My 81-year-old patient appeared on my screen for a telehealth visit, encircled in a halo-like formation by four of her eight children, one of her granddaughters and her pets. She had been my patient since the start of my medical residency, almost 20 years ago. I listened as the details of her medical history were relayed piecemeal by her family.
Her symptoms indicated she might be experiencing spinal cord compression, a condition that indicates that a malignant tumor might be pressing on the spinal cord. The condition requires emergency medical treatment. Untreated, it could lead to complete paralysis. I immediately recommended that she be brought to our emergency room for examination. Without hesitation, my patient looked directly into the webcam and said, “I will not go.”
She knew that Covid-19 visitor policies in the hospital meant her family would be unable to visit her. “I think it’s my time to go,” she said. She explained that she felt she would soon die, and if these were to be her final days, she wanted to spend them at home, surrounded by her children, grandchildren and pets. After discussing the risks of not pursuing further medical evaluation, we agreed that she would benefit from in-home hospice care. Two weeks later, she died.
She knew that Covid-19 visitor policies in the hospital meant her family would be unable to visit her. “I think it’s my time to go,” she said.
Covid-19 was not the registered cause of death on her death certificate, and she did not test positive for Covid-19. But I believe the virus was still somehow responsible for her death. The fear of being in the hospital alone forced her to decide against a treatment plan that likely would have altered the trajectory of her life.
The visitor policy at Michigan Medicine, where I care for mostly older adult patients, has been drastically altered during the Covid-19 pandemic. Since March 2020, our hospitalized adult patients are not allowed to have any visitors, except in rare exceptions or at the end of life—and even then, the number of visitors is severely restricted. Our hospital’s Covid-19 visitor policies are not unlike those at hospitals across the country. These changes and precautions made perfect sense to me at first, but when I saw the impact they had on my 81-year-old patient, I began to think that we needed to seriously rethink our policies. How does our vision of the good shape such decisions?
Who and What We Value
“Do not cast me away when I am old,” begs the psalmist in Psalm 71, “do not forsake me when my strength is gone.” The psalmist’s plea is a timely clarion call. In myriad ways, we have cast out our older adults. I now realize that part of the blame for this lies in how we teach and train our medical professionals to view life.
I teach the skills of “doctoring” at the University of Michigan Medical School. Recently, we had a session on “Ethics and the Pandemic,” where we discussed a May 2020 paper published in the prestigious New England Journal of Medicine by Dr. Ezekiel Emmanuel.
In “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” Dr. Emmanuel and his colleagues lay out four ethical principles that physicians should follow when faced with the allocation of limited resources: “maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.”
From this, it would appear that there is nothing to argue with in Dr. Emmanuel’s paper. But he and his colleagues go on to write: “maximizing benefits can be seen as saving the most lives or saving the most life years by giving priority to patients likely to survive longest after treatment” [emphasis added]. Giving priority to the worst off “could be seen as giving priority to the sickest” or, in a twist of logic, giving priority “to the younger people who will have lived the shortest lives,” they write.
“Do not cast me away when I am old,” begs the psalmist in Psalm 71. The psalmist’s plea is a timely clarion call. In myriad ways, we have cast out our older adults.
Over nearly two decades of practicing medicine, I have never thought to include younger people in the definition of “worst off” in this way. Still, the ethical principles laid out by the authors of the paper align with what other countries have done with their resources. In Italy, for example, priority for ventilatory and I.C.U. support needed to fight Covid-19 was given to younger people.
Almost all of my students came to see Dr. Emmanuel’s paper as ageist medical discrimination. The paper provoked serious reflections about who and what we value in society and how our views have very real consequences because it is out of these cultural views that policies are developed and real-life actions are decided. I reminded my students that any policy discriminating against a person on the basis of his or her age is a civil rights violation. But how did we even get to the place where an overtly ageist paper is featured in one of the most prestigious journals of medicine?
Education Without Formation
At a recent conference with medical residents, I raised the topic of physician-assisted suicide and euthanasia for palliative care patients with incurable diseases. I hoped to challenge them to think about their view of the person and, hopefully, to reflect intentionally on the real value they believe human beings have. I gently reminded them that their entire vocational work involves the care of human beings and that thinking about how they see the value of human beings is of utmost relevance to their formation.
Later, a resident at the conference paged me. Never, in all the years he trained as a doctor, he told me, had he been challenged to think deeply about the value of human life. Saddened and alarmed by this reality, I agreed to meet with him and two other interested residents so that we could explore and deepen our understanding of the “good” in patient care. It was profoundly unsettling to me that these residents, who had attended the most prestigious medical schools around the country, felt they had not been prepared to think about the “big questions” in medicine: How does one consider the weighing of often competing goods in health care? What does it mean to be human? Are human beings valuable? And if so, from where do they derive this value?
Earlier this month, I hosted a talk with Dr. Wes Ely, a professor of medicine at Vanderbilt University Medical Center in Nashville, Tenn., and a visiting professor of the program on Health, Spirituality and Religion that I lead at the University of Michigan Medical School. Dr. Ely shared his research into critically ill Covid-19 patients, which found that having loved ones at the bedside of an older patient in the I.C.U. with Covid-19 was one of the most important protective factors against the patient developing delirium, an independent risk factor for death.
Dr. Ely raised a sobering point during our discussion. Reminding us of the oath we take as physicians to first “do no harm,” he asked whether in the creation and enforcement of pandemic-time policies we had remained faithful to our promises? Or, he continued: “Have we actually done harm to the sick and to society even though the policies had been created with the idea that they would save lives by lowering the risk of Covid-19 transmission?”
How does one consider the weighing of often competing goods in health care? Are human beings valuable? And if so, from where do they derive this value?
I contracted Covid-19 in the course of my work as a physician, so I do not take lightly the importance of minimizing the risks of spread. But I now see that some of the policies have not only cost lives—they have interfered with our very ability to engage in fundamental activities that define us as human beings.
We have forgotten that we belong to each other. We have forgotten that we—and therefore our patients—were created in relation to God and each other. We have inherent and inviolable dignity because we are made in the image and likeness of God. We have forgotten that people are inherently valuable because they are the imago Dei and not because of what they do, have or have not done or what they are able to contribute to society.
“Do you think about the 85-year-old patient with late-stage dementia who is hospitalized on your service with aspiration pneumonia in the same way you do the 39-year-old businessman in the hospital who has suffered a heart attack?” I now ask residents, “If not, why not?” Do these views of the person perhaps reveal ageism and ableism that was inculcated in us by the society in which we live and the education we have received?
We have forgotten that we—and therefore our patients—were created in relation to God and each other. We have inherent and inviolable dignity.
Education without formation is not education at all. Formation, as its etymology suggests, “gives shape” to our education. Without it, there is no way to make proper sense of what we are taught—to see and place things in their bigger context of meaning.
Through friendships I have developed with philosopher and theologian friends over the years, I’ve been fortunate to fill in some of the gaps in my own education. They challenge me to think deeply about foundational issues integral to my vocation. But I know that many others have not been as fortunate to have had such opportunities.
We are not technicians caring for complex machines. We are physicians caring for our sisters and brothers, each the imago Dei. If we don’t have space within our training to reflect upon the meaning of our vocation and what it means to be human, then what are we even doing?
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