COVID-19 Highlights Our Shared Vulnerability

We must be able to “let go” of the small stuff and be more willing than ever to “forgive and forget,” to move on with our annoyances and inconveniences, realizing that we are all in this together.

“Vulnerability, weakness, and neediness are to be avoided,” we are told, “Success, preparation, and strength are our defenses.” Suddenly, however, we all find ourselves quite vulnerable, and in ways that may not be immediately apparent but that nonetheless affect us on some level.

Historically, ethics has sought especially to protect the vulnerable. Medicine itself, one may argue, has as its very core mission meeting people at their most vulnerable—when we are sick, injured, dying. Many spiritual traditions have prioritized the needs of the vulnerable, seeing service to the hungry, thirsty, sick, exposed, and imprisoned as essential qualities of the good person. Clinicians recognize and respond with empathy to their patients’ vulnerability. Facing their own vulnerability, and that of their colleagues, may be a greater challenge.

Despite all of our apparent sophistication, we suddenly find ourselves all very vulnerable to a single strand of RNA that is 29,811 nucleotides long.

Our vulnerability, regardless of our roles, extends well beyond the possibility of contagion, illness, and death. Infection is the apparent and clear vulnerability that we all face. We mitigate that risk as best we can—hand washing, social distancing, personal protective equipment (PPE). However, there are deeper layers of vulnerability that demand exploration.

A silent but real vulnerability that each of us shares at this time is the risk of a serious acute illness other than COVID-19. A broken leg, acute appendicitis, or an asthma attack could land us in the hospital, or at least require a visit to the Emergency Department. By being in the hospital right now, despite necessary precautions, we would be at an increased risk of infection with SARS-CoV-2 and have the potential for developing COVID-19. Added to the intrinsic vulnerability that an acute illness poses, there is also now the potential for COVID-19 infection if we had to go to the hospital or emergency room. Moreover, besides potential infectious exposure, being hospitalized right now would likely take resources away from patients with COVID-19 whether it be nurses, hospital beds, or simply the much coveted personal protective equipment. In a recent opinion piece in the New York Times, trauma surgeon Dr. Elinore Kaufman highlights the potential significant strain that acute illness could place on the healthcare system. Dr. Kaufman witnesses the almost daily reality of gun violence in Philadelphia. Many of the patients that she cares for are critically ill and will require a ventilator and a bed in the Intensive Care Unit (ICU) in order to survive. Right now, patients suffering from COVID-19 likely need these beds. Gun violence is a preventable acute illness, and Dr. Kaufman urges people to put down their guns now, and hopefully forever.

It is also a very scary time for people with ongoing medical problems. For instance, patients with chronic kidney disease must visit dialysis centers several times each week—many times in close proximity to other patients—thereby increasing their risk of exposure (on top of the inherent susceptibility that comes with their disease). Many other serious medical conditions that require frequent contact with doctors and hospitals now carry with them the added risk of contracting COVID-19. Cancer patients are another particularly vulnerable group right now. Patients with cancer may have their treatments delayed, modified, or both because of their lowered immune system and susceptibility to COVID-19 and also because of concern about having the necessary resources for more critically ill patients. Physicians who treat cancer are working to balance cancer patients’ need for treatment against their risk of infection. The American College of Surgeons recommends that patients with lower-risk cancers have their operations delayed, whereas those with higher-risk tumors should proceed with surgery.

Balancing the competing moral claims of protecting patients from infection while providing them with adequate care will be very challenging. This will be particularly true if there are other, perhaps more critically ill patients also simultaneously trying to access care. This is where the clinician shares vulnerability with the patient. Having to make decisions about whether your patient with cancer should go to surgery or receive chemotherapy first is typically based on characteristics of the tumor. Now, these decisions may have to consider which treatment has the lowest risk of having the patient become infected with COVID-19.

Clinicians who must make soul-wrenching decisions about rationing care now face the risk of lasting psychological and spiritual damage. We are accustomed to moral dilemmas in which we make tough decisions, sometimes on limited clinical data. When do we tell a family that the patient is unlikely to survive an acute illness? When do we recommend stopping aggressive interventions and instituting comfort care only? We are familiar with these hard decisions—they are part of our job—but this is different. This is about deciding which of two or more patients, each with equal need for a single ventilator, will get it. This is not part of the job that we ever imagined we would face.

When confronted with a large number of patients at one time, and with limited resources, we may also not be able to provide the kind of care that makes us proud to be doctors. We may not be able to spend the time talking to families, double checking labs, holding a dying patient’s hand. We may be asked to help manage patients and conditions that we haven’t seen or cared for since our training. The way in which we are accustomed to practicing may have to be modified in order to do the most good for the greatest number of patients at the same time. That will be very hard for a group of people who pride themselves on being very good at what they do, even at times being perfectionists.

Recognizing our shared vulnerability, all of humanity, is only the first step. It cannot end there. We must also exhibit mutual empathy for each other. We must be willing to put ourselves in other people’s shoes. We must be able to “let go” of the small stuff and be more willing than ever to “forgive and forget,” to move on with our annoyances and inconveniences, realizing that we are all in this together. We also have to take care to keep each other out of harm’s way. One dramatic way, as we have seen, is to not shoot at each other. But there are simpler, though no less profound, ways to keep each other safe right now. Doing so will make us, and the world, better.