Outpatient Services During a Pandemic: Finding Your Ethical Footing
By Debra Gorman-Badar, PT, MA
The COVID-19 pandemic and our public health response has tested the tension between two social goods — our health safety and our economic security. Within the stark limitations of our businesses, government agencies have deemed physical therapist services "essential" leaving it to outpatient physical therapy clinics and hospital departments to make the professional decision to continue to provide services. Especially concerning are in-person outpatient services.
Many are relying on their intuition to make these decisions. However, ethical decisions based on personal ethical intuitions are often unclear, dubious, and debatable. As a health care ethicist, I find the reasoning processes of health care ethical deliberation can give us more concrete guidance to discuss and decide our good, right, and reasonable actions during unprecedented and uncertain times.
Before proceeding, we must address three considerations.
First, the science of COVID-19 is not fully understood. We, as physical therapists, rely on scientific experts and public health officials to keep us informed of the "best evidence" regarding COVID-19, which seems to change weekly, if not daily. Therefore, we must be judicious in using this uncertain and shifting expert knowledge as the foundation for our decisions.
Next, our public health response to the COVID-19 pandemic is about surviving, not thriving. Outpatient physical therapist services are not emergency, or even urgency, services in health care. Certainly, our patients have disabilities that enormously benefit from our services, but those who need us most during this time — the elderly and the severely disabled — are the very ones that need to "stay home, stay safe."
Last, as health care professionals our first priority is always our patient’s well-being. We all know health care providers who are "only in it for the money" — an attitude gravely contrary to both sociological and philosophical definitions of professionalism. During the COVID-19 pandemic, decisions cannot be made primarily for a provider's economic well-being.
The current relationship between our two social goods of health safety and economic security requires creative thinking and decision-making. In circumstances such as these, when we're reminded of our interconnectedness and interdependence, it's useful to look at possible courses of action through a four-category framework: What actions are prohibited? What acrtions are ideal? What are permitted? What are required? In categorizing our actions, we should consider the consequences and trade-offs of different actions, our professional responsibilities and obligations, and the virtues needed to make the right decisions at the right time in the right place.
Most important, we are ethically required to think deeply and discuss widely when deciding how we are providing services. This necessitates risks-benefits analyses, selecting patients for the allocation of services and how they receive services, and always relying on patients to make the best decisions for their health and lives. We must follow the principles of our Code of Ethics and exercise the virtues held by our profession that call for prioritizing our patients, while also considering our economic obligations and commitments. Finally, we must balance our relationships in considered and creative ways that integrate the multiple human stories of the COVID-19 pandemic.
Our society, which values individualism, is being asked for a communitarian response to a pandemic. We are being asked to consider, both individually and collaboratively, which goods and how much of those goods we need from others and society. In addition, we are being asked if and how we can help provide those goods to others. Political decisions to reopen the country are being made even though the high and intense levels of testing and contact tracing recommended by many public health experts are not yet happening. Public health officials are predicting multiple waves of infection rates that may require returning to social distancing and further economic closures. This heightens the need for well-thought decisions for providing outpatient physical therapist services.
I am unceasingly amazed at the creativity and resourcefulness of physical therapists and physical therapist assistants. No "best" decision exists. However, there are better ways to think through and reason to the decisions we are being asked to make. Well-informed, thoroughly-discussed, and morally balanced decisions about how and when to provide outpatient care, especially in person, are needed. Within local settings and specific contexts, good, reasonable practitioners will make different decisions regarding how to care for all those who need them. During COVID-19, it is our professional skill in knowing how to creatively adapt, adjust, and cope — skills we teach our patients every day — that will bring us through these uncertain and unprecedented times. My hope is that we will all have a story we are proud to tell.
Debra Gorman-Badar is a doctoral candidate at the St. Louis University's Albert Gnaegi Center for Health Care Ethics