A Recap of The Center’s 27th Annual Summer Conference

For CBHD, 2020 was a year like no other. With the global COVID-19 pandemic, shutdowns, lockdowns, and calls for physical distancing, it quickly became clear that hosting a summer conference, as CBHD had done for 26 years, would simply not be possible. This led to a quick pivot, where the planned Bioethics & the Body conference was postponed until 2021, and in its place a new conference was proposed: Bioethics in Real Life: Lessons We’re Learning from COVID-19.

Considering the number of concerns raised by COVID-19, this was a natural topic for a bioethics conference. Issues of triage, resource allocation, personal responsibility, research and vaccine ethics, healthcare disparities, and a host of other topics were brought to the fore by the pandemic, and many were and still are scrambling for answers. With this in mind, CBHD invited a roster of speakers who could address these burning questions from a Judeo-Christian framework, teasing out their implications for both medical professionals and the general public.

Matthew Eppinette, CBHD’s executive director, opened the conference with a roadmap of the following presentations and a meditation on Jesus’ parable of the Good Samaritan.[1] The first plenary session was given by Dónal O’Mathúna on the topic of research ethics during a pandemic. He contended that research ethics needs to encompass more than simply IRB approval and study design. O’Mathúna argued for the necessity of performing randomized controlled trials during a pandemic while acknowledging that there are numerous ethical considerations involved that must be taken into account, including prioritization when not everything can be studied at once. He analyzed several studies that were done during the pandemic and how they did or did not contribute to an ethical furthering of our information on COVID-19 and its potential treatments, and concluded his presentation with reflections on what the Bible has to say regarding research ethics, including several biblical principles that should inform researchers, the most important of which is solidarity—a commitment to justice and equity that goes beyond mere empathy or feelings but encompasses words and actions.[2]

Faith Fletcher’s presentation focused on perhaps the greatest scandal of the COVID-19 pandemic: the health inequalities experienced by minority populations in the U.S., especially African Americans, who have been more likely to contract and die from COVID. Fletcher provided several explanations for these health disparities, focusing especially on social disadvantage—minority populations are more likely to be part of the “essential” workforce, live in a multigenerational household, and have barriers to practicing preventative measures like physical distancing.

In addition to these, African-Americans also experience healthcare inequities—a lack of access to doctors and facilities, a lack of accurate information, a lack of testing, and a lack of means to pay for treatment. Fletcher described these inequalities as “unjust, unfair, and avoidable.”[3] Drawing on her experience working with African-American women who are HIV-positive, Fletcher provided several ways of addressing these issues, both during the COVID-19 pandemic and beyond. She argued that we can address health inequities through better “access, availability, and accessibility” to “information, services, and goods.”[4] She also pointed out that African Americans tend to have a deep distrust of systems, including healthcare systems. How can we combat this culture of distrust? Through community engagement, which includes better research protocols and a special focus on accounting for vulnerabilities and disparities. Fletcher also provided guidance on how to better engage communities. One example of this is to recognize that people are not inherently “vulnerable” and acknowledge their “strengths, assets, and resiliencies.” She concluded her presentation with an account of the virtual town halls held by her institution, the University of Alabama at Birmingham School of Public Health, which brought multiple community stakeholders to the table, including doctors and faith leaders, in order to educate the community, answer their questions, dispel myths, and build trust. Keeping all of these things in mind can thus create “a more inclusive and community-centered” bioethics agenda.[5]

The next presentation, by Joseph Wiinikka-Lydon, focused on moral distress and injury caused by the pandemic. He defined moral injury as “the way in which one can feel like they are no longer able to strive and be a good person because of what they have done or failed to do.”[6] Though originally developed in the context of war, this concept has been used to describe the experiences of healthcare professionals. Unlike many other studies, Wiinikka-Lydon took into account the political dimensions of the pandemic and how these have “conditioned and shaped experiences of moral injury and in which such experiences are inevitably embedded.” Through accounting for these political dimensions, he argued that the concept of moral injury could not only help to describe healthcare workers’ experiences, but also challenge the traditional paradigms on moral injury.

Wiinikka-Lydon covered the causes of moral distress in the healthcare context as well as some of the methods that were suggested pre-pandemic for mitigating moral distress. However, he pointed out the many shortcomings of these suggestions because of the unique factors raised by the current pandemic, and suggested ways of thinking about moral injury going forward, such as viewing moral injury as something more than acute distress becoming chronic (as this places too much blame on the victim for ostensibly handling the stress poorly). He also raised several poignant questions regarding how we think about moral injury: Are there times when injustice is so bad that someone is morally deficient if they do not experience moral injury? Can moral injury be an indication that someone is viewing a situation more accurately than those around them? Do we need to develop better diagnostic tools for identifying instances of moral injury, and should those tools focus on diagnosing the individual, or the society that is creating the injury? If moral injury can be seen in a more epistemological frame as providing prophetic insight into the state (and failures) of a culture, what can we do with the insights it provides to bring healing to both the individual and the culture?

Wiinikka-Lydon concluded his talk by providing prospective ways forward for healthcare workers who have suffered a moral injury, arguing that, given the political dimensions of moral injury previously discussed, they may need to find methods of “living out their injuries,” especially in ways that are politically engaging:

But for some, more direct actions will be necessary to get them a sense of agency again. This may require organizing in networks of solidarity, where healthcare workers work not only to treat the patient in front of them, but to advocate and fight for the budgets and resources that make the best of care possible. . . . When we think then of bioethics and moral injury in the time of COVID, we may need a political vocabulary to add to our clinical and ethical ones, using terms such as "prophetic speech and knowledge," "solidarity," "organizing," "protest," and even "coercion." This will allow healthcare workers not just to treat their personal feelings of shame, anger guilt and betrayal, but also feel an empowerment to change the conditions that gave rise to such injury, and perhaps also help us help those in the larger society see some things that they have yet not seen.[7]

This presentation was followed by David Hyams from the U.S. Department of Health & Human Services, Conscience & Religious Freedom Division (CRFD), who overviewed the mission and activities of the CRFD, the relevant U.S. laws governing conscience protections and religious freedom, and select HHS actions during COVID-19. Hyams covered several HHS initiatives in response to the COVID-19 pandemic. In the midst of hospitals closing to visitors, they issued guidelines ensuring that patients still had access to chaplains in compliance with the Religious Freedom Restoration Act (RFRA). They also provided guidance regarding masks, allowing people to have accommodations if their religious beliefs make it difficult to wear certain types of masks. Finally, they provided guidance to faith communities on how to meet as safely as possible in the midst of lockdowns without infringing on their first amendment rights.[8]

As COVID-19 is a global pandemic, CBHD also invited speakers who could provide insight into the course of the pandemic in a non-U.S. setting. Thus, Drs. Ken Muma and Bramwell Wekesa, two Kenyan physicians, spoke on their own Kenyan context and the unique logistical and ethical challenges raised in it. Muma provided an overview of the situation in Kenya, which included many policies found throughout the world: mandatory quarantine for those infected, mask mandates and hand washing, curfews, travel restrictions, and changes in hospital function such as eliminating elective surgeries and shifting resources towards COVID-19 preparation. They also detailed some of the struggles particular to Kenya, such as a lack of critical care beds, few physicians, a 20% illiteracy rate, and high levels of poverty and unemployment.

One factor that makes the Kenyan experience of the pandemic quite different than that of other countries is the social context, especially the concept of Ubuntu. There is no one word for this in English, but the concept reflects the communitarian notion of African life: “Man is a man because of community.”[9] In this community-oriented society, lockdowns, quarantines, and travel restrictions affect people very differently, and led to anger when they disrupted traditionally communal events such as burials and weddings. Travel restrictions have had severe effects, causing people to stay away from hospitals and drastically increasing the cost and travel time of public transportation (which affects the poor and vulnerable the most).

Muma went on to use several broad categories to group COVID-19 ethical issues in the African context: human dignity and rights (Is it acceptable to limit travel within a country if that ends up restricting access to food and healthcare? What should we make of the government forcing incarcerations under the guise of “quarantine”?); benefits verses harms (Who should benefit from limited resources? Who gets admitted, and what gets funded?); equality, justice, and equity (Can you mandate handwashing when not everyone has access to running water, or wearing a mask when not everyone can afford one? How should policies be framed so that they do not burden the poor and vulnerable in society more than everyone else?); non-discrimination and non-stigmatization (How can we stop communities from rejecting the sick or those working in healthcare out of fear?); and respect for cultural diversity and pluralism (How does a communal society adjust to the necessity of distancing? How can traditionally communal practices be done safely?). Muma concluded his address with some of the ways his own facility, AIC Kijabe Hospital, had tried to address these issues, especially through working with stakeholders in the local community and making healthcare accessible to the most vulnerable.

Bramwell Wekesa addressed the same African context, but while Muma addressed the issues facing society at large, Wekesa focused much more on the struggles of healthcare workers specifically. After an overview of particular policies and precautions implemented by his hospital, Wekesa outlined four major challenges faced by Kenyan healthcare workers: (1) the fear of putting oneself or one’s family at risk when dealing with patients; (2) the uncertainty caused by the poor understanding of COVID-19 that led to constantly changing safety and treatment protocols; (3) the changes to the physician-patient relationship caused by masks, distancing, and telemedicine, and the reduction of privacy and confidentiality that often accompanies a positive diagnosis; and (4) the harms that have come about as part of the pandemic. These harms include the psychological harm brought about by distancing and lack of contact in a communal culture; the medical harm that comes to patients when healthcare workers are overworked, understaffed, and under resourced; the stigma faced by healthcare workers (as those who are healthy become loath to interact with someone who could have been exposed); and the moral distress that comes from realizing no curative options remain and feeling like they have allowed a patient to die.[10]

The next presentation came from Matthew Anderson and was titled “The Imago Dei and the Value of a Life (in a Pandemic).” In this address, Anderson considered the toll taken by COVID-19 regulations and how we can determine whether they were “worth it,” as making such a judgment raises questions of how we determine the worth of human life. He pointed out that Christians tend to be averse to such judgments as they view humanity as being made in the image of God and therefore of infinite worth. However, Anderson argued that “a carefully specified understanding of humanity’s infinite value does not entail that each individual has a life of infinite or even maximum duration, and that it permits some comparative judgments in making policies that would save lives in a pandemic.”[11]

He began his defense of this position with a discussion of the image of God and what we learn about it from the life of Christ. From this, Anderson argued that human value and dignity come from our being a creature loved by God and for whom Christ died. We recognize that as a part of the fallen world human life is limited, and that even death cannot rob people of their dignity and worth. Understanding this has implications for how we deal with topics in healthcare, and Anderson applied it to several situations arising from the pandemic. One example is hospital visitation policies—if the infinite worth of humans means saving every life possible, then visits should always be prohibited for people’s own safety. But, should we recognize that death cannot rob a person of dignity, then we see that there are other goods, such as being physically present with the dying, that can be pursued even if they put some lives at risk.

This balanced view has broad implications for public policy. Since human lives are unique and infinitely valuable, policies should “honor the irreplaceability of each person by seeking to prevent their premature deaths.”[12] This means that the number of lives saved could be an acceptable measure of a policy’s success. What the policy aims for is important, though, and there is a difference between making decisions that strive to balance multiple, conflicting goods and those that deal in strict utility. When resources are scare, this means that sometimes we will have to choose who to save and who not to save, who to prioritize and who may not get treatment. Anderson’s understanding of dignity means that we can make these kinds of decisions; we do not have to adopt a stance of “zero-risk” for people, and we do not need to expend every resource we possess to save any single person. Nor do we have to resort to random chance as the only just way of distributing scarce resources. For Anderson, then, a better understanding of the imago Dei and the infinite value of a human life should result in better policy.[13]

The final plenary of the conference was given by Cheyn Onarecker, who used the lessons that are being learned from the COVID-19 pandemic to determine ethical “areas of improvement” to be considered before a future pandemic. Throughout his presentation he raised numerous ethical dilemmas grouped around three main principles: the duty to treat, respect for the dignity of all persons, and caring for the caregivers. [14]

In the current pandemic many questions have arisen around the responsibilities of healthcare workers to their patients and profession. How much risk should they be expected to take upon themselves during a pandemic? As a physician himself, Onarecker believes that “we have a duty to treat. We are better trained, we have the knowledge and skills to reduce the risks, we have a promise to keep to the ones who have supported our decisions to pursue careers in medicine, and our service is the only appropriate response to God, who loved us and called us to serve.”[15] However, he did not view this duty as an absolute, and acknowledged there are many situations (such as when a healthcare worker has an underlying condition or has a vulnerable family member at home) where wisdom and prudence should be used to determine the best course of action.

Many questions have also arisen around triage decisions, resource allocation, and crisis standards of care. Onarecker approached these issues within the framework of human dignity, arguing that while these kinds of decisions may be necessary during times of crisis, we must understand why we make them. Simple utilitarian calculus is not enough, and discrimination (whether based on age, disability, wealth, ethnicity, or any other status) must be avoided. Onarecker provided seven principles for making these kinds of decisions to help avoid these pitfalls and ensure that every patient is treated fairly and with dignity. Finally, his third principle was caring for the caregiver. He argued that institutions have four duties towards the healthcare workers they employ: “(1) provide protection for healthcare workers to the extent that protection is possible; (2) furnish the tools necessary to treat the sick; (3) use their community influence to help support the healthcare worker’s needs during the crisis; and (4) provide appropriate care for healthcare workers suffering from burnout, moral distress, and other mental health disorders.”[16] He concluded with some practical steps that institutions can take in order to better care for their workers during ongoing crisis situations. By heeding Onarecker’s three principles and working through the issues ahead of time, society will be better ethically prepared to handle the next pandemic or public health crisis.

Despite the unusual year, we at CBHD were thrilled with the conference participation and grateful to all those who were willing to adjust to the challenges of an online conference. Due to the timely nature of the conference topic, we are working on creating an e-book based on the presentations given at the conference, which is planned for publication in 2021. And, though it had to be postponed for a year, the Bioethics and the Body conference will take place June 24–26, 2021. Speakers include O. Carter Snead, Jeffrey P. Bishop, F. Matthew Eppinette, Donna J. Harrison, Beth Felker Jones, Kimbell Kornu, D. Christopher Ralston, and Peter J. Smith. We hope to see you there!

References

[1] F. Matthew Eppinette, “Bioethics and Pandemic: Framing the Discussion” (opening address, The Center for Bioethics & Human Dignity’s 2020 Annual Conference, Bioethics in Real Life: Lessons We’re Learning from COVID-19, Deerfield, IL, June 26, 2020).

[2] Dónal P. O'Mathúna, “Research to the Rescue? Generating Evidence Ethically for COVID-19” (plenary address, Bioethics in Real Life, June 26, 2020).

[3] Faith Fletcher, “Ethical Engagement of Vulnerable Populations: COVID-19 Pandemic and Beyond” (plenary address, Bioethics in Real Life, June 26, 2020).

[4] Fletcher, “Ethical Engagement of Vulnerable Populations.”

[5] Fletcher, “Ethical Engagement of Vulnerable Populations.”

[6] Joseph Wiinikka-Lydon, “Moral Injury in the Time of COVID” (plenary address, Bioethics in Real Life, June 26, 2020).

[7] Wiinikka-Lydon, “Moral Injury in the Time of COVID.”

[8] David Hyams, “Protecting Civil Rights in Time of Pandemic” (plenary address, Bioethics in Real Life, June 26, 2020).

[9] Ken Muma, “COVID-19: Bioethical Issues in a Low Resource Setting” (plenary address, Bioethics in Real Life, June 26, 2020).

[10] Bramwell Wekesa, “Resource Allocation Decision Making in Low and Middle Income Countries: Constraints and Solutions in COVID-19 Era” (plenary address, Bioethics in Real Life, June 26, 2020).

[11] Matthew Anderson, “The Imago Dei and the Value of a Life (in a Pandemic) (plenary address, Bioethics in Real Life, June 26, 2020).

[12] Anderson, “The Imago Dei and the Value of a Life.”

[13] Anderson, “The Imago Dei and the Value of a Life.”

[14] Cheyn Onarecker, “Being Ethically Prepared for the Next Pandemic” (plenary address, Bioethics in Real Life, June 26, 2020).

[15] Onarecker, “Being Ethically Prepared for the Next Pandemic.”

[16] Onarecker, “Being Ethically Prepared for the Next Pandemic.”