Vulnerable Populations

Overview

This section will discuss ethical questions that are particularly relevant to a range of vulnerable patient populations. By “vulnerable,” we mean patients who may be at particular risk of suffering physical or mental health consequences, financial hardship, or discrimination. Vulnerable populations may require additional aid and protection during a time of crisis, and, yet, can often be forgotten when public health measures are enacted for the population as a whole. This section will remind us of crucial issues and concerns affecting vulnerable groups.

Please note that the ethics relating to homeless, low-income populations, and communities facing racism and xenophobia can be found in Module 3, as well as in the supplemental material here.

Children

While it is predicted that, from a disease morbidity standpoint, children will be less affected by COVID-19, the downstream implications on this population should not be forgotten. The most obvious impact may be on educational progress. According to UNESCO, as of March 23rd, 2020, more than 1.3 billion learners were out of school due to COVID-19. While teachers and school boards are dedicated to continuing a child’s educational year, digital learning is an imperfect system, especially for children that do not have access to internet or have had to step into new roles (childcare, cooking, etc.) due to the pressures on the adult population. Wang et al. (2020) stress that, when kids are out of school, they are less active, have longer screen time, and have irregular sleep patterns. Moreover, the article points out that the psychological impact of such prolonged isolation must not be forgotten. Sprang and Silman (2013) showed that the mean posttraumatic stress scores were four times higher in children that had been quarantined than in those who had not. Lastly, the livelihood of children is closely connected to that of the adult population, which is being severely affected by the pandemic. For instance, parents who continue to work outside of the home may have difficulty finding childcare, as schools and daycare centers remain closed.

The pediatric population is a dependent, and thus vulnerable, population. The ethical discussion then becomes how one thinks through the allocation of resources to a population that will experience profound repercussions from the pandemic but 1) will be less affected from a purely health standpoint and 2) does not directly contribute to the economy. While many argue that there will be a substantial trickle-down effect of supporting the caregivers of children, and thus, this should be the population targeted with funding and resources, it could be argued that failure to address the specific pediatric repercussions of COVID-19 will have substantial impact, which will continue to be felt far into the future.

Thought Questions:

  • Once things return to the status quo, how do we best repair the educational and psychological stressors that children face during this period?

  • Is a dependent population that is not directly linked to economic productivity inherently less deserving of resources during a pandemic?

People with Physical and Developmental Disabilities

Societal responsibility towards people with disabilities has been a focus of discussion when situations such as pandemics or mass disasters arise and forces us to decide the most efficient and moral ways to distribute help. Experiences from Hurricane Katrina have highlighted a disproportionate effect on people with disabilities in dire circumstances. Several U.S. states have proposed guidelines for resource allocation during crises with limitations for certain groups; most notably, Alabama has outlined an emergency allocation plan that deems people with severe intellectual disability as “unlikely candidates” for ventilators. Several arguments have been made against the allocation of scarce resources to the disabled. These arguments propose that people with disabilities require extended time of resource use, “have a limited long-term prognosis as a result of their disabilities,” and, in some cases, might have limited benefit from the medical intervention due to a pre-existing disability.

People with disabilities may not always require additional resources, however, and we must be careful not to let unconscious bias prevent us from prioritizing this population. As Edmund G. Howe discusses in A Possible Application of Care-Based Ethics to People with Disabilities during a Pandemic, care-providers experience “unwarranted pessimism” in seeing people with disabilities as “less likely to be happy with their life than is the case.” He also argues that non-disabled persons may have a tendency to “reflexively want to distance themselves from people with particularly visible and evident disabilities. Thus, a policy regarding equality of access to treatment during a pandemic may be particularly warranted.”

In his New York Times Op-Ed, Ari Ne’eman, a disability rights activist, advocates for a “first come first served” approach in efforts to avoid discriminatory behavior in healthcare delivery, especially during the COVID-19 crisis. Although he recognizes the sacrifice imposed by this approach, he argues that there is value in maintaining certain moral principles, explaining, “I believe that nondiscrimination is not just a tool to accomplish an end — it also is an end in and of itself.”

Thought questions:

  • Do you agree with Howe’s argument that care-providers may incorrectly assume that those with disabilities live less happy lives? If so, how do you think this affects their healthcare management?

  • What ethical approach would you implement in your policy and action to avoid discriminatory behaviors against those with disabilities?

Pregnant Women Seeking Abortion

As many states have called for "elective" or non-essential surgeries to halt, some states’ governments have argued that surgical abortions are non-essential and should be stopped to allow personnel and PPE to be re-allocated to the fight against COVID-19. The issue of whether surgical abortions should continue during this crisis strikes at a familiar and important question: is abortion an essential part of women’s healthcare, or is it something that women ‘elect’ to pursue but is not crucial to their health and well-being?

The American College of Obstetricians and Gynecologists, along with other medical professional organizations representing OB/GYNs, published a statement that calls for surgical abortions to continue, as they are a time-sensitive and essential part of women’s healthcare. Governors from conservative states disagree, and a handful of governors have ordered surgical abortions to stop. Others are considering similar action.

In addition to the question of what constitutes "essential care," it is important to consider reasons abortions may be in higher demand during this pandemic. First, women may have difficulty accessing contraception if in quarantine, they have no safe way to travel to a pharmacy, or their pharmacy may have a shortage of their contraceptive medications. Second, intimate partner violence often increases during disasters, and there may be higher rate of sexual assault and resulting pregnancies. Third, China has seen an increase in divorce rates after COVID-19, and times of marital instability and financial distress have been linked to greater demand for abortion. If demand for abortion increases while the availability of abortion decreases, many pregnant women seeking abortion will be unable to obtain one during this pandemic.

Thought questions:

  • Do you agree that abortion is an essential part of women’s healthcare? Why or why not?

  • How should we think about the use of PPE for surgical abortions as compared to other uses during this pandemic? What kind of demand for PPE is posed by an ongoing pregnancy and delivery?

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