Approaches to Medical and BioMedical Ethical Concerns
Examined Post Covid 19
How has the COVID-19 pandemic surfaced, and in some instances influenced medical decisions which require physicians and nurses to grapple with the principles of health care [medical/bio] ethics? In a post COVID-19 pandemic world are traditional standards for making medical choices, which in some cases weigh life and death in the balance, sufficient for rendering the best possible benefits for both patient and society? How is our understanding of the relevant nuanced principles advanced through a prism of Islamic bioethical concerns?
Show Topics and Highlights
Has there been any particular spiritual issues that have came about with COVID-19 where it's presented ethical challenges?
. . . . because your loved one is in front of you dying and you can't do anything.
“One of the things that we do with Muslim life planning Institute is we do a lot of work in the area of medical religious partnerships.”
“Medicine is the most humane of the sciences and the most scientific of the humanities.”
What is bioethics vs medical ethics vs social ethics?
Who makes the decisions about who gets ventilators when there is a limited supply?
“Through what lens should we view the action of accepting vaccines?”
“This is the first time that I find that the global community has come together to really help people who are helpless, who don't even know how to proceed.”
Profound Conversations Executive Producers are the Muslim Life Planning Institute, a national community building organization whose mission is to establish pathways to lifelong learning and healthy communities at the local, national and global level. MLPN.life
The Profound Conversations podcast is produced by Erika Christie www.ErikaChristie.com
Full Transcript
Erika Christie
Hello, everybody. Thank you for joining us today for our webinar entitled approaches to medical and biomedical ethical concerns examined post COVID-19. A little summary for what we're going to be talking about today is as follows. How has the COVID-19 pandemic surfaced, and in some instances influenced medical decisions, which require physicians and nurses to grapple with the principles of health care ethics in a post COVID-19 pandemic world, our traditional standards for making medical choices, which in some cases, way life and death in the balance sufficient for rendering the best possible benefits for both patient and society? How is our understanding of the relevant nuanced principles advanced through a prism of Islamic biomedical concerns? And Linda, it's all yours.
Linda Howard
All right, thank you, Erika. Welcome to another episode of Profound Conversations. And I will be talking to two very dynamic speakers about very important topic around medical ethics, especially as it relates to this time period of that we're in right now with COVID-19. So we're going to be asking questions about kind of some of the some of the things that we're facing now. And we'll also we'll be talking about some of the things that we may be facing, post pandemic. So while I read a little bit about the two, the two conversationalist that we have today, I'll just ask both of them to get yourself ready. Dr. Curry's here's your preps that I will be asking you both about what you do and why you do it. So, first we have Dr. Sachedina. And he is a PhD, professor and endowed triple it chair in Islamic Studies at George Madison University of Fairfax, Virginia. he conducts research and writing in the field of Islamic law ethics in theology, both Sunni and Shiite. He his work is in social and political ethics, both interfaith and interfaith relationship, Islamic bioethics and Islamic human rights and Dr. Carrese. He is a professor of medicine at john hopkins University School of Medicine, and he's a core faculty member of john hopkins Berman Institute of biology Ethics in the chair of the ethics committee at john Hopkins Bayview Medical Center, and he is the chair of the institutional review board at john Hopkins School of Medicine. So, now I will start with Dr. Sachedina and asks you to tell us a little bit about what you do and why you do it.
Dr. Abdulaziz Sachedina
Okay, um, thank you very much for this opportunity to talk to all of you, especially Dr. Carrese, because here I am a novice when it comes to medicine. My work is mostly finding ways of helping people to understand the difficult moments they have to come to grips with the idea of suffering, why why are we going through this? What did we do wrong? So that I think those are the things that come to mind immediately in the minds of the People who suffer or who have lost their beloved, you know, in this pandemic. So my work is trying to connect spiritual and religious aspects of any tradition for that matter. I although I'm trained in Islamic Studies, but I speak to all people as a chaplain, I speak to even those who don't believe in anything. And this are these are the very difficult moments for many people to understand the infectious disease caused by Coronavirus sell. It really has increased the burden off talking to the people or the right people in the community to try to help them in understanding the situation with which we are faced today.
Linda Howard
All right, well, that is a really good segue for us to talk to Dr. Carrese. Because one of the things that we do with Muslim life planning Institute is we we do a lot of work in the area of medical religious partnerships. And it's through this partnership that we believe that that is the key to building healthy communities. So we're talking to you, we'll be talking to you a little bit more about kind of those religious connections. And Dr. Carrese if you could just talk to us about what you do in the medical space and why you do it around ethics.
Dr. Joseph Carrese
Great, thanks. So, again, as Professor Sachedina said, Thank you for inviting me to be a part of this. Thanks to everybody who was involved Linda. Mr. Karim Ali. Happy to be here. I guess. So I'm a physician and a bioethicists and I sort of trace my career sort of foundation back to college where I was a pre medical student and a major in biology but also took a lot of fun. Lots of courses always interested in philosophy and ethics. And I had the ability and fortune to cultivate that through the years in medical school and residency. So I think one of the reasons I do what I do is I really enjoy the interface of medicine and the humanities, and in the form of bioethics. And I think, to me, that makes a lot of sense because I think there was a professor of bioethics and medicine at Georgetown, Dr. Edmund Pellegrino, and I'm hoping to get this quote, right but he said something like, medicine is the most humane of the sciences and the most scientific of the humanities. And I think it's a very nice crossroads. Because of medicines, humanities and science because we're taking care of people and and involves their lives and the complexity of their lives. So that's one reason I do medicine and bioethics. I think the other thing that drew me to medicine was the notion of service. I grew up in the in the capital Like tradition, and that was one of the good parts of the church. As I recall, it was a focus on service and social justice. And I think that I took that from my childhood serving others. My mom was a nurse. My dad was a public school teacher. I like to pick up on one of the comments that Professor Sachedina made about having a role as a chaplain. I work closely with the chaplains in our hospital on the ethics committee. So they're members of the committee. They're important members of our consultation service. And we have a very interdisciplinary group that includes a focus on the spiritual dimension of our patients. So that's something we try to address at Johns Hopkins, broadly, but especially at the Bayview Medical Center, where I'm primarily based.
Linda Howard
Has there been any has there been any particular spiritual issues that have came about with COVID-19 where it's presented ethical challenges?
Dr. Abdulaziz Sachedina
Especially dealing with the end of life decisions, which is not very easy because the new infection is really causing people to lose hope that if if somebody in the family is suffering from that, and when the doctor say there's no hope there is no chance that we can really say this person. That's the most difficult part. When people like me enter the conversation, how do you make the family understand that this is something beyond your medical control, even the whole idea of COVID-19 is new. We are still trying to understand exactly how to deal with it. Then we come to you know, some of these issues connected with the funeral funeral. services where exactly the person will be buried. Because when when you when the patient dies in the hospital, there is a fear of that that person will not receive for a funeral and will have to be, you know, discarded the body would have to be discarded pretty soon. All these things really create very humanitarian crisis. Because you love your loved one is in front of you dying and you can't do anything. You can't even go close to the person because it is not good for you to be close by your see them from far away, you try to talk them an email or something like that. And that is the most difficult part by and also I think the DNR you know, Do Not Resuscitate order. Muslim bioethics does, you know, allow people at the end of life to make decisions in such a way that It does not interfere with the natural workings of the time of death. So to interfere in that work of God is not very much encouraged, we should be allowing nature to take its course. And we know that medical profession does not do it very easily. It wants to do everything to save the person. But in COVID-19, we find that all those efforts are really, sometimes few times we don't know where to move.
Linda Howard
Wow, Dr. Carrese. Do you have anything you want to add to that?
Dr. Joseph Carrese
I agree with all of that. I think that was really wonderfully stated. I think, as you were beginning your remarks, Professor, I was thinking of the thing that you ended up talking about, which was the extreme difficulty of families being separated from their loved ones at the end of life and not being able to you know, one of the main objectives of palliative care is no one dies alone. But in fact, apart from the health care professionals are at the bedside. Many, many, many patients are dying alone in sense of being apart from their family members. So I think that's very distressful. I think there's a lot of occasion here for moral distress and spiritual distress because of the issue of hope being undermined.
This the experience of isolation that many patients are having. Yeah, I think they're certainly chaplains are an integral part of our palliative care team. So they're at the frontlines helping to To address these difficult challenges, is the spiritual dimension of what patients and family members are experiencing reaching out to family members. I think that the the additional challenge that healthcare professionals feel is that we want we we are most, we want to be in a position to be able to help our patients and usually we're in control of the facts. And, and, and, and have expertise and can offer something. And as the professor mentioned, the given this is all novel. And we don't know, we're we're in an unusual spot here that we I mean, there's a lot of things in medicine we don't know and a lot of uncertainty, but this is completely new. And we're, we're we've been ambushed by this and so our usual ability to sort of have command and control and expertise and skill has really been taken away from us. We're learning as we go here and fumbling along. And that's an uncomfortable, unusual spot for us to be in and it's it's quite stressful I would say.
Dr. Abdulaziz Sachedina
What I find to be very disheartening is the inability of the family members to be around the person who's suffering. Because as a chaplain, you know, you are negotiating the space in the hospital between the families, medical team, social workers, and you are there to help them to understand what they can deliver what they can do. One of the things that I find very hard, you know to do here is that I can't be close to the patient, I can't, the family can't come close to the patient because, you know, there's a fear of, you know, being affected by it and your infections could go different ways. And also, we might be bringing something in to the patient and which would endanger the patient's you know, even well being more. So, what we are really trying to understand is that, how do we help the society the friends the family is the neighbors To learn to care for one another in such moments, so our our work is in social ethics. And it's not only social ethics where we are defining the space for each individual or family, a sitter tality. It's a collective response, which is demanded from us as chaplains as the hospital workers as the medical healthcare providers, we are all working together. This is the first time that I find that the global community has come together to really help people who are wonderful, who are helpless, who don't even know how to proceed, and how to face an encounter the situation or the health hazards.
Linda Howard
So we're talking about you know, bioethics in a probably in a sense that we don't typically think about it. So why don't we go back a little bit and just do a one on one on one Exactly is bioethics versus medical ethics. And you used another term, which was social ethics. So can we talk a little bit about what those three things are the bioethics, the social ethic ethics, in the medical ethics.
Unknown Speaker
I think Dr. Carrese can also really respond. But let me try. Let me try to do that. That bioethics is really considering all questions that have moral implications for the patient for the healthcare providers, for the social workers, for the insurance companies, by the way, and how exactly are we going to provide the treatment that is necessary or not necessary? Is it extraordinary? It is, is it optional pay, you know, care? It's like the question about ventilator where there are no ventilators available. Sometimes you get a call from the patient. Should I go I'm feeling This symptoms Should I go to the hospital? And when well of course, we have to be careful of you know, rushing them to the hospital because there might not be enough equipment to help them out because we have been hearing about now things are improving, but in the early days, it was very difficult to guide them. So bioethics is really part of the social ethics, medical ethics Boyd in Biomedical Ethics. They all deal with the very important human questions of how to respond to the ultimate questions. Sometimes the patient is asking, why am I being going through this? I was a good person I didn't have anything to do with anyone I didn't I never bothered anyone here I am, you know, suffering from this, you know, unknown disease and known, you know, virus, what exactly have I done? It's not only the answer the champion gives but also the medical professional who gives, that puts his, you know, mind at rest. So our function has been very much trying to best defy the fears and the scare that the patients are going through at the moment. People talk about Coronavirus as if it is something a calamity no it is in a way a calamity. All of a sudden we are we are asked to remain home. Well what do we do at home? How do we how do we spend our time in reflection? Prayer What do we do? It is not easy to guide is not easy to guide.
Linda Howard
So, to form a medical doctors perspective, Dr. Carrese, How is bioethics typically defined?
Dr. Joseph Carrese
I would agree with what Professor Sachedina said I would, I mean, certainly the core, whatever form of ethics we're talking whether it's bioethics, medical ethics, social ethics, the core issue, as I see it is figuring out what we ought to do what's the right thing to do under any given circumstance and in the field of healthcare as a physician Dealing with patients that often comes up in the form of be having a conflict between two important obligations. So let's say I have a patient. And the surgeon has said, you should have your right leg amputated because it's a gangrenous and if you don't get your leg amputated, you'll become septic and you'll die. So it's a question of your leg or your life. And the patient, if they have full decision making capacity may say, I'm not having my leg amputated, they basically decline, what's being recommended. And the ethical conflict there is between our obligation to benefit the patient and protect them from harm by conducting the surgery on the one hand, versus our obligation to respect their right to be autonomous and self determined. And those two things are in conflict in that circumstance that I described. And sorting that out is challenging and very difficult. So that's one concrete example of, of bioethics. I think of bioethics as the broader category with in which there are many sub categories like clinical ethics, the issues that come up in clinical medical care, research ethics. So one of my roles is chairing an IRB and the issues that come up in, in the circumstance of human subjects research. There's public health ethics, which we're dealing with a lot right now because of the public health implications of Coronavirus ethics related to emerging technologies. So, within bioethics as an umbrella, lots of subcategories. Historically, I think medical ethics, which is a bit distinct from that, although people use the terms interchangeably, medical ethics, historically referred mostly to professional ethics, along the lines of what's stated in the Hippocratic oath. So you take the Hippocratic oath, you should profess to these following obligations and responsibilities there your ethical and moral duty for centuries, that's what medical ethics was all about was the professional obligations and rules and responsibilities and then bioethics has Field emerged relatively recently, historically, probably some people pin it down to the 1960s or so when technology really came forward. Initially, the main technology was dialysis. And there was a group of people in Seattle that were making a decision about, there was only a limited number of dialysis machines and more patients who needed it, then there were machines and who would get them. And that really put bioethics on the map to some extent. But that's a really well historically a relatively recent development.
Linda Howard
So let's take this to today because we're we're looking at some of those same issues today that you talked about, like with the dialysis when we talk about ventilators. So and I know some jurisdictions has issued some standards of care that physicians should follow when they have to make a decision when there's a limited number of ventilator, who gets the ventilators how has how has john Hopkins Bayview? Or your committees that you sit on dealt with those issues that when you have to make those decisions around COVID-19? Who gets those limited resources?
Dr. Joseph Carrese
That's a great question. A really difficult question, one that we're actively grappling with. I'm actually leading the team on our the Johns Hopkins Bayview Medical Center campus that's coming up with the procedures for what we're going to do if we have a shortage of ventilators. Fortunately, that hasn't happened yet. And hopefully, it won't happen. But we want to be prepared. There is one allocation decision we've already started to wrestle with. And that is the drug REM disappear, which has been shown to have some benefit but isn't a short supply. And I can tell you some details about how we're making that decision. But the Johns Hopkins Medical system, started dealing with this in March, and was basing they basically came up with a framework for how to make an allocation decision if you get to the point where there's more People who need a ventilator than there are ventilators and a rationing decision has to be made. And the framework that the Johns Hopkins health system is using is based on work that was done by the director of the Berman's to the founding director Ruth Faden and one of our pulmonary care, critical care doctors, Dr. Lee Doherty medicine and engaged in a project. After the I think it was the h1 and flu epidemic. So for the last several years, it was a project that combined philosophers and empirical research and they interviewed stakeholders across the state of Maryland, asking them what they thought about this, what principles and rules do they think we should use? So it has there's a lot of frameworks that are being used nationally right now, one from Pittsburgh, but the Maryland framework, it has the virtue of being based on both empirical input from stakeholders, including the public, as well as philosophical thinkers. And you know, the the main goals of the framework are to be fair and transparent. And save the most lives and the most number of life years. And they the scoring algorithm is based on that. And I won't get into the details of it. But one of the things that was addressed in this framework is addressed in this framework, because Ruth Faden has spent most of her life writing about justice and social justice is making sure that whatever scoring system is used, you're not disproportionately affecting it. disadvantaged people, groups of patients who are people who have already historically been disadvantaged minority populations, for example, who are higher risk for certain chronic diseases and might be adversely affected by some of the scoring systems that are out there. So I'll just quickly say with REM disappear, we've had to come up with a procedure that based after a couple of criteria are met which is You have your qad positive for COVID-19. You need oxygen because on room air, your oxygen saturation is less than 94%. you're eligible for reduced fare and for the entire people, pool of people are eligible. The solution is to pick names out of a hat basically a lottery. We consider that to be the fairest way to do it. Wow.
Linda Howard
Dr. Sachedina?
Dr. Abdulaziz Sachedina
What what really has come up quite often is the whole question about distributive justice in allocation of the resources. And who is in this particular situation, we find that the older or senior citizens are, you know, feeling that they are being discriminated against they are not getting what they should be getting. And what we discovered in the nursing homes for example, where there was a neglect on the part of the nursing homes To take care of the elderly people, and we've we found you know that there was also the problem of poverty. What we have been trying to do in the communities, faith communities is trying to understand and make them realize that they can take control of their situation, advanced directives, for example, we have been talking about this in the Muslim communities, because there are opinions. In other words, what we are dealing with is also a cultural issue. in different cultures, people understand their own situation differently. We deal with it, America is multicultural, and therefore, you know, there has to be a proper understanding of how exactly do we communicate with people who don't understand one culture and the lingo is not really acceptable because it does not make that human, you know, understanding very easy it pinches them. No That's not the way we see it. And I think that's the thing that we find in the religious communities, there is a cry out for help, that we are a community we are a collective body we are not individualistic. In that sense. We want to understand the situation we are faced with. Again, I I can quote Dr. Pellegrino, I have met him several times, you know, and Josh, Dan, and his heads quite clearly that one of the challenges of Biomedical Ethics is to explore the cultural, pre understandings, and how do we break those things in order for us, even as Americans, here I am for last 50 years, I come from Tanzania, so I'm bicultural. I have different culture and understanding African culture. And you know, my own culture and now American culture, so I'm multicultural. How exactly do I deal with pain? How do I deal with the shortage of resources, who do I tell if I'm in need? Can I open my hand? Can I back? Can I open my hands and say, I need your help? What should I do because there's a self respect involved. There are so many issues that I find that we are negotiating as chaplains, because I work at the University of Virginia hospital as a chaplain. And we have I have, when I have more when I'm on duty, I'm in the ICU surgery department, or I'm in the pet robotics department, again, both very vulnerable, because you have people who are really struggling with trying to see if this life can be saved. And then you have the children's section, quadratic section, where you are seeing the helplessness of the parents, how do we deal with those issues? In other words, we are really, we need to what, what it has taught me at the moment is that we need to explore different cultural expressions of what does it mean to be well, what does it mean? To receive medical treatment, what does it mean to the family can't come? They can't see you. Here is a culture that is you know, surrounded by the families. People run around, you know, this is what happens if the hospital situation, Muslims run to see their families all the time they're in the hospital. And here is one of these diseases one of these virus where you can't do that the person is in isolation is quarantined, so you can't even go. In other words, there are so many doors of communication locked up on the ethicist. How do we close doors in order for us to reach out?
Linda Howard
And one of the things you said because you mentioned this term a few times, so I want to talk about this a little bit and that's multicultural. And one of the things that we do with Muslim life planning Institute and also another organization that I'm connected with, is that we do a lot of work around building multicultural competency So the question that I have, and I don't know whether or not either one of you can, you know, can answer this, but one of the concerns that I have is that a lot of these processes are put in place a lot of the protocols are put in place with by people who may not actually have that multicultural competency. They may have an understanding of their particular culture, but when we're designing these protocols that impacts all of humanity. How are we making sure that those that are driving protocols that are driving policies have that competency?
Dr. Joseph Carrese
So I'd like to jump in I couldn't agree more with with what the professor said. One of the transformative experiences for me in my career was spending four years in the Public Health Service on the Navajo Indian reservation and encountering a culture that is of course completely different from my own and how I grew up a different set of traditions and a completely different language. And after those four years did a two year fellowship in bioethics and anthropology with Al Johnson up in Seattle University of Washington, came back to that community to try to understand some of the challenges I was experiencing at the interface of traditional bio Western biomedicine and Western culture and traditional Navajo culture. So I couldn't agree more that we need to be first aware that that we are in a very diverse multicultural society. We cannot make assumptions about anybody what their beliefs are and what their how they would want to live their lives. We can't make even assumptions about basic notions as Professor Sachi Jr. was saying, what is what is benefit mean? What does harm mean? What does wellness mean? The particular challenge I was in encountering one of the challenges encountered in practicing medicine on the nav and the Navajo community I was on was just the simple act of communicating about risk. And, and, and engaging people in conversations about advanced care planning, which you mentioned, was considered harmful and dangerous. Because of the how it was understood in traditional Navajo culture, the relationship between language and reality, that the spoken word had the power to make something happen in fact, their entire traditional healing system is is grounded in that traditional healers will speak ritual language in order to restore harmony and balance. So for for a doctor to be saying, Hey, you know, if you don't take your blood pressure medicine, you might get a stroke. That was that's a bad thing to do. And no and no respected healer would say it that way. And we're stumbling into that all the time because our Western model of bioethics ethics is focused on disclosing risk. Risk disclosing information so someone can engage in informed consent. So that was a wake up call for me. It really was an important learning point for me that I've tried to keep track of to answer your question as Howard about how do we address this and the protocols and the procedures and the way we conduct business in the medical system? I that's a challenge. I think one way we do this through education. So I run a monthly noon conference called ethics for lunch and we will regularly address cases that raise cross cultural issues and try to educate our residents and medical students and nurses about this. We have a wonderful Chief Diversity and Inclusion officer at Johns Hopkins Medicine should be to heal golden who's a endocrinologist by training a physician. But her sole responsibility now is to make all of us more aware and more competent and, and better at what we do with respect to issues of diversity inclusion. So I think we're trying but it's something we it's we're we're not that we haven't solved for sure and we need to continually be reminded of it but I think I guess the other thing I would say is I you know, I don't want to wait into the political territory right now but I think this country its its its greatest strength is our diversity. It's it's we're all immigrants. We're all I my my immigrant story is my grandfather from Southern Italy. 100 years ago came to this country. No one here can say that they're not an immigrant except the natives except the Navajo baby. And celebrating that understanding that working with that is something we should all be doing, I think.
Linda Howard
Now, if we were to look at let's kind of look at where we are today, and this is Dr. Sachedina, for a question for you, if we were to look at where we are today in terms of with the Muslim community and, and, and I'm taking this into kind of an out of the medical space where we start looking at bioethics. So if we look at issues around, for instance, marriage during this time of COVID-19, what are some of the considerations that might happen in the community? When we start talking about how do we begin, you know, do we do testing before marriage? How did you begin to communicate to facilitate that because that's something you know, marriage is very important from a religious perspective as well.
Dr. Abdulaziz Sachedina
Let me begin by saying that marriage in Islam is a contractual agreement. It is not sacred exchange of vows. It is more an understanding between a man and a woman who say, all right, The woman offers the man offers, you know, woman a contract and a woman accepts or rejects it. So, here she has an upper hand, she might say to the man that I need you to be tested for Coronavirus or for any other disease that is, you know, transmittable to other person. So, I really would like to do that. In fact, I would say that it can also be written down in the contract in the contract marriage contract, that I want both the parties to be free of any of these, you know, disease that you know, can be communicated, you know, to each other. So, that has also allowed by the way, this curse of the law saying that, yes, if there is a problem, you know, that a man is suffering from vd and ever disease, then has no right to contract their marriage because the woman who is getting married to him will suffer. So there is already this principle in place. My action should not be causing harm to another person. How about my life partner? Can I cheat her? Or can she teach me of saying that, you know, she could hide some of the disease that she might be having? Oh, I'm, you know, I'm depressed all the time and she might not even reveal that in here, you know, the marriage occurs and the marriage takes place. So before the marriage takes place, this is the very important part before the marriage takes place. There is a certification now required among Iranians among Iraq is that you know, there should be free of any, you know, transmittable disease and this and that, and I think it just worked quite well in in the case of Coronavirus. I don't see any problem. If the parties are saying that we better get tested out we better find out if we have, you know, these disease or not. So I think it is actually the requirement of the Sharia the principles is you should not be causing harm to someone by keeping quiet about the situation in which you are the one who might cause that harm to that person. Because that would nullify your moral standing misery God, you're cheating. That's not right. So it has to be honest exchange. Now, I don't mean to say that in the traditional societies, these things are always known. No. Sometimes you know, the families cover up. They don't say everything. But it is there. The protection is there.
Linda Howard
So that Dr. Carrese Have you seen like that there's been any issues in terms of people wanting to insist on testing before there is contact.
Dr. Joseph Carrese
Be contact with somebody who's who they know is affected?
Linda Howard
Right. It could be it could be a marriage contract, it could be before you return back to work and you know, where there is, you know this requirement because traditionally, you know, even when you talk about an a workspace, you're not required to reveal any kind of medical condition. You know, this is so hap so how are we dealing with this with respect to COVID-19?
Dr. Joseph Carrese
Yeah, so it's that's been one of the problems and challenges nationally is the the the lack of testing at the level we should be testing I just spent two weeks ago I was on a COVID inpatient service as an attending physician, it seems to me I should have been tested before and after I finished. But we have a limited number of tests. And so we're having to have criteria established and triage who gets an allocation of resources basically issue just like personal protective equipment and ventilators and Reb disappear. We don't have enough tests to test everybody should be and so we're having to make decisions. So we have like an infectious disease set of experts who make Call but I we have patients who call and say I'd like to be tested. And they can't just get it they have to answer a series of questions. And if they, you know, meet the the pre determined criteria for testing, then they can get it otherwise, right now they have to wait. And clearly this is a huge problem. Again, despite what some people are saying about everyone who wants to test can get a test. That's that's not the case now. And it really should be the case, especially as we're getting into the phase of more and more jurisdictions opening up and more people starting to not social distance, we need more testing to be able to appropriately and optimally manage that situation.
Linda Howard
Now thinking thinking ahead a little bit. I know we don't have a vaccine yet. But when we when a vaccine is developed, we still may be dealing with an issue of a limited supply and how to use To actually distribute this vaccine. So will we be facing some of those same challenges that we may be facing when we start talking about issues of limited supply of medication or limited supply of ventilators? How do you do? This is a kind of a two part question. How do you deal with those medical ethics issues in terms of how the vaccine is distributed? And then when we talk about issues around multicultural competency, how do you develop that the necessary trust and those that you want to distribute the best vaccine to, to be able to say, trust us with this vaccine that might not be fully tested, or there may not be a confidence that the vaccine will create more benefit than harm? And I'll throw that out for either one of you to kind of jump in and have some conversation around those questions.
Dr. Abdulaziz Sachedina
Let me begin with an important observation. This is my Observation By the way, having having been working in the hospital as a chaplain and being a patient myself at different times, I think I have, what I have discovered is the question of autonomy, which takes a very important part in the American culture is not always operative in other cultures, which are collective cultures. In many ways, people are coming from the third world countries, for example, one now, immigrants here, they have a very different understanding of autonomy, what we are looking at is, what will be the collective danger, what will be the collective, you know, aspect of the obligation. But what we have discovered in this COVID-19 is that it requires a collective response. It's not individual, it's not only collective in that sense, and therefore, when the vaccine comes, we have to somehow identify We are privileged in one community or the other one, you know, individual or the other, it can't be done. ethically that's wrong. You can't privilege one over the other. Secondly, the whole question is that, how do we manage equity? What exactly do we mean by that? If we have unlimited resources, who exactly is going to benefit from the vaccination that we have now found, but there are not enough to go around for everyone? I think those whose lives are more in danger would necessarily be privatized, in the, at the level of receiving that, you know, vaccination first, and then those who can wait or who can be delayed and this is what I call the cross cultural understanding of autonomy and collectivity. How exactly do we do that without causing a sense of discrimination without causing a sense of injustice, and then A challenge for the medical team for the healthcare providers. And for anyone who the World Health Organization is faced with that, what exactly how do we how do we deal with it? We are now dealing with it in Asia and Africa in other parts, how are we going to help them if we do not have enough resources to play around? So these are some of the issues that are really to be confronted, and then need responses today.
Linda Howard
So that we start as a, as a community, like as communities, what do we start to do now to prepare so that we're not looking at trying to make decisions? Oh, the vaccine is out. Okay. Now let's figure out how do we make sure that as a community that we are treated in a fair and equitable way.
Dr. Joseph Carrese
I think that one of the things that works in the community is education, we need to educate the public and there isn't much going around. Let's say in a Muslim communities, whether in the mosque or anywhere else, and there isn't much of that kind of education coming along that here we need something to do as a community to understand the situation much better at the ethical spiritual level, at the social level and also at the political level that we need to really understand. I think it requires re establishing the important webinars and educational opportunities in the community to help people understand the issues we are faced with today.
Yeah, I agree with what's been said. I think one way of thinking about justice is not that it's there's different formulations for justice and you know, one of them is one form of relation of justices everybody gets the same amount. But I think speaking to what the professor was just saying, if we look at communities that are more need another formulation of justices, people who need more, get more. And in order to help them achieve a similar outcome, I think if we look at the communities that have been most affected by this, I think there's a strong argument to be made that some communities need more help now, and maybe they should be first in line for the vaccine. I mean, when I was just on service 90% of our service was non English speaking in the vast majority of them were Latino. So the Latino community around the Bayview Medical Center is getting hit extremely hard by this. And there's probably multiple, multiple factors that are contributing to that. But one of them has to do with the nature of their work and the fact that they aren't typically with their jobs. Don't allow them to work from home like we're all Right now in a protected environment and doing this from home, their living arrangements sometimes involve more people and, and this smaller space. And, and there may be other factors but they are clearly being disproportionately affected by what's going on here. And, and so maybe that's a that should be factored into who how we think about vaccine allocation. I just want to comment on another point made by Professor Satya Dena, the notion of autonomy and how we can think about that. Yes, this notion that in many cultures the social unit, as compared to an individual within that unit is the more important consideration and individual prioritizing the socialization and fitting into the social unit and the practical implications of that for Medicine are, who gets who's involved in decision making? Who to whom do we disclose information? And if we are not aware that different communities have different ways of approaching this, we may be not involving the right people in decisions and not disclosing information to the right people. So, yes, we need to be aware of that and that there may be differences. The final thing I want to say, we brought up the issue of trust. I think that's very important. I think, you know, at Johns Hopkins, we've been struggling with this. We've not been on the right side of that issue with, for example, the African American population. And our focus on sort of, you know, international work and national work and maybe not the communities right around us and our approach to research ethics. So I think it's important for us to Not only build trust, we've been trying to work on that, but maintain trust and do that through transparency and including the community and the decisions that are made and the process that we use.
Linda Howard
And now we have a couple of questions lined up. So Erika, are you ready to bring up some of the questions?
Erika Christie
Yes, I am. And yes, we do have a few questions for you. First question. through what lens should we view the action of accepting vaccines? With the trust issues that exist juxtapose to the seriousness of COVID-19? Is it our responsibility to be vaccinated.
Dr. Abdulaziz Sachedina
From religious ethical point of view. I think we need to do anything that would stop The spread of the disease. So vaccination, if that's the solution, then we have to abide by it now, who is going to benefit from it? And what are the politics of that vaccination, etc. I think these are some of the issues that the government administrations could take care of, but at the level of the people, how the people feel about it, I think if it is, it needs another kind of education is like the flu shot. I think when when the flu shot came out, there are many people who did not want to take that shot, and yet it was required, it was good for them to do it. Same thing will appear, you know, but this is even far more dangerous. The level of trust has to overcome the fear and the suspicion of the people, people suspect. They don't always submit to what the medical team or the wh o tries to say. So we have to be aware of that.
Dr. Joseph Carrese
I would agree, I think the vaccine question is really important and illustrates a lot of the issues we have, I would, you know, my call my infectious disease colleagues point to if you had to pick one thing in the history of medicine is completely transformed how we live and the quality of our life, just one intervention. It's the development of vaccines, it's completely transformed. You look at so many diseases that have either been eliminated, or under control across the world that used to kill millions of people a year. So vaccines as an intervention are an amazing accomplishment in the history of medicine. And I in addition to you know, what the professor said about, about trust, I think I see this as I and echoing what you said, this is a collective responsibility. And we've had a challenge I've many of my patients who I recommend the flu shot too, and they won't get it. We have an anti vaxxer movement in this country and you see outbreaks of measles. Because parents will give their kids, their kids the childhood vaccines. I think that's a huge problem. And I think it's it's vaccines are not just a question of individual safety and protection. That makes sense. But it is a community responsibility. We have a responsibility to our grandparents, the more vulnerable populations, the young children, the pregnant women. This is something I think everybody should be on board with and, you know, communicating that message. And, you know, the track record for vaccines are they are extremely safe that the the literature that's pointed to, for example, with autism was all fraudulent research, unfortunately, that got out there and it stays out there. But the work that linked vaccines to to autism was was wrong and fraudulent. And there's really it's a very, typically extremely safe intervention.
Erika Christie
Awesome. And next question. Do you see ethical dilemmas with contact tracing? Specifically, as we've balanced the need to control the spread versus privacy and self prescribed choices?
Dr. Abdulaziz Sachedina
Sometimes privacy is pushed too far. For the benefit of the generality, yes, my privacy is important, but what do you find the source of further harm in our society? Need there is a need to find out if I'm suffering from something that could be communicated that could be you know, spreading the disease to others. And I think that there, we have the choice between privacy and the larger benefit. This is what we usually talk about is utilitarian principle. What do we do? How do we handle it? I know there's a lot of discussion about utility and people are really angry with this principle in medical ethics. And yet, I think when it comes to the seriousness of a disease, and the way that disease need to be understood, through the contact, who exactly was in touch with this particular individual at a particular time, can be traced it there. It's like trying to know, genetically, what we have inherited. And I think sometimes it impinges upon our privacy, that they find out that autism is, you know, part of the genetic problem or you know, diabetes is part of the genetic problem. The, you know, there are incurable diseases that, you know, come to the genetics. So, I think that there is a fine line that needs to be, you know, defined carefully, looking at the larger benefit of the people and what it is going to do for the larger benefit of the people.
Dr. Joseph Carrese
I couldn't agree more. I mean, I think content we we're in a public health emergency right now, this is a global pandemic. And contact tracing we hear from public health officials is one aspect of what we need to be doing to get this under control and keep it under control. And there's a long, you know, medical and historical precedent for public health considerations. outweighing individual rights, whether it's the right of privacy or the right of liberty even we, we have the ability the state has the ability to quarantine people and forcibly treat them for TV, for example, if the patient isn't accepting therapy and voluntarily because of concerns about the community, and that that's played out with SARS and Ebola in recent years as well. So there definitely is a tension there we privacy is extremely important. confidentiality is extremely important. personal liberty and freedom of movement are all extremely important. But at some point, they're not absolute. And they may have to give way to other important considerations, like public health considerations. And here, I think we have something to learn from the cultures and the communities that privilege the social unit and the collective and subordinate individual interests to the collective, and say, Hey, we have to take one for the team here, and maybe give up a little bit of our privacy and give up a little bit of our liberties in order that all of us will be better off.
Erika Christie
Excellent. Linda, we've got lots more so let me know when you want me to stop. Okay.
Linda Howard
Just know that we're recording this. So why don't we take a couple of more questions and, and if anyone has to drop off, they can listen to the answers and recording.
Erika Christie
Excellent. Next question. Some of us have elderly parents, either in nursing homes or independent apartment homes. What do you think it looks like post pandemic for those Who want to reengage with parents?
Dr. Abdulaziz Sachedina
Human relationships are not easily built on the advantages or the benefits, sometimes there is a risk involved. And I find that many times, although we might be shunning that out of the concerns, sometimes even for the, for our parents, we might not be able to see them partly because their condition is such that by our going there, we might be, you know, affecting them more negatively. Under those circumstances, I think the risk and benefit analysis has to be done very carefully. And we cannot because the elderly need us, those who are in that age group, they need us they need their children, they need their you know, younger ones to come in and give them the hope that they are you know, losing. So I think that it's a weighing the pros and cons Have visitations pros and cons of keeping the contact that they need from us.
Dr. Joseph Carrese
I agree. I'm thinking of my own dad who's 88. And he's a retirement community. And, you know, he's socially isolating. And I'm one of eight children. So he has eight children. And some of them live near him. He's in upstate New York. And it you know, my sister just visited him on Memorial Day weekend, and I was biting my tongue. Say, why? Why did you do that? But she's trying to help him and give him food and clean his apartment. So I think one one answer to this as we get onto the backside of the curve, and we're opening up more and contemplating visiting older patients and there's the testing. Having that more ubiquitous and more easily available, will be part of the solution here. I think if we can reassure ourselves that we've been tested, we don't have it, then it's easier to allow this visitation to take place and testing not just once every six months, but maybe more frequently.
Erika Christie
Excellent. Next question. Can you speak regarding the ethical considerations Medicaid, Medicare and insurance companies are exploring regarding both COVID-19 treatment and post infection care? And this person writes, I recently became aware of several situations where Medicaid has refused care for post infection long term acute care needed for kidney and lung damage caused by the virus and its treatment during hospitalization. Do you know of any options or recourse for patients in this situation?
Dr. Abdulaziz Sachedina
Dr. Carrese? I would hand it over to you.
Dr. Joseph Carrese
I was gonna ask you to answer that question.
Dr. Abdulaziz Sachedina
I have bad feelings about the way our insurance Companies sometimes function. And I feel as if there is so much injustice there. So I might be very much prejudice, you know, so please, Dr. Carrese?
Dr. Joseph Carrese
I don't have a good answer to that. It's actually a little bit of news to me. So this is one. This is an example I think of sort of fumbling along and learning as we go. I'm not familiar with that happening. I that doesn't make sense to me. If somebody has a, it's certainly there. You know, I'm a proponent of a single payer universal plan, where we all the rules are, are articulated and agreed upon. And right now we have a circumstance, especially as we moved away from Obamacare, where insurance companies can write their own rules. And so if you haven't read, it's possible that some of the people who are asking these questions or maybe familiar with insurance companies that if you haven't read this fine print, you find out that you don't have the plant you thought you had so That may be part of what's going on here. If it's something else, I would have to look into it and get more information. But I think, you know, certainly we should have a system where everybody has access to insurance and everybody has access to basic levels of coverage. And I would assume that should absolutely include the ramifications of a serious illness that, you know, in this case, nobody had control over and did bring upon themselves and they should be provided care for that and that care should be covered by an insurance company.
Linda Howard
Let me let me jump in a little bit and I don't know all their circumstances but being doing work as a health care compliance officer and working a lot with Medicare and Medicaid plans. One thing is that sometimes people are in a Medicare or Medicaid plan. Whether they're working directly with the government as opposed to being in a managed care plan, and sometimes stills interpretation of what is a covered service can vary depending upon who's making those decisions. So if it's a part of a, if it's a part of a managed care plan where you're getting Medicaid or Medicare benefits, there is an appeal process. So I would definitely suggest that if there's coverage that has been denied that you have some concerns about that you should go through that appeal process. And it's usually that a lot of times you could start out with their medical director or you can go through the formal process, appeal process, but there is a process in place. Now, if someone has done all of those things, and it's still not being covered. Reach out to me, I'd like to hear a little bit more about the circumstances and I might be able to provide some direction
Dr. Abdulaziz Sachedina
In my experience of 50 years that many of them Tough ethical questions, the way they are determined. The final say is with insurance companies. Under the most difficult circumstances, when somebody's life is threatened, somebody's child is threatened. The final decision is the financial decision. You know, either it is the insurance company or Medicare or whatever it is. I think they are the ones who cast the final vote on this issue. I hope, I hope one day we'll see more compassion in terms of who are we dealing with when they are in that condition? And I hope we don't end up in that condition and suffer that way.
Linda Howard
And, and I will say that that is true that a lot of times we do get an answer from insurance companies. But what I want people to understand is no doesn't necessarily mean now that you have a right to change. Challenge. Sometimes it's very difficult when you're sick when you're just going through a lot of stress. But patients, advocates can sometimes assist in that process. There has been a number of times where I've turned a no to a yes. So know that when the insurance company tells you No, that is not the final, you can go through an appeal process, and you may even be able to bring a lawsuit.
Dr. Joseph Carrese
So that's great to hear. And I'm glad that you're doing what you're doing to advocate for people. But I have to say, as a primary care doctor, the fact that we have to go through these hurdles, and that I have to spend time and energy advocating for my patients to get something they deserve, or I have to include a social worker to help with that. Some patients don't have and some physicians don't have the bandwidth to keep that fight up all day long every day for all their so they end up insurance companies sometimes end up winning just because people are worn out, or don't have the time or don't have the bandwidth. And that's just should that should not be the case. It should not be that the system is structured in a way that people have to fight for what they would I think is a, you know, basic human right, which is health care. So it's just it's unfortunate and frustrating that the system is structured this way, I think.
Linda Howard
Agreed. So we are we are seven minutes past the hour. And I thank both of you for for your time and for giving us some extra time. And if there's any other questions, Erika, maybe we can look at how we can address those questions at a later date. But this has been some very good information that I'm sure all of our listeners got. Got a lot from so thank you for coming and speaking with us. I think Erika Christie, who has been our engineer, she does a lot The post production work that you see in the in the podcast and Karim Ali does, through his media company, the post production work AaliaNetwork, does a lot of post production work on the videos and my other business partner, Samuel Shareef, where we work together to put together these shows what the topics are in all of the work that goes into before you see what you see. So I think I think all of those, and just a little promo for next week. We will be doing a show next week that will be dealing with some of the issues that has been big in the news around some of the incidences with police and members of the community and some of the the violence that has taken place around that but we will be looking at those issues, not just from from announcing that this is what's happening. But to really kind of ask some of those questions and dig deep as to why some of these issues are happening, what impact does it have on the mental health of community members? And what is the what are the social dynamics that's happening between the police force and the community that these incidents of our current? So if you are if you're not on our mailing list, please get on our mailing list so you can get the information for for next week's show. And thanks, everyone, for hanging in there with us for a few extra minutes. And this has been our I think, our ninth episode of Profound Conversations. Thank you.
Dr. Joseph Carrese
Thank you.
