Print this case study here: The Case of Isolation
The Case of Isolation
Isolation: Its Meaning, Impact and Prevention
The Covid-19 pandemic has brought several words to the forefront of society, culture, and life. Examples include coronavirus, triage and ventilators. But if one word has become the defining word of the pandemic and 2020, I would argue that it is isolation.
The implications of isolation depend upon context. Isolation could be a requirement for hospitalized patients who have contagious diseases (like Covid-19) and thus require special safety precautions. These normally involve additional personal protective equipment, including masks, gown and gloves, which help to contain and prevent the spread of disease. Such precautions are certainly common in the Intensive Care Unit (ICU), a setting that “particularly favors cross-transmission: highly infection-prone patients are present, readily transmissible nosocomial pathogens are prevalent and hands of healthcare workers, the most significant means of transmission, play a dominant role in patient-care. Regrettably, host susceptibility to infection cannot generally be modified and the presence of microorganisms is unavoidable. Consequently, the prevention of infection dissemination critically depends on eliminating the means of transmission” (Rubinovitch, Eggimann & Pittet). Isolation created by ICU protocols is normal and routine in the intentional effort to reduce as much spread as possible due to the nature of diseases and patients.
A Different Isolation
But a different isolation exists outside of hospitals and ICUs. Far more people face isolation and loneliness with far worse health impacts than one might expect. A 2020 study of the National Academies of Sciences, Engineering, and Medicine (NASEM) showed that “more than one-third of adults aged 45 and older feel lonely, and nearly onefourth of adults aged 65 and older are considered to be socially isolated. Older adults are at increased risk for loneliness and social isolation because they are more likely to face factors such as living alone, the loss of family or friends, chronic illness, and hearing loss” (Opportunities for the Health Care System (2020). The study goes on to list some of the negative health impacts loneliness can have:
- Social isolation significantly increased a person’s risk of premature death from all causes, a risk that may rival those of smoking, obesity, and physical inactivity.
- Social isolation was associated with about a 50% percent increased risk of dementia.
- Poor social relationships (characterized by social isolation or loneliness) were associated with a 29% increased risk of heart disease and a 32% increased risk of stroke.
- Loneliness was associated with higher rates of depression, anxiety, and suicide.
- Loneliness among heart failure patients was associated with a nearly 4 times increased risk of death, 68% increased risk of hospitalization, and 57% increased risk of emergency department visits. (Opportunities for the Health Care System (2020).
It is clear from the evidence that isolation and loneliness should be given even more of the attention it deserves as a potential public health crisis. The first Tenet of Osteopathic Medicine, which expresses the underlying philosophy of osteopathic medicine, states, “The body is a unit; the person is a unit of body, mind, and spirit.” Recent research makes it clear that isolation and loneliness can strongly and negatively impact both physical and mental health.
The Ethics of Prevention
Isolation is being accelerated by the Covid-19 pandemic, particularly among nursing/long-term stay residents and vulnerable populations. Nursing home residents have seen a high increase in weight-loss (Danilovich et al. 2020), a sign of larger issues. While the data is small right now, many say that Covid-19 lockdown measures are fueling a mental health crisis on a population already impacted by isolation. The AARP states that “more than 70,000 longterm residents and staff have already died from COVID accounting for 4 in 10 pandemic deaths. They say that feelings of loneliness, abandonment, despair and fear among residents — and their toll on physical and neurological health — are only pushing the pandemic’s death toll higher.” (Paulin, 2020).
Research demonstrates the impact Covid-19 is having in multiple ways on vulnerable populations. Still, there are steps we can take to prevent it from growing. Simard and Volicer (2020) outline steps to address the isolation and loneliness of nursing residents, including wearing name tags, connecting with families in ways other than inperson, and by families coming to windows and safety screens.
The ethical principle of nonmaleficence (do no harm) manifests in many different ways. Without deeper conversation on the true nature of harm, it is important to remember that in healthcare, we are always debating the risks and benefits, the good and the harm, of every action or inaction. Good actions can sometimes have negative effects. This does not mean the action was unethical, but if an unintended effect can be addressed, the failure to properly address it is unethical.
Bioethics in the News
Mr. Rider is a 42-year old who identifies as male. He was admitted to the hospital for shortness of breath and kidney complications. The patient is found to be in acute kidney failure, with his nephrologist recommending dialysis. Mr. Rider does have decision-making capacity but does not have any family or surrogate decision maker. When this topic is discussed, the patient says, “I’ve pretty much been on my own for as long as I can remember.” When discussing dialysis, Mr. Rider says he is not sure about it because, “I don’t really see what the point is. It sounds like a whole ordeal and for what? No one really cares about me, so why keep on going on?” With this understanding, social services have been requested for the patient. But when preparing for discharge to home with home health, Mr. Rider says he does not want to be discharged. Why not? While he does not want to go through dialysis, he also does not want to “go home and die alone.” Mr. Rider is requesting to stay in the hospital to die here. He is not yet end-stage with his kidney disease and death is likely far off enough to not qualify for hospice. Yet, the patient is adamant about remaining in the hospital. An ethics consult is requested.
Our Stoic Culture: Pros and Cons
One of the more famous philosophical movements of ancient times that still has an impact today is Stoicism. Philosophical Stoicism is the source of our modern terms “stoic” or “stoical”, the meanings of which are very similar to what characterized those ancient practitioners and teachers of Stoicism.
The Stoics believed that emotions were interferences with sound character, that being quick to passion or anger was evidence of lesser moral character. It was not that emotions in themselves are wrong, but that they are caused by “false judgements” and best avoided. The Stoics also believed that it is within the power of the individual to overcome these “false judgements” and live a good life. While others may impact you and be unkind and the world may be unfair, all of that is outside the control of the individual and thus it is the individual’s responsibility not to be overcome by them.
Probably the most famous Stoic philosopher, the Roman Emperor Marcus Aurelius, perfectly expressed Stoicism in his Meditations, stating,
When you wake up in the morning, tell yourself: The people I deal with today will be meddling, ungrateful, arrogant, dishonest, jealous, and surly. They are like this because they can’t tell good from evil. But I have seen the beauty of good, and the ugliness of evil, and have recognized that the wrongdoer has a nature related to my own—not of the same blood or birth, but the same mind, and possessing a share of the divine. (II. 1)
This mentality of private reserve has been honored, glorified and amplified in at least some parts of North American culture. From film actors like Gary Cooper to “the strong and silent” character type, stoicism has become an expectation or aspiration for many people. To suffer in silence. To remain reserved in the face of crisis. As Marcus Aurelius states:
Whenever you suffer pain, keep in mind that it’s nothing to be ashamed of and that it can’t degrade your guiding intelligence, nor keep it from acting rationally and for the common good. And in most cases, you should be helped by the saying of Epicurus, that pain is never unbearable or unending, so you can remember these limits and not add to them in your imagination. Remember too that many common annoyances are pain in disguise, such as sleepiness, fever and loss of appetite. When they start to get you down, tell yourself you are giving in to pain. (VII. 64)
True Human Nature
I believe that the application of philosophical Stoicism is not wrong and that it does have its place within our culture. I have incorporated many key aspects of Stoicism into my life and personality, particularly the understanding that while others impact you, only you are responsible for how you react. No matter what happens, you choose how you react. I also somewhat like the Marcus Aurelius quote, “Put an end once and for all to this discussion of what a good man should be and be one” (X. 16). Admittedly, it counters my passion for metaethics and ethical discussions.
There is a place for Stoicism even today. However, I perceive no merit in “silent suffering” if we also value and seek human connection. There is, historically, a strong cultural belief in the United States that individuals are isolated islands and that people rise or fall in isolation based on their own merits. Perhaps this hearkens back to the EuroAmerican “frontiersman” and “explorer” ideal types. To some people, this “rugged individualism” of the solitary soul remains a romantic idea. But it goes against what I believe is true human nature. We are fundamentally social creatures. By nature, we are born into families and subsequently seek out others for connectional bonds. This may take different forms, as some of us are introverted and others extroverted. But for all of us, human connection is important. Be it spending time with many people or alone reading a book, both are forms of acting in the most human way of connecting with others.
So too in difficult times of life, by nature we do not suffer alone, we suffer together. When a patient gets a bad diagnosis, it is not just the patient who suffers. The pain is felt by many. This is called empathy. Empathy too is natural and would not exist if humans were isolated islands. In COVID times of pandemic when quarantine is oftentimes requisite, relational isolation must be resisted so as to prevent the harms that come from an unnatural way of life. Stoicism, especially when forced or reinforced, can go too far as to become unhealthy or even fatal.