“I Do Solemnly Swear”: The Ethics of Medical Education in the Time of COVID-19

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The morgues are overrun. Morale and personal protective equipment run low. In every borough of New York City, physicians and nurses fight tirelessly to keep pace with the surge of COVID-19 cases at the epicenter of the pandemic in the U.S. Amidst a shortage of beds and other essential medical equipment, the need for qualified healthcare providers is one of the greatest challenges facing this beleaguered city. When cases peaked in late March, several New York hospitals sought additional help from obstetrician-gynecologists and radiologists in their emergency departments, but that was still not enough to meet the growing need (Rothfield, et al., 2020).

In the midst of this chaos, fifty-two medical students from New York University’s Grossman School of Medicine, along with a few hundred others, elected to graduate early to work in hospitals suffering from personnel shortages until they begin their residencies in midsummer (Dwyer, 2020). While many applaud these students and their institutions for this innovative response to the COVID-19 crisis, others argue that there are serious moral considerations that weigh against having them on the frontlines of this pandemic.

Some medical program supervisors caution against commissioning medical students at this time because it could have detrimental and long-lasting effects on their careers in medicine. Dr. Martin Kaminski and Dr. Frances Ue of Harvard Medical School argue that the credentialing bodies of medicine should push back residency start dates to protect newly minted doctors and their patients. In their view, teaching hospitals will be unprepared to offer adequate instruction to novice residents at their scheduled start time in early July—when the pandemic is expected to reach its peak (Kaminski, et al., 2020). If these inexperienced early graduates were to work in hospitals under the pressure of a pandemic, the likelihood that they may err or take costly risks to themselves would be too great to permit. Since hospitals are not able to prevent such hazards or ensure their safety as they confront various daily challenges, they should not put their students at risk.

Medical officials and students have also raised concerns about the harms that could be suffered by their patients if these medical students join the frontlines. The Association of American Medical Colleges urged medical schools in mid-April to refrain from involving their students in any direct patient care activity except in cases of critical health care personnel shortages (AAMC). Anna Gosha, a MS2 student at Stanford University, wrote in support of this decision by the AAMC. In her view, medical students pose certain risks to patients and healthcare providers that seasoned medical professionals do not. Gosha and many others worry that students might become “super-spreaders” of the virus by encountering numerous patients daily at various clinical sites (Gosha, 2020). Provided that a high proportion of asymptomatic spreaders of COVID-19 are among younger populations, it is possible that bringing young medical students to the frontlines could lead to an increased spread of the disease outside of hospitals’ COVID-19-only zones (Heneghan, et al., 2020).

On the other hand, some physicians argue that it is imperative for students to uphold their Hippocratic Oath despite the unprecedented circumstances. In fact, some contend that the decision made by the AAMC to halt all clinical rotations undermines the moral foundations of medicine and sends a mixed message to students about their “special obligations” to society, no matter what the situation may be (Baker, 2020). Dr. Thomas Gallagher and Dr. Anneliese Schleyer from the University of Washington School of Medicine argue that more experienced medical students would provide much-needed relief for front-line providers. Moreover, they believe that COVID-19 makes for a valuable teaching moment that reinforces physicians’ ethical obligations to their patients (Gallagher, et al., 2020).

Some physicians also point out that the COVID-19 pandemic probably will not be the last pandemic that these students face during their careers in medicine. In their view, the lessons learned in their clinical experiences now will benefit these students and our society for years to come (Stokes, 2020). While many of these lessons may be hard to swallow in the present moment, the grit and knowledge gained through these challenges can have a lasting positive outcome for healthcare and generations of students to come.

As the AAMC and medical schools around the country grapple with these challenging circumstances, medical students continue to find creative ways to serve those in their communities affected by COVID-19. Many have offered their help through grocery drop-offs, blood donation, and research on vaccines and virology (Gosha, 2020). While their informal efforts to serve are inspirational in many ways, it is still an open question whether they should also be expected to apply their medical school knowledge on the frontlines of this overwhelming public health crisis. Afterall, these students have taken the Hippocratic Oath and promised: “I do solemnly swear, by that which I hold most sacred: that I will be loyal to the profession of medicine, and just and generous to its members” (Dwyer, 2020). If any time calls for loyalty to the profession of medicine, that time is now.

 Discussion Questions:

• What are the central values in conflict over encouraging or allowing medical students to graduate early to join the frontlines of this pandemic? Do the possible costs outweigh the possible benefits?
• Do medical students have a duty to assist in hospitals under any circumstances—pandemic or other types of public health crises? Why or why not?
• At what point does a physician-in-training assume “special obligations” to society, particularly “the duty to treat” patients?
• What practical and ethical obligations do medical schools and teaching hospitals have to their students and trainees? 

Further Information:

AAMC, “Guidance on Medical Students’ Participation in Direct Patient Contact Activities.” Association of American Medical Colleges, April 14, 2020. Available at: https://www.aamc.org/system/files/2020-04/meded-April-14-Guidance-on-Medical-Students-Participation-in-Direct-Patient-Contact-Activities.pdf

Baker, James. “Excluding med students and letting trainees opt out of Covid-19 care is bad for medicine.” Stat News, April 8, 2020. Available at: https://www.statnews.com/2020/04/08/excluding-medical-students-trainees-opting-out-covid-19-care-bad-for-medicine/ 

Dwyer, Jim. “One Final Step for 52 Medical Students, Eager to Join the Fight.” The New York Times, April 6, 2020. Available at: https://www.nytimes.com/2020/04/06/nyregion/coronavirus-medical-students-early-oath.html

Gallagher, Thomas and Anneliese M. Schleyer, ““We Signed Up for This!” — Student and Trainee Responses to the Covid-19 Pandemic.” The New England Journal of Medicine, April 8, 2020. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2005234

Heneghan, Carl, Jon Brassey, and Tom Jefferson. “COVID-19: What proportion are asymptomatic?” The Center for Evidence-Based Medicine, April 6, 2020. Available at: https://www.cebm.net/covid-19/covid-19-what-proportion-are-asymptomatic/

Jacobs, Andrew, Matt Richtel, and Mike Baker, “‘At War With No Ammo’: Doctors Say Shortage of Protective Gear Is Dire.” The New York Times, March 19, 2020. Available at: https://www.nytimes.com/2020/03/19/health/coronavirus-masks-shortage.html

Kaminski, Martin and Frances Ue. “If Covid-19 will peak in June, teaching hospitals should consider delaying the start of new medical residents.” Stat News. 26 March 2020. Available at: https://www.statnews.com/2020/03/26/covid-19-peak-delaying-july1-start-of-new-medical-residents/

Rothfield, Michael, Somini Sengupta, Joseph Goldstein, and Brian Rosenthal. “13 Deaths in a Day: An ‘Apocalyptic’ Coronavirus Surge at an N.Y.C. Hospital.” The New York Times, April 14, 2020. Available at: https://www.nytimes.com/2020/03/25/nyregion/nyc-coronavirus-hospitals.html

Stokes, Daniel. “Senior Medical Students in the COVID‐19 Response: An Opportunity to Be Proactive.” Academic Emergency Medicine, April 13, 2020. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161842/#acem13972-bib-0007

 

Authors:

Sophie Schott & Alicia Armijo
The Ethics Project
University of Texas at Austin
May 12, 2020
 

https://liberalarts.utexas.edu/ethicsproject/

Image Credit: Sandra L. Ford / CDC

 

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