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Margaret McLean: Making Life and Death Ethical Decisions in the Pandemic and in Life

Margaret McLean is the director of bioethics at the Markkula Center for Applied Ethics. She is also senior lecturer in religious studies and affiliate faculty in bioengineering. She teaches courses on ethics related to healthcare and biotechnology.

In 2017, she was awarded a Certificate of Special Congressional Recognition from the Congress of the United States and the Santa Clara County Medical Association Citizen’s Award in recognition of her significant contribution to the health field.

In this conversation, we discuss how hospitals are making life and death ethical decisions, how the pandemic is impacting vulnerable communities, how normal people can help change unjust systems, how religion impacts ethics, and how working with end-of-life patients has shaped how Margaret thinks about death.

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Interview Highlights

GC: To start out could you just describe briefly to some of the work you're you've been doing in these past couple weeks?

MM: In the last couple of months since the pandemic hit the United States and we've been sheltering in place in the Bay Area, I've been doing a couple of things. One is us professors had about a week to get our courses online, and I have not taught online before, so that's been a very steep—actually a vertical—learning curve.

I also consult at a number of local hospitals, and all of them started preparing for the possibility of the virus, then the possibility of crisis and needing to triage scarce medical resources. I've been involved in conversations and the actual writing of policies around triage and other matters that are important right now in the health care environment.

GC: Given that you study pandemics, were you surprised when the pandemic began?

MM: I was actually not surprised after hearing the news out of China and the build of the epidemic there, how fast it was spreading and how little we knew about it. I think what's surprising is how much we don't know about this particular virus.

GC: What are some of the bigger ethical issues related to the coronavirus that are important right now?

MM: The one that comes to mind first for most people because it's caught so much attention are the questions about scarce resources and those come in a couple of forms.

One is the surprising lack of personal protective equipment for health care workers. We were completely caught flat footed by the fact that health care workers could not and I think still in certain areas cannot adequately protect themselves from being infected as they do their work.

The other scarce resource that has caught the headlines of the papers has been ventilators. At the beginning of this virus coming to United States, the wisdom was that people who were severely affected needed ventilators and so it became clear that that we needed to ramp up the number of ventilators.

New York became the poster child for what happens when you don't have enough ventilators. And so locally the hospital started thinking about ‘if we don't have enough ventilators or other scarce medical resources, tests, testing kits… how do we allocate what we have?’ That is a huge ethical issue because it might mean the difference between someone getting the treatment that they need and someone else not getting the treatment.

The third is that there has been increasing concern about access to health care. This pandemic has opened the curtain on some of the inequalities and vulnerabilities that have been there but haven't been on the public radar until now.

Questions about insurance and who's paying if you get sick and you're in the E.R. Who pays for that if you're uninsured? And questions about what we're seeing now is the kind of differential infection rate and differential infection rate in certain communities where African American and Native American and Latinx communities are more affected by the virus than other communities. Questions about justice and distribution are in front of us.

GC: How do you make difficult ethical decisions involving putting values on human life?

MM: First of all, you begin to think about it by taking a step back and looking at saving those lives that can be saved, and trying to maximize the number of lives that you can save. That's the beginning point for or the development of what are called triage guidelines that help you make a decision.

I am I am fond of saying—and I truly believe—that the worst time to make an ethical decision is when you have to. So having thought through ahead of time and considering questions like the one you just asked ahead of time. Put them down on paper in the form of a policy that then can be followed so that decisions aren't being made on an ad hoc basis.

GC: How does the pandemic value lives differently?

MM: There’s not much bright side to a pandemic, but I think what this pandemic is doing is putting a spotlight that we really have needed to address for a long time, and one of them is access to healthcare. It’s to put in place the ability for people to have equal access to good healthcare, which says ‘we value all these lives the same.’

People who live in this neighborhood with this zip code are valued as much as people who live over here with this zip code and have had access historically. How can we take what we’re learning now about differential access and the pathology of this disease that’s sorely affecting already-vulnerable populations and not lose this lesson?

As a teacher, there are always two or three things I want student to walk out of the class with. One of the things we have to walk out of this pandemic with is understanding that vulnerable populations deserve our attention.

GC: I know you've also dealt with some like end of life issues. Are there any lessons you've learned from either thinking about or working with end-of-life-related topics?

MM: I think there is a sense among some people that when someone is dying, they become somehow different: they become somehow kinder or gentler or more introspective.

My experience has been that people who are dying become ever more themselves. There's an authenticity that needs to be acknowledged and cherished even.

To support someone in their dying is really a privilege; to be able to help a family with often the toughest decisions they will ever make, it is a privilege. It's hard, but as a as a clinical ethicist I am often with patients and families at some of the most intimate and tragic moments. If I can help them look at their values and ask those really important questions that lead them to good decision-making around the decisions that the physicians need to know… do you want us to put him on a ventilator?

All of us are going to have to make those sorts of decisions either for ourselves or for someone else. That's the other piece that I want my students to leave the classroom with is understanding that even if you're a finance major or you're a computer science major, the questions in my medical ethics course are questions you’re going to have to answer maybe not today, but ten years from now or twenty years from now. You will be making these sorts of decisions about your own health about the health and well-being of family members or of your parents and your grandparents. So the best thing we can do is to think about those decisions ahead of time.

GC: If you could send a message to every person in the United States, what would you want to say?

MM: I think if there was a single message it's to take the time to do ethics well. It's to understand that we all make decisions about right and wrong; the heart of ethics is being able to decide between right and wrong. Decisions are hardly ever black-and-white and so understanding that in the shades of gray, in trying to decide between two really difficult options, neither of which is really something I want to do. Just to sit down and think hard about it and to take the time to make the decision—not to just knee-jerk ethics but to really think through what do you value, what are the consequences, who am I becoming?

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