by Craig Klugman, PhD, Kelly Michelson, MD, MPH, Kayhan Parsi, JD, PhD
In response to the COVID-19 pandemic, groups of regional ethicists have organized to better foster collaboration and dialogue in their cities and states. Here in the Chicago metropolitan area, the COVID-19 Chicago Bioethics Coalition (CBC) was created on March 20, 2020, the same day Governor J.B. Pritzker announced the “shelter at home” order for the state of Illinois. One of the authors (KM) organized the coalition to discuss the bioethical challenges of the current pandemic. The CBC is comprised of over 50 bioethics experts from over a dozen Chicago-area institutions (and a few outside the region), including major academic medical centers, universities, and health systems. Like our current crisis, this coming together of the Chicago bioethics community is unprecedented.
The main work of the CBC has been to share policies and experiences across the various area health systems. The CBC has held weekly video conference meetings to share plans for: 1) allocating ICU beds, ventilators and ECMO, 2) triage policies and committees, 3) visitor policies, 4) remdesivir distribution, and 5) vaccine distribution. A CBC representative attends regular Chicago Department of Public Health (CDPH) meetings to keep up-to-date on city data and local government efforts. Subcommittees have explored a variety of issues such as : 1) unilateral Do Not Attempt Resuscitation (DNAR) orders, 2) research protocols, 3) professional education, and 4) public education through writing Op-Eds and media outreach.
The group has sought to be a community resource for the hard medical and public health decisions that have and may still need to be made. CBC members have tried to encourage a coordinated effort so that allocation plans did not differ by hospital, but instead took a regional approach. To do otherwise risks patient “hospital shopping,” having patients seek out a hospital where they would have the highest chance of getting a desired intervention.
CBC members have encouraged an emphasis on social justice, ensuring that allocation plans would not marginalize historically disadvantaged groups. For instance, although the federal government has not collected any demographic data on patients with COVID, the city of Chicago was one of the first places to track the devastating effect this virus has taken on communities of color. In practice, most allocation policies seemed to discriminate against some vulnerable population: the aged, those with disabilities, those with chronic illness, minority populations.
The CBC explored an approach toward not only regional policies shared by institutions, but also pooling resources where necessary to avoid the worst-case scenarios. For example, before a hospital implemented its triage policy because of a lack of ventilators, could that institution borrow such devices from other hospitals if have any unused ventilators? If a hospital was short on staff, could they pull health care providers from other hospitals that had excess capacity? In other words, should resources as well as policies be considered regionally instead of within a single institution or system? These are all challenging questions, as Greater Chicago is a region of ten million people with a heterogeneity of over 200 academic medical centers, faith-based and secular health systems, and community hospitals, each of which have unique missions and financial needs. These institutions have a longer history of competing than collaborating which created resistance to adopting model policies and sharing resources. These questions and issues also prompted a discussion about whether the CBC should take on a more assertive advocacy role. Not surprisingly in a field that has generally not taken strong positions, the group did not reach consensus.
As we have continued to meet regularly and the crisis becomes the everyday, the CBC members have begun to reflect on what the group is and should be. Is it only a forum for academic debate and discussion? Are we networking to find writing partners and relevant topics? Are we just sharing responses to shared challenges? Should such a coalition advocate for certain policies? Is this a new permanent entity or will it dissolve over time when the pandemic threat passes? Moreover, should a group like the CBC focus efforts beyond the acute care setting? For instance, should the group’s discussions have focused heavily on clinical ethics issues at the bedside in acute care settings? The CBC has not really addressed the serious issues that non-acute care settings, such as nursing homes and assisted living centers, are facing. Some of this reflects the bias of current clinical ethics. But it’s essential that bioethicists address these issues as well.
At this point, the CBC has focused on being a forum for discussion and collaboration for bioethicists in the Chicago region. Sharing approaches and policies, providing education to our various constituencies, working with the media, as well as writing journal articles, OpEds, and letters have been important responses to the pandemic. Our hope is that members of the CBC can continue to help each other assist their respective institutions, as well as bring more light than heat to this critical public health crisis.