By Patrick Ercolano
This article originally was published by The Hub at Johns Hopkins University and is posted with permission.

When Italians self-isolating during the COVID-19 outbreak were presented with a hypothetical situation in which orders to remain at home would be for shorter periods than they had expected, they were pleasantly surprised and said they would be more willing to stay in isolation.

But people negatively surprised to hear that the hypothetical extensions of the orders would be for longer than they had anticipated said they would be less willing to maintain or increase their isolation.

These findings, from a new study co-authored by Berman Institute of Bioethics faculty member Mario Macis, shed new light on people’s willingness to self-isolate. The study, a working paper produced for the National Bureau of Economic Research, also highlights the importance of effective communication of stay-at-home orders by public officials, says Macis.

In the following Q&A, Macis, an associate professor at the Johns Hopkins Carey Business School, shares his views on topics such as current U.S. social distancing policies, setting an “all clear” date ending those policies, enforcement of stay-at-home orders, and the psychological impact of long-term isolation.

QUESTION: Was the main finding of the study surprising to you at all?

MARIO MACIS: More than surprising, it was eye-opening. When stay-at-home orders were extended longer than expected, people become less willing to increase and more likely to decrease self-isolation efforts. The result was stronger for individuals who were already fully complying with the recommended self-isolation measures (including not leaving the house except for emergencies). This was the eye-opening part. The efforts of compliant individuals should not be taken for granted.

How would you evaluate U.S. social distancing policies to date, at both the federal and state levels?

We are way past a situation with few isolated outbreaks, and I think authorities are becoming more and more aware that the response requires coordinated efforts that go beyond single communities and states. I was glad to see that in spite of a lack of nationwide standards, the governors of New York, New Jersey, and Connecticut quickly coordinated their actions and adopted a uniform approach to social distancing. Today at least 30 states have stay-at-home orders in place, and that is good.

Is it a wise approach to set any kind of “all clear” time, whether it’s Easter or mid-summer or next spring? Should government leaders leave the date open-ended?

Our study shows that negative surprises can jeopardize compliance with social-distancing measures. The epidemic is severe, and there is fundamental uncertainty about how long these measures would need to stay in place to be effective. Therefore, a prudent approach would require making people aware that this could be a protracted effort. This does not mean leaving the date open-ended, but just transparently communicating that people should get ready for a prolonged self-isolation period. Emphasizing that the measures will end by a certain date might generate falsely optimistic expectations, which might then translate into disappointment when the measures are extended.

Your paper touches on the issue of whether people in democratic societies, like Italy’s and the U.S.’s, would be able to comply with strong enforcement policies such as fines and geo-tracking. Did you find whether those were effective in Italy, and do you think they could work in the U.S.?

Strong enforcement policies such as fines for transgressors can be important signals. Italy and many U.S. states and cities are using them to reinforce the message that people need to stay home. However, it is unclear that compliance can be achieved with fines alone. Plus, monitoring and enforcement are costly. There is a role for communication, persuasion, and expectations-management.

Some people argue that the price of long-term self-isolation is made more costly by the negative psychological impact on individuals. Is there a reasonable way to balance these concerns? Or is the negative psychological impact (like the negative economic impact) part of the collateral damage of taming the pandemic?

Yes, self-isolation is costly, both economically and psychologically. We can enact policies to mitigate those costs, but it is clear that the epidemic made everybody worse off. The finding from our study that fully compliant individuals might reduce their efforts if the restrictions are extended for longer than expected highlights that “social isolation fatigue” might indeed be at play. This is one reason why managing expectations is so important.

(Besides Macis, the paper’s co-authors are Guglielmo Briscese of the University of Chicago, Nicola Lacetera of the University of Toronto, and Mirco Tonin of the Free University of Bozen-Bolzan.)

Due to the COVID-19 epidemic, schools are closed and parents are forced —they did not choose—to school their kids at home. This is a drastic difference. I remember when my siblings and I became homeschoolers in 2005, we were ecstatic. Unlike some of the usual myths like “homeschool kids are antisocial or cannot adapt to regular school,” we were top of our class and decent (as in nerd-decent) at sports. Our education at home was an ever-changing process, we had new benefits, but also rigid responsibilities. We attended homeschooling groups, learned from different techniques and teaching strategies and came up with our own. Despite advices, we found ourselves comfortable in replicating school at home, with some interesting twists. Regardless of the household’s pedagogical choice, something is certain, homeschooling is not easy.

The need to school children at home, should not be confused with homeschooling. Although, the word offers an accurate description for both cases, they are not the same. First, children and parents were not desiring the change nor were they prepared. Second, we are facing worldwide challenges due to COVID-19. Therefore, we are not in the optimal conditions to add more pressure to parents and kids.  Third, the majority of children that are at home now will return to school with different instructional levels, depending of what parents were able to achieve during the pandemic. The ethical concerns about Emergency-Homeschooling are not the same — and should not be confused — with Homeschooling.

Some of the concerns of Emergency-Homeschooling are Beneficence and Justice. First, kids can be exposed to frustration, food insecurity, education insecurity, among other negative situations. Second, due to COVID-19, children are isolated at home, which means that their social network have been disrupted; adding another negative impact for their wellbeing. In my case, besides my immediate social network — the siblings— we had our homeschooling association group, plus our elective classes outside home. All of these are not available during a pandemic where social distancing is needed; another Emergency Homeschooling hallmark. For parents, they are faced with further pressure and responsibilities, their children education. This adds to the strain of the individual and family wellbeing and mental health. In the case of Justice, we have an unbalance distribution of burdens. Parents are struggling with work; some may continue remotely, others cannot. In other words, as Dr. Ruth Faden warns, children are not receiving equal response during the COVID-19 emergency. Furthermore, low income communities do not have the resources to strive in the new educational setup, such as technological access.

What are some of the solutions that may help mitigate the ethical concerns? Internet searches may be overwhelming, parents should follow recommendations from their school, State and U.S. Department of Education. If parents would like more information regarding homeschooling, it would be helpful to start with support groups in your community or State. Remember, there is not one-type or correct homeschooling approach, and most information is not tailored to emergency homeschooling.  Depending on the situation, you should let children become part of the decision-making.

At the national or State level, plans to increase the benefits and minimize the harms of children and parents should be implemented. Some of the efforts include providing free school meals. Schools should consider remote mental health check-ups or, at least, teacher remote check-in with students. Although every grade is different, there should be an effort from schools and/or districts to help parents organize their children’s education. Due to the current situation with COVID-19, education should be goal-driven rather than time driven. Efforts should also be made to help mitigate student stress, specially seniors regarding graduation requirements. Some States have adjusted graduation requirements such as grading system and limiting minimum credit. In resume, Schools should facilitate the required information to parents; and continue to offer support remotely to both students and parents during Emergency Homeschool. Nonetheless, the priority is to take care and remain healthy during the difficult times of the COVID-19 pandemic.

Vivian V. Altiery De Jesús was homeschooled since her 8^th grade. She is currently a fourth-year medical student at Puerto Rico and Master of Bioethics candidate at the Berman Institute-Johns Hopkins School of Public Health.

This story was originally published as part of Bloomberg School of Public Health’s COVID-19 Expert Insights Series and is posted by permission.

By Jackie Powder

For U.S. hospitals the worst case scenario is imminent: Too many COVID-19 patients for too few ventilators.

Jeffrey Kahn, PhD, MPH, the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics, discusses the ethics of allocating lifesaving equipment and a Hopkins-led project to guide hospitals through such difficult decisions.

How are hospitals grappling with these issues?

There has been lots of discussion among our colleagues nationally about what approach people are using. Nationally, many hospitals are looking to a Maryland project as a model. It was started after the H1N1 pandemic by a group at Johns Hopkins to develop a plan of rationing care in a public health emergency. A statewide community engagement process gathered public input on the fairest, most ethically acceptable way to allocate medical resources. Last year, that project published a framework to guide the allocation of scarce mechanical ventilators.

What are the ethical underpinnings of this framework?

It’s based on a balancing of values, characterized in the project’s report by a “multi-principled approach … that strives to save the most lives, preserve the most life years, prioritize evidence-based decisions, and show compassion to non-recipients.”

In the framework, what factors are used to determine how ventilators will be allocated?

The Sequential Organ Failure Assessment (SOFA) score is used in the Maryland project, to predict the likelihood of short- and long-term survival of people who need to go on ventilators, combined with prioritizing points based on our understanding of the COVID-19 infection so far and who’s most likely to fare worst and fare best.

How does a triage team figure in decisions on access to ventilators and other medical care?

The team implements the framework in a consistent way across the institution and removes triage decisions from the physicians caring for individual patients. Those decisions could conflict with their role to provide appropriate care, and it’s just not fair to put them in such an untenable position, not to mention the increased moral distress it would bring.

After someone is on a ventilator, for example, how long does it take to have a clear sense of whether someone will actually improve or not—a week, 14 days? 21 days? There will need to be assessments made at stages of care to decide whether continued use is appropriate. Another scenario is two patients, one ventilator, same score, same set of facts. How to decide? It may then come down to a lottery. These are unthinkable decisions for Americans to be facing, but that is the nature of this public health emergency.

Besides ventilators, what other resources for treating COVID-19 patients could be in short supply?

ICU beds and Extracorporeal Membrane Oxygenation (ECMO), which is a potential last-resort lifesaving procedure if ventilation isn’t successful. [An ECMO machine pumps and oxygenates a patient’s blood outside the body.]

You hear about the demand for ventilators because the need is a direct result of COVID-19. But the crisis has also affected the blood supply because donors are staying home.

If health care rationing becomes necessary, what would you tell people who are concerned that well-connected and wealthy patients will always get preferential treatment no matter what?

Among the commitments highlighted by the Maryland project is that any process must be public and transparent, so that those sorts of concerns are addressed clearly and directly. I think everyone’s fervent hope is that with strong public health interventions we won’t have to confront these questions.