile soil for conspiracy theories. I walked away from that encounter wondering how our interaction would go if she had COVID-19.

The COVID-19 pandemic has, in its relatively short but rampant course, tested several of our tenets, values, and skills, both at societal and professional level. To make matters even more complicated, the ethical issues change as the pandemic itself evolves (Table 1). For consultation-liaison psychiatrists, the pandemic has tested our clinical reasoning, administrative decision-making under stress, and individual levels of acceptable risk. It has also tested our capacity to make ethical choices and to adhere to bioethical postulates while struggling to ensure uninterrupted care for our patients during a massive, disruptive public health event. Many a time during this troubling period we found it difficult to balance basic bioethical principles, such as autonomy, beneficence, and justice.¹ Those challenges have been immensely amplified by the current social and political moment, one that sees a frightening combination of political rift, a knowledge gap about the SARS-CoV-2 virus, and the ability of individuals to advance their political agendas through social media.²

Ethical Challenges Evolve as the Pandemic Advances

Ethical Challenges in the Early Stages of the Pandemic

In the early stages of the pandemic, as COVID-19 appeared on the horizon and then arrived in the United States, we faced the ethical dilemma of resource shortages—allocating a limited number of ventilators to a vast number of patients who might need them.³ While not a psychiatric dilemma in nature, this ethical challenge affected many physicians who served on the bioethics committees of our respective institutions. Soon afterwards, we were forced to make painful decisions about our own practices, such as switching to the telepsychiatry mode or limiting the presence of trainees on premises to reduce the exposure risk.

The question of what constituted acceptable risk for clinicians was also raised early during the pandemic. Should all clinical services be switched to telepsychiatry and, if not, what patients could be seen in person, and with what personal protective equipment (PPE)? Subsequently, among C-L psychiatrists participating in ACLP’s dedicated COVID-19 listserv, a broad but not codified consensus arose that patients with positive or uncertain COVID-19 status should be seen via telepsychiatry, while those who were confirmed negative could reasonably be seen safely in person, still with adequate PPE.

Many clinicians had to switch to a telepsychiatry model rapidly with little or no prior training. Although telepsychiatry offered the advantage of uninterrupted care during the crisis, it also introduced several challenges. Those challenges included issues with privacy, the use of non-Health Insurance Portability and Accountability Act-compliant platforms, billing and reimbursement issues, and inability to adequately perform parts of the physical examination (eg, assessment for extrapyramidal signs). Telepsychiatry also limited our ability to address with acute crises arising during the session. Examples of such acute crises include patients revealing imminent suicidal intent but refusing to disclose their location, patients engaging in self-harming nonsuicidal behaviors as a result of the emotionally charged content of the session, or patients presenting intoxicated during a psychiatric consultation. Even mundane situations, such as patients driving or attending to other tasks and chores during the session, can present as an ethical challenge.

While we tend to perceive modern communication devices as ubiquitous and readily available, they remain unavailable for many our patients. Our patients often lack adequate access to telepsychiatry services, which requires possession of hardware, computer operating skills, and a stable internet connection. Many rural communities lack a reliable broadband connection, and many individuals in the cities do not have mobile data plans.⁴ Failure in any of these areas restricts the encounter to a telephone conversation, which further limits clinical findings otherwise appreciated with in-person evaluations.

One of the ethical dilemmas that has persisted throughout the outbreak was our daily decisions to commit patients to involuntary psychiatric inpatient treatment. Even in the most normal of times, such decisions can be difficult and painful. In the context of the COVID-19 epidemic, however, the ethical challenge was that we were committing patients to a communal inpatient setting in which they could be arguably much more vulnerable to COVID-19. In such cases, we advocate for beneficence (providing treatment) over autonomy (refusal of treatment) but should also remember to consider nonmaleficence (making sure that patient is not harmed while on the unit). A psychiatrist’s decision aimed to protect life, in could ironically result in a situation that might endanger the patient’s life because of the COVID-19 epidemic.

At the time, emergency policies, such as Centers for Medicare & Medicaid Services 1135 waivers, were put in place to allow for adjustments in practice without irreparably compromising our ethical approach to patient care, but they were limited in duration and scope.⁵

Ethical Challenges During the Active Pandemic

With time and with mobilization of considerable resources, the outbreak was partially mitigated, but the pandemic continues. Some of the contingencies introduced in the early stage, such as visitation limitations, were removed,⁵ but the need to coexist with COVID-19 has brought new ethical dilemmas into our daily practice.

Some of the challenges in an active pandemic are direct and unique to COVID-19. These challenges include physicians struggling to accept the inherent risks of contracting the disease or treating patients who refuse to accept the existence of the illness or who question its lethality. Some of the challenges are not unique to COVID-19 and could occur in any setting that might require profound, long-term reliance on telepsychiatry services (Table 2).

Ethical Challenges Can Be Direct and Indirect

One of the major, individual challenges for many physicians is the decision to work throughout the pandemic. We all joined the field medicine to help individuals in need, yet we are now beginning to find our work to be too taxing, overwhelming, and dangerous. Some clinicians find themselves in a state of burnout, while others feel unprepared to deal with a challenge of this magnitude.⁶ Historically, physicians were expected to tolerate personal risk associated with caring for contagious patients, but that tolerance has not been broadly tested in our generation of clinicians until now. This outbreak demonstrated that some clinicians were not willing to accept that elevated level of risk for a prolonged period, due to either personal health concerns or because of vulnerable, high-risk household members. As a result, a substantial number of clinicians have left the practice of medicine.⁷

As an alarmingly infectious disease, COVID-19 raises both practical and ethical challenges for clinicians who continue to provide on-site services. At what point should clinicians be asked by their administrators and supervisors to provide in-person care when telepsychiatry was available and, perhaps, preferred by the clinician? Which members of the team should be given priority to work remotely? How can we distribute risk among clinicians fairly, in line with the principle of justice? During the COVID-19 epidemic, shortages of medical staff resulted in psychiatrists deployed to medical floors or intensive care units to care for COVID-19 patients.⁸ If the number of patients with COVID-19 overwhelms the hospitals again and psychiatrists are redeployed to general or internal medicine for the second time, what selection criteria will be used for these assignments? The issue of privileging procedural competency during the initial outbreak was addressed by emergency waivers at various levels. What was not addressed at the time, and still remains an issue, is the ethical element of individual competency perception and disclosure to patients. Should you be telling patients with COVID-19 that you are a psychiatrist and not a specialist in internal medicine or infectious diseases? Should you disclose your misgivings about your ICU competence and skills to patients and their families? Or would you employ all but vanished approach of therapeutic privilege?

In addition to individual risk tolerance, consultation-liaison psychiatrists and other psychiatrists who work in academic settings grapple with the ethical challenge of trainees on our services who are directly exposed to the risk. The agony of such conflict is amplified when we watched our residents get redeployed to treat COVID-19 units.⁹ In limiting trainees’ clinical exposure, we impose a paternalistic rule on our trainees that directly hinders their growth as independent practitioners. At the same time, residents are doctors (and thus bound by the Hippocratic Oath) and paid employees, and they may see themselves as more morally and ethically bound to show up.

At the broader level, the highly politicized environment surrounding COVID-19 also poses unusual ethical challenges. Refusal to accept mainstream scientific consensus has led large numbers of individuals to ignore the advice of physicians and public health authorities. The media ecosystem that has grown around such alternative reality communities creates a self-reinforcing echo chamber for conspiracy theories and science denial.¹⁰ How should psychiatry evaluate the insight of a patient who denies the existence of their illness? How should we approach their decisional capacity?

At this stage, we must accept that certain beliefs and attitudes towards COVID-19, while at odds with science, are a part of a cultural paradigm that is prevalent in many parts of our country and the world, sadly reflecting our fractured social fabric.¹¹ To that end, clinicians should exercise extra caution when evaluating patients whose presenting complaint may involve or revolve around COVID-19 to tease out actual psychopathology from what are now culturally accepted beliefs.¹² We have to be particularly aware of our countertransference in such situations, lest they compromise our ethical norms from a different angle. Are we at risk of alienating or providing subpar care to patients who blatantly question the risks of COVID-19 or its existence, ridiculing all mitigation measure, including social distancing?

When caring for inpatients with psychiatric disorders, we are entrusted with their well-being and obligated to prevent the appearance and the spread of COVID-19. Sometimes that may require us to place patients in isolation, even when we know they tend to do poorly when extricated from the therapeutic milieu. Strict rules, visitation limitations, frequent COVID-19 testing, room changes, and early discharges impinge on our ability to provide quality care while keeping patients safe from COVID-19. We are frequently required to test our patients for COVID-19 (eg, prior to inpatient admission), and patients’ occasional refusal to subject themselves to the tests further complicates already compromised care, presenting us with yet another conflict between patient autonomy and other principles of bioethics like beneficence.

The rapid, widespread adoption of telepsychiatry in response to the COVID-19 pandemic ushered one of the most radical changes to the practice of psychiatry in a generation. With this seismic shift in patient care came many new ethical challenges. For instance, do telepsychiatry services represent a comparable value to in-person services, and should they be reimbursed at comparable rates? Physicians, arguably, do not incur the same cost of business when doing remote care; is it ethical to charge the same?

As physicians and clinics rapidly transitioned to all-remote provision of care, we noted that some of the most vulnerable patients were being left behind due to a lack of access or inability to use smartphones or tablets. We find ourselves in a position to advocate for a reasonable access to care for all our patients, thus satisfying the bioethical principle of justice. Once we facilitate access to either or both modalities of care, how do we arrive at a decision about when to see patients in-person and when to have a telepsychiatry encounter outside of the COVID-19 constraints? Is convenience, either for the patient or the provider, a sufficiently justifiable reason? We will have to address these issues going forward long after COVID-19 is gone.

Another set of challenges arises from the safeguards put in place over the years to maintain doctor-patient confidentiality. Those safeguards are being extended to cover the telepsychiatry care as well. All confidentiality protections, however, focus on patient’s privacy and confidentiality. Should similar or at least some privacy protections be extended to the provider side at this time? What if the patient lets other individuals, outside of the camera frame and not visible to the provider, observe the session? What if the patient records or streams the session? Should there be provisions in place that would allow clinicians to give or decline consent to such arrangements? Is it ethical for the clinician to provide or withhold care in cases where confidentiality may be jeopardized by the patient? Those are only some of the ethical questions that arise with telepsychiatry services, a process that, before our own eyes, is likely to transform the doctor-patient relationship for years to come.

Ethical Challenges in Late Pandemic

Once a reasonable control of the pandemic spread has been attained (through social distancing, immunization, or any combination of the public health measures), the current ethical challenges will likely wane, but new ones will arise. While massive immunization seems like a very logical step to curb COVID-19, the vaccine raises its own set of ethical dilemmas. The first challenge we are facing during the initial rollout is to determine who gets the vaccine first? We are being forced, as a society, to de facto prioritize individuals and provide them with a potentially life-saving compound. Some of us have already been given the opportunity to receive the vaccine, while some of our colleagues have not. What do we make out of that distribution? How does that affect and, perhaps, transform our relationship with our colleagues in the future?

At the patient end of the vaccine endeavor is the steady rise of vaccine hesitancy. We have been aware for a while that, in an imagined outbreak scenario, US residents tend to be twice as concerned about the vaccine than they are about the illness it prevents.¹³ Now that the COVID-19 vaccine is available, we know fewer than half of US residents would outright accept a free, Federal Drug Administration-approved COVID-19 vaccine.¹⁴ This refusal only partially reflects our current political and societal divide; the number of vaccine skeptics includes a plurality of minorities. Latinx Americans and African Americans are far less likely than Caucasians to accept the COVID-19 vaccine.¹⁴ This antivaccination trend may represent wariness toward governmental institutions and policies that may enshrine implicit, systemic racism, but may be based on other factors as well.

The ethical challenges in these instances are to identify the fine line between education and encouragement vs coercion and immunization mandate.¹⁵ We can only imagine how the immunization scenario will play out in psychiatric patients and how clinical decisions will, in part, be guided by our patients’ immunization stat, including issues of decisional capacity and informed consent. While a small number of patients with psychiatric disorders may develop paranoid ideations involving the vaccine, most will exercise reasonable decisions that may be questioned by our colleagues and providers from other specialties. It will be our responsibility, among others, to advocate for a fair and nondiscriminatory access to immunization for patients with serious mental illness (SMI).

At the societal level, there is a much broader set of issues that will soon arise attached to an individual’s immunization status. Those issues will include our freedom of movement, ability to travel, or our employment status. While not inherently psychiatric, such challenges may stir considerable emotional responses, as many in our society (inclusive of us, our patients, and our colleagues) may feel discriminated against, either by not being offered a vaccine or by feeling forced to accept one against our personal preferences. As mental health clinicians, we will have a first-hand opportunity to witness how clashing ethical principles (eg, autonomy vs beneficence) will play out in the public sphere and potentially lead to significant emotional distress that may surface in the form of new mental illnesses or exacerbations of existing behavioral signs and symptoms. For those reasons, psychiatrists should request to participate in the ethical considerations pertaining to mass immunization.

Concluding Thoughts

The COVID-19 outbreak has brought up a considerable number of new ethical issues and dilemmas. Some of them are unique to COVID-19 and will fade as the current pandemic recedes. Other challenges are associated with possibly lasting changes in practice (eg, telepsychiatry) and those challenges will last as long as the novel modes of metal health care delivery continue to evolve and gain ground.

Although this article raises and identifies a number of ethical questions, it provides only a few answers. The best way forward through the thicket of COVID-19-related ethical issues does not come from a single prescriptive, authoritative source. Rather, it will be achieved through a vigorous, healthy, and productive debate.

Dr Huremović is director of psychiatry at North Shore University Hospital, Manhasset, NY (a Division of Zucker-Hillside Department of Psychiatry, Northwell Health, Inc.). Dr Goodman is a resident in the Zucker-Hillside Department of Psychiatry, Northwell Health Inc. Dr Prabhakar is a psychiatry fellow in the Zucker-Hillside Department of Psychiatry at Northwell Health Inc. pprabhakar1@northwell.edu

The authors would like to thank the Academy of Consultation-Liaison Psychiatry Bioethics Special Interest Group for their contribution to COVID-19-related ethical dialogues.

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