The nation's health care system is once again faced with overwhelming need pressing against limited resources. Medical professionals, including health care social workers, are forced to make hard choices that test the ethical boundaries of medical arbitrage. The scenarios below are all real-life situations communicated to GVT by health care social workers in the past month.
SCENE ONE - A NYC HOSPITAL EMERGENCY ROOM
The waiting room of a NYC hospital emergency room is full and spilling out onto the street. Nurses are having trouble coping with the chaos. They call down the social worker on duty and ask her to help organize the mob in the waiting room. The patients occupying the waiting room all seem to have arrived at the same time and all have varying degrees of illness or injury. COVID-19 patients struggling to breath, heart attack victims with arrhythmia, gunshot wounds, auto accidents, drug overdoses; CHAOS. Who gets the next available bed?
SCENE TWO - ADMISSIONS IN LA
Two COVID patients; an 82-year-old great grandmother who is already in the advanced stages of the infection, and a 37-year-old nurse who has finally fallen ill with a COVID-19 infection. Who gets the next available ventilator?
SCENE THREE - KANSAS CITY ICU
A COVID patient who has been struggling on a ventilator for two weeks is beginning to fail. The nurse informs our social worker so that she might contact the next of kin. The next of kin have never been allowed to visit and did not admit the elderly patient. Who should be contacted? What should be communicated? What is the prognosis? Shouldn't a doctor communicate this information?
SCENE FOUR - OFFICE OF THE MEDICAL DIRECTOR
Social worker in an ethics committee meeting on arbitrage is asked her position on the following question - Because the elderly are more likely to die, should they get priority over younger patients who are critically ill but more likely to survive if they get immediate treatment? What are the ethical considerations?
Over time, repeated exposure to morally distressing situations can take a physiological, psychological, and emotional toll on social workers and those in many other caring professions. During the current spike in this corona virus pandemic, health care social workers are reporting increased feelings of frustration, powerlessness, anxiety, anger, guilt, and resentment - common psychological ramifications of moral distress.
Moral distress arises when one knows the right action to take, but internal and external constraints make it difficult to take such action. When an individual fails to take what they believe is the morally right course of action on behalf of a patient, it can result in crying, loss of sleep, irregular heartbeats (palpitations), gastrointestinal disorders, headaches, and muscle pain.
“This Didn’t Have to Happen…”
Everyone now agrees that the U.S. response to this deadly pandemic was both uninformed and blatantly irresponsible. "This didn't have to happen," is the battle-cry of most of the traumatized health care workers we have talked to. Institutional and local pressures have led to poor patient outcomes and medical staff perceive themselves as complicit in acts that let patients down and violate their moral codes. They may even feel betrayed, lied to, or coerced by systems, institutions, and/or leadership that set priorities that fail to align resources and behaviors with a medical professional’s judgment about what is needed.
This intersection of moral injury due to not being able to properly care for patients along with a sense of being betrayed by the larger systems in which health care is delivered is now playing out in full view as the COVID-19 pandemic spreads