key: cord-0939974-efqggfov
authors: Larkin, Gregory Luke
title: Caring in a time of COVID: the vaccine of virtue
date: 2021-04-25
journal: Eur J Emerg Med
DOI: 10.1097/mej.0000000000000805
sha: df2e81b2ea7d3298f282c978835e9cea969b3954
doc_id: 939974
cord_uid: efqggfov

nan

The SARS-CoV-2 pandemic has created mass intellectual and moral uncertainty [1, 2] . At the micro, meso and macro levels of healthcare, COVID-19 has created more questions than answers on how we work individually, in teams, and as a profession as a whole. Resource limitations, social-media pseudo-science, abbreviated peer-review and a shifting public health landscape have fostered dynamically changing rules on C-19 triage, testing and treatment -which, in turn, has left space-suit/PAPRbedecked emergency physicians floating in a relative vacuum of moral and clinical guidance.

To fill this vacuum, lawyers, administrators and bioethics mavens far removed from the ED hot zone, have hastily drafted and re-drafted evidence-free policies on political correctness and social justice that clinicians at the coalface have been commanded to digest and follow. Although moral pluralism can inform ethical EM practice, physicians themselves are often absent from impactful ethical and policy deliberations and end up being ruled by them after the fact.

Although Emergency Physicians certainly can and should engage proactively in ethical deliberations with other stakeholders, it can be frustratingly difficult to find time in between donning and doffing their PPE. A busy and besieged 24/7/365 ED setting seldom allows for digestion and deliberation of emerging policies and guidelines -let alone an after-hours ethics committee consult. Indeed, time and information constraints inherent in EM practice have made a reflection on important ethical principles and utilitarian guidelines difficult at the bedside.

Our moral compass is further impaired when the magnetic North keeps moving. Continuously revised guidelines, algorithms, policies and rules, such as those in the current COVID-based climate, can be bewildering. Nazi doctors argued at Nuremberg, for example, that there were no rules against the crimes they committed; hence, new rules had to be written down, whereas the Green Commission was still in session. To prevent such atrocities in the future, a more reliable, timeless and pre-emptive ethical anchor is needed; that anchor is virtue.

Of all the classical theories of ethics, Aristotelian Virtue Ethics is the oldest [3] . Virtue ethics is concerned with habits of character, which are developed with practice and good motivations -and not merely good action alone. Unlike outcome-based (utilitarian) or rule-based (Kantian) approaches, virtue ethics focuses on agent character, or in this case, the doctor themself. A focus on aretê or excellence, on who is being, like a Jungian archetypal Albert Schweitzer, allows one to assess a situation with an internal compass, an internal locus of control, rather than upon some external distant authority, rule or law [4] .

In this age of workforce democratization and de-professionalization, an inward focus on ones personal commitments and virtues can help subdue ego-based needs for recognition, power and control. The feminist ethic of care, with its focus on nurturing relationships, is one example of virtue ethics in action. Herein the personal and emotional inform the moral and ethical; virtue is as much about feeling and being as it is about doing. By living in harmony with our higher selves, we can master what Epictetus, a freed slave in the Roman Empire, suggested long ago:

and then do what you have to do" [5] .

The virtues are tragically missing from the most medical education today, and it shows. A recent postpandemic survey of members of the American College of Emergency Physicians in 2020 revealed that younger doctors were far less willing to embrace compassion, fortitude and duty as cardinal virtues of frontline workers at the coalface of COVID. Physicians under 40 years perceived the pandemic as a more personal threat; they were significantly more likely to be willing to abandon the workplace and significantly less likely than their older counterparts to perceive combatting COVID as an opportunity to honour themselves and their profession.

However, by keeping their inner heartfelt virtues a secret, the older generation has failed to model, mentor and nurture the moral habits, aspirations and ideals of character to their student physician progeny. No more. It is incumbent upon the experienced artists in emergency medicine to lead us; those who are not burned out and who, honoured to serve in a crisis, understand deeply and personally, the power of character, must share the Promethean fire of virtue with their young charges so they too may feel not only technically competent but also resiliently humanistic, emotionally mature and happy to serve.

The cardinal virtues of emergency medicine have been suggested previously, and they include the classic virtues of fortitude, prudence, temperance and justice as well as six others: (1) unconditional positive regard; (2) charity; (3) compassion; (4) trustworthiness; (5) vigilance and (6) agility [6] . There are many others, of course, such as humility, resilience and teamwork, all of which are central to responding to a mass casualty event or pandemic.

It is important to note that virtue is not merely the absence of vice. In fact, many of the so-called vices in other areas of life (e.g. distractability, adrenaline-addiction, impatience, etc.) can become virtues in the crucible of the emergency department. High levels of confidence, for example, may appear as hubris and arrogance in some settings, but confidence is required when one must explain to a bereft parent that absolutely everything possible was done to save their child, particularly when one has to disclose this assurance in the face of heart-breaking defeat.

Similarly, one need not be a martyr or saint to be a virtuous emergency physician; but one would do well to remember EM is a fraternity of very special sinners with a special calling in this life, a calling that virtue ethics recognizes, informs and supports. Also, where there is the correspondence of calling and work, virtue, professionalism and purpose flow effortlessly.

In summary, the post-COVID world has created an opportunity to rediscover and reclaim the moral compass that inspired and guided our once noble profession. Virtue and correspondingly virtuous behaviour can help save the life of lifesavers and become one of the more useful vaccines against the twin pandemics of frustration and fear that plague the heart and soul of emergency medicine [7] .

European society for emergency medicine position paper on emergency medical systems' response to COVID-19

The challenge of emergency medicine facing the COVID-19 outbreak

The Nichomachean Ethics

After Virtue

Discourses and Selected Writings. (Translated by Dobbin, RF)

Virtue in emergency medicine

Mapping, modeling, and mentoring: charting a course for professionalism in graduate medical education

There are no conflicts of interest.