Continuing the legacy of critical ethical analysis of contemporary medical issues

Beecher Prize Winners

  • Rethinking Roles and Rules: An Ethical Analysis of the Response of Medical Education to Public Crises

    by Abraham Cheloff
    2020 Winning Essay

    In early 2020, a novel virus known as SARS-CoV-2, novel coronavirus 2019, and COVID-19 swept across the world at an alarming rate. As the spread of the virus increased, medical schools and hospitals started to act to protect trainees from the still unknown and mysterious illness. In mid-March of 2020, the American Association of Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME) issued a statement that asked medical schools across the country to remove medical students from clerkships and other activities involving patient care for two weeks (1). The reasoning provided was that these two weeks would give hospitals time to preserve much needed personal protective equipment (PPE) and medical schools time to educate students regarding COVID-19. Now, this relatively short suspension turned into a much longer one, medical schools have had to make decisions regarding whether students will be allowed to work with patients as well as what medical education will look like during and in the aftermath of the pandemic. Since changes to medical education could have impacts on current and future patient safety, as well as trainee preparedness and safety, the possibilities deserve a full ethical analysis of its implications.

    Since there has not been a pandemic in the last hundred years, analyses of decisions made and the corresponding ethical considerations during pandemics are virtually nonexistent. There are, however, publications by ethicist and medical educators that describe a variety of global crises as well as the roles medical students have taken. Using the lens of medical student participation in disaster response during a variety of historical events, we will herein attempt to analyze the current response of medical education to the COVID-19 pandemic, as a disaster, including its effects on patient care and medical student training. Herein, I will outline some benefits and risks to medical student clinical participation in light of COVID- 19, and asses the question of student participation as a duty vs a choice. Then, I will review the historical participation of medical students in previous disasters through an ethical lens and do the same for current

    policies, practices, and activities enacted by medical schools in response to COVID-19. Furthermore, and finally, I will recommend policies for present and future implementation that are ethically justifiable and seek to reduce the negative effects on trainees and patients.

    The Benefits and Risks to Medical Student Participation during COVID-19

    Considering the vast destructive effects that disasters, including pandemics, can have, preventing and decreasing harm is considered an ethical responsibility (2). Although medical students are not yet physicians, they have a multitude of skills that could prove effective in meeting these goals. Studies have shown that medical students as a group are willing to respond in the event of a disaster, with 59-94% willing to participate in the event of an infectious epidemic (3, 4). In addition to their eagerness to be involved and engaged, medical students are often excited to learn and execute procedures, such as placing IV lines, suturing, and performing physical exams that are tedious to seasoned staff (5). Allowing these students to perform these tasks allow the more experienced staff time to complete more advanced activities during the pandemic. Medical students, who may have more time to devote to individual patients than their attending or resident counterparts, can also increase patient comfort and decrease anxiety during a pandemic. Finally, since medical students in the United States and across the world may feel they lack the preparedness to necessary participate in disasters (3, 4, 6), deploying medical students to participate in the pandemic response would only serve to enrich their education and better prepare students for the next disaster.

    While there are multiple risks to both patient safety and medical students themselves that must be considered whenever students are deployed, it is especially important to do so during the high-risk and high-stress hospital environment of a pandemic. Since medical students often do not feel prepared to participate in disaster response (3, 4, 6), their lack of education will put additional work on supervising faculty to both train students to do whatever roles they take on as well as ensure patients are not harmed by the process. With the growing complexity of medical care and increased burden on hospital operations during a pandemic, increasing the need for supervision of medical students would decrease the previously

    stated benefits of freeing staff time for other activities. Moreover, medical students’ the lack of education and experience may lead to an increased risk of exposure and illness. One study shows a severe lack of proper PPE and infection control education in medical schools throughout the world , with over 50% of students failing to report injuries and exposures (7). This study further underscores the need for additional education for medical students in environments where infection control is of the upmost importance.

    The risks to a medical student’s mental health during a disaster is another concern that must also be considered. Participation in disaster relief efforts has showed some positive effects on medical student mental health. In a study performed after the March 2011 “triple disaster” in Japan consisting of an earthquake, tsunami, and nuclear accident, individuals who volunteered showed increased growth, particularly in “personal strength”, as well as an increased desire to be a physician (8). Furthermore, this as well as other studies show that those who volunteered were no more or less likely to report distress than those who did not, no matter how long they volunteered for (8, 9). Results also indicate that for those who did experience an adverse emotional response, the effects were greatest in students who identified as female, or who participated in activities that were intense or required low supervision (9, 10). The researchers acknowledged that the effect on female participants was associated with a lack of confidence in their abilities, and that societal attitudes may be a factor contributing to this differential. Further harms may be incurred since medical students often do not seek appropriate care for either physical and mental health conditions since the fear the lack of confidentiality at student health centers as well as the possible retaliation against their academic status in medical school (11).

    In addition to the risks on medical students for participation during disasters, there are also potential risks to patients that should be acknowledged. In the normal course of care, patients are informed when medical students are a part of their care, though some may not be aware of how a medical student differs from other members of the care team. Incorrectly being introduced as “doctor” by other members of the care team may lend to this confusion (12). However, medical students also play a part of this lack of consent. One study showed that as students advance in their clinical years, they are less likely to introduce themselves as medical students. This lack of consent was found to be especially prevalent in

    patients requiring anesthesia, since these patients placed an increased importance on understanding medical student involvement as compared to non-anesthetized patients (13). The increasing number of patients who will be sedated and intubated during the COVID-19 pandemic combined with the sudden increase in responsibility of medical students and lack of supervision, may lead to a decrease in understanding by patients of whom on their team is a medical student and what qualifications that students holds or has completed.

    Risks to patients can be further stratified, and this stratification is not necessarily the same across patient identity. In the setting of a pandemic, medical students will interact with a variety of patients that may be difficult or novel, and these patients may include distressed children or patients with poorly treated mental illness (14). A study on students being trained in advanced trauma life support indicated that when provided an unfamiliar scenario, such as one that involves a pregnant woman or child, medical students were easily distracted (15). While more research must be done and since these results cannot be generalized, the high-pressure situation of a pandemic could exacerbate many of the above-mentioned risks, and thus must be taken into account when determining the types of medical student participation throughout the pandemic.

    After weighing these benefits and risks, the AAMC released a statement intended to guide medical schools on the types of direct patient care that medical students should be allowed to participate in. The AAMC reaffirms that medical students must be appropriately trained and supervised in whatever activities they participate (16). They further emphasize that medical student participation should occur only when there is a critical need due to a shortage of healthcare workers. The AAMC is cognizant of many of the risks of medical student involvement, including increased exposure, increased PPE use, and increased need for students to receive COVID-19 testing, which is currently limited. This analysis requires that the benefits outweigh the risks before medical students can be involved in direct patient care.

    Medical Student Participation: A Duty or a Choice

    To better understand the choices that medical education will need to make for its students amidst the pandemic, the first, overarching question to be considered is whether medical student participation during the pandemic should be mandatory or on a volunteer basis. While many medical students have shown an interest in participating in the response to disasters, including pandemics, the number is not 100% (3, 4). While this eagerness to serve should be lauded and appreciated, it must not be misconstrued with a duty to act when one does not reasonably exist. It has long been held that physicians, as professionals, hold a duty to act because of their responsibility to society. Ethicists argue that, even when risks to the physician are present, their unique ability to heal supersedes these risks to themselves (17, 18). From this, it can be assumed that the duty to heal for a medical student should be determined by their individual abilities as well as the ways in which they would be able to assist during the pandemic. A thoughtful ethical analysis leads to two possible positions regarding the duty of a medical student. In one position, medical students were seen as either not having the same abilities as physicians or as existing on a spectrum between lay-people and physicians. In either case, medical students could not have the same duties as physicians if they did not have the same abilities, though one could argue that they should practice up to their current abilities just as physicians are required to. According to the second view, which was based on philosopher Judith Jarvis Thompson’s analysis of obligation, it is mandatory that everyone do what they can to avoid moral indecency. In this case, which may provide the stronger argument, medical students have a duty to act up to their current abilities, and to do otherwise would be indecent when the state of the world requires their assistance (5, 19).

    There are also a number of legal issues that must be considered before medical students can be given clearance to participate. Since Hurricane Katrina, legal protections have been passed that protect health care professionals who volunteer in the face of disaster, so long as they are licensed (20). While these legal protections may not apply to medical students, they, as unlicensed individuals, may be covered by Good Samaritan laws, which are designed to protect those who provide medical care to those who would not ordinarily receive it (21). At the same time, identifying medical students as Good Samaritans would automatically confer a lack of duty, as Good Samaritan legislation was enacted to encourage health

    care works to treat in an emergency setting where they have no duty to act. Furthermore, once any assistance is offered, the medical student would be duty bound to remain with the patient until they could transfer care to someone of higher training and would otherwise have abandoned the patient (21). At the same time Good Samaritan laws only apply to emergencies when a patient is unable to otherwise consent. Since consent is of the utmost importance during a disaster, Good Samaritan laws do not and could not apply in these cases, leaving medical students without appropriate legal protections.

    We must also consider whether the medical education system, including medical schools and hospitals, have the legal duty to protect medical students throughout their educational experience and particularly during a disaster. Being averse to legal action, schools forego a supposed student-duty-to-act in order to protect themselves and their assets. During the SARS epidemic of 2002, medical schools in Asia were closed after an incidental exposure left students ill (22). From a legal standpoint, as well as an ethical one, student participation can be prioritized only when their risks are minimized. There are those who would argue that medical students, given their lack of knowledge, should have priority for PPE, vaccines, and other hazard-reducing measures in the interest of decreasing the risks associated with their lack of experience (5, 19). During a pandemic, however, this can be complicated. Prioritizing masks for medical students will take away from the already sparse supplies that are needed for frontline workers. If there is a shortage of supplies, it would be unreasonable to put medical students in the position of choosing between their profession and health. While the concept of a duty to act for medical students is altruistic and may even be reported by some medical students as a duty they feel they must fulfill, its implementation in the COVID-19 pandemic would create legal concerns for medical schools.

    Additionally, requirements such as a priority for facemasks and vaccines for medical students would create a moral sacrifice on the part of frontline workers that would achieve moral indecency even by Thompson’s standards. Thus, medical student participation must be on a volunteer basis.

    The AAMC reaches a similar conclusion but on a seemingly different ethical basis. AAMC guidelines conclude that medical student participation should be voluntary. They further state that this decision must be consistently conveyed in clear messaging to students and that, if direct patient care is

    part of required clerkship experience, online opportunities should be made available in their stead (16). This requirement stems from the recognition that medical students, whether hoping to impress supervising physicians or out of misguided morals, may participate in direct patient care against their own better judgement. Understanding that medical students are vulnerable to this type of coercion at any time in their education (23), but are especially vulnerable when attendings and others who are supervising trainees are working in situations that cause intense stress will help medical schools and other institutions see the need for a voluntary mechanism of participation.

    An Excerpt of Medical Student Participation in Past Disaster Responses

    The response of both the medical system as well as medical education to disasters has changed drastically over time and can certainly be influenced by a number of factors such as the type and intensity of the disaster as well as the resources available. By analyzing the adaptations that have been made during past disasters, as well as their perhaps unintended consequences, we can better understand the implications of current changes being made to medical education.

    During discussions around COVID-19 mortality concerns, the current pandemic is often compared to Pandemic Influenza. Between 1918-1920, a deadly outbreak of influenza spread across the globe, infecting over a third of the world population and ending the lives of approximately 50 million individuals (24). While current mortality has not reached this magnitude, the Pandemic Influenza of 1918- 1920 does represent a time when a pandemic led to mass changes in medical educations. Dr. Isaac Starr, a medical student in 1918, recalls medical students being put on the front lines. While fourth year medical students took on the role of interns, third year medical students, who would have been in their core clinical year, supported the effort as nurses (25), with only one trained nurse available for consultation throughout the day. During this time medical students were put in an ethically precarious position, filling roles that they were not necessarily trained for and had little to no supervision. Such situations existed in regular hospitals as well as to makeshift hospitals at schools, private homes and other areas that were staffed by medical students (26). The dangers of lack of supervision, including lack of patient consent

    and harm to student mental health were of the utmost concern in 1918 and continue to be today. In 2005, following an earthquake that struck Pakistan and the surrounding areas, medical students were sent unsupervised to treat patients because “elderly and physically weak senior doctors were not able to undertake the long hike” (27). What resulted, as may have been expected, was a group of students thrust into emotional turmoil at the sight of people trapped under semi-collapsed buildings. Without the proper training, students rushed to pull people away without concern for the instability of the buildings, leading to student injury as buildings continued to collapse. These students, instead of assisting, became a source of liability to other rescuers. These experiences not only reinforce the need for proper supervision, but also emphasize the need to for medical students to receive the proper education in order to ensure that they are prepared for the new challenges encountered during a disaster.

    Following the attacks on the World Trade Center in September 2001, many medical students in New York volunteered to assist with the influx of patients. In one role, medical students accompanied physicians to the World Trade Center in order to provide first aid. Even though these medical students were receiving the proper supervision by physicians, the project was dismantled since it was determined that sending teams to the site posed a risk to staff and students and that too great relative to the minor first aid that they rendered (28). Thus, even though these students were receiving the appropriate supervision, student safety was balanced with the benefits that those students could provide. Away from danger, students continued to support hospital operations by acting as “runners” in the hospital to help ensure the passage of information when telephones were overloaded. It was determined that this role held a better balance of risks and benefits. It is important to note that students in this role were not unilaterally removed from danger due to their roles as medical students, but rather considered as members of the healthcare team that could provide in a time of need.

    COVID-19: Medical Student Participation in the Present

    With medical students at all stages of clinical education having their education suspended or moved online, many are left wondering what impact this has on their graduation status and future training as a physician. When considering the risk to benefit ratio in whether students should be allowed to participate clinically at this time, it would be prudent to remember that medical students serve multiple roles in the hospital, sometimes as learners and other times as clinicians. The benefit to medical education does not justify the risks medical students pose, including acting as fomites, consuming much needed PPE, and requiring the supervision of physicians who have many other obligations at this time (29). On the other hand, by the end or even the middle of the core clinical year, medical students are prepared to support a variety of operations including interviewing patients, communicating with families and other members of the care team, and writing notes. While medical student involvement in patient care can increase the work of attendings due to needed supervision, it should be balanced against the burden on the healthcare team that students are able to alleviate. Furthermore, preventing students from fulfilling their duties to patients and participating in the healthcare team may decrease their cohesion with the medical profession and prevent them from developing attributes of core professional such as service and altruism (29). To prevent medical students who want to volunteer simply due to their role as a trainee should be seen as unethical. Rather, in order to avoid moral indecency, we should carefully weigh the benefit each specific student can bring given their level of training to the level of supervision required for their activities.

    While medical students need to participate in the required clinical education, the benefits that learners can bring as clinicians must be balanced against their ability to complete their work safely. Given the shortages of PPE experienced across the country (30), a major consideration in deploying medical students back to the wards is whether there is enough PPE to support these students, and whether this use would detract from hospital needs. While this consideration may mean that the action to suspend medical student involvement in patient care is the best we can do within our current means, it does not mean that we are acting in an ethical manner. Ethical responsibilities include acting to prevent or decrease the effect of disasters before they occur (31). In the aftermath of disasters, educators have not only recognized the need for additional disaster management education and preparedness plans in medical schools but also the

    development of innovative curricula to meet the educational need (32-34). Unfortunately, medical school curricula nationwide have not responded to this need. With this lack of disaster medical education, our medical students as well as our interns are less prepared to participate in disasters when they occur (35).

    Despite the negligent or sluggish response by multiple actors to support hospitals during a disaster, medical students themselves have discovered new and innovative ways to respond within their means. Harvard Medical School students quickly mobilized to support patients, healthcare workers, and the general community during this uncertain time. The students are split into four main tasks, including creating education resources for healthcare workers, education resources for the public – which has become especially important given the conspiracy theories that have been circulating – and providing support for health care workers and vulnerable populations (36). Given the circumstances, the need for safety, and the lack of preparedness by hospitals, medical schools, and the government, these medical students and many others across the country found a way to continue to support their communities, on a completely volunteer basis, despite the roadblocks and risks in their way. During what is certainly an increasing difficult and stressful time these self-less acts not only represent the level of ethical behavior we should strive for but also both validate and illustrate that the future is in extremely capable hands.

    Conclusion: Recommendations for the Future

    Amidst any type of disaster, there is bound to be conflicts between what one hopes to achieve and what is realistically possible. This is true for the COVID-19 pandemic as well. As much as many medical students would love nothing more than to return to the clerkships and continue to support their patients and hospitals, their safety, and the safety of those around them, must come first. While medical students have discovered ways to remain involved despite both the lack of training and availability of PPE, medical schools, hospitals, governments, and all other parties must be urged to better prepare for the next disaster, whatever it may be. Ezekiel J. Emanuel, MD, PhD, Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, recognizes the transformation ahead. He writes, “The reconfiguration of medical education seems inevitable fueled by online educational technology and

    the need to transform clinical training” (37). While transformations can be painful, they are required to ensure that next time, medical students are in the position to participate to the fullest of their abilities while mitigating as many of the risks as possible. Only then, says Thompson, would moral decency be achieved.



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