Clinical and Organizational Ethics Related to Pandemics: A Short Backgrounder
This resource is intended for members of Local Ethics Teams or Ethics Committees who may find themselves asked to facilitate ethics consultations or education relating to the COVID-19 global pandemic. This is a living document. Please send suggestions for change to Amanda.Porter@dal.ca.
Public health emergencies like pandemics challenge health care providers to move from thinking centrally of their individual patient to consideration of the community as a whole. They alter, in fundamental ways, the context in which care is delivered and the assumptions that we normally take for granted (for example, that there are enough resources for everyone to receive indicated treatments, or the primacy of liberty and autonomy). Pandemics force normally very risk-averse institutions to confront and manage unavoidable risks. Decision makers may be operating under a high degree of uncertainty, time-sensitivity, and intense emotion.
Central ethics issues for stakeholders in the health system will include conflicts between individual freedom and a common good, conflicts between the duty to care versus the right to safe working environments, and wide-ranging challenges around resource allocation.
Transparency about how relevant ethical values are being balanced is especially important during pandemics. This openness and honesty can help to promote trust, mutual understanding and compliance at a time where people are asked to make personal sacrifices and act in solidarity for the benefit of society and when their usual ethical habits do not apply. Despite a general understanding that individual liberty may be constrained during a pandemic, the expectation is nonetheless that liberty is only restricted to the extent necessary to achieve an important, shared goal.
Collaboration is also centrally important during pandemics given the interconnectedness of the health system, the interdependency within and between societies, and the ease with which viruses can spread. What is done in one part of the health system has implications for everyone. Decisions elsewhere in the country or the world can have significant effects on health in Nova Scotia. The news illustrates that health care decisions have ramifications across the board, including for social services, the economy, law enforcement, and education. Pandemics truly force us to work against siloed decision making.
Many decisions during pandemics are likely to involve identifying the least-worst option available. Administrators and health care providers may find it helpful to adopt a harm reduction approach, where we acknowledge that harmful consequences can’t realistically be eliminated, and instead we seek to mitigate or minimize risk.
Pandemics call on health care providers, administrators, patients and families to be creative and flexible regarding the model of care delivery and the location and timing of health services. Staff may find themselves reflecting on their professional identity and integrity. They may experience tensions that arise from their various roles as health care providers, colleagues, teachers, parents, caregivers for other family members, and as community members. As always, ethics consultation and education cannot provide definitive answers and solutions, but it may help to clarify what values are at play and in tension and provide a safe space to ask and explore difficult questions. Ethics consultation and education can help to promote a reasonable decision-making process, validate moral distress and enable improved mutual understanding.
Questions that might arise for zone ethics committees/local ethics teams:
- What does the duty of care mean in a context where we don’t have the usual PPE or staffing?
- What is a reasonable departure from the standard of care? How do we determine this?
- What should I do when I feel like I’m prevented from doing the right thing, or I feel like I’m being forced to do things that I don’t agree with?
- How should I manage disagreement with colleagues about the right thing to do?
- What are the limits of patient confidentiality? What does respect for privacy require?
- What is the fairest distribution of burden or risk, both within and between teams?
- What counts as a relevant difference that might justify differential treatment?
- What level of risk is it fair to ask people to take on?
- How much better than nothing does a practice have to be in order to make it acceptable?
- What unintended harms are we generating? Can these be mitigated? Are these unintended harms overriding?
- How do we weigh very different kinds of harms against each other (e.g. physical, psychological, economic, social harms)?
- When is it fair to displace a problem onto a different part of the health system or society?
- What kinds of substitutes are acceptable?
- Should we use family members to support care? Should we restrict access by family members?
- How and to whom should limited resources be allocated (or reallocated)?
- What decisions should be left to individual health care providers and what kinds of decisions should be decided at a higher level of administration?
- How does the environment in which I’m providing care affect the standard of care?
- Whose interests are being represented in decision making? Whose interests aren’t being represented?
- Will proposed changes exacerbate existing inequalities?
- What social supports should be made available to health care providers and administrators to support them in managing and living through this ‘marathon’?
Hastings Centre Report, Ethics Resources on the Corona Virus https://www.thehastingscenter.org/ethics-resources-on-the-coronavirus/
Joint Centre for Bioethics, Stand on Guard for Thee: http://www.jcb.utoronto.ca/people/documents/upshur_stand_guard.pdf
National Collaborating Centre for Health Public Policy, Public Health Ethics: Selected Resources Ethics in a Pandemic: https://www.ncchpp.ca/docs/EthicsPandemicLiteratureReview_En.pdf
New England Journal of Medicine (Collection of resources on COVID-19) https://www.nejm.org/coronavirus?query=RP
World Health Organization. 2020 (February 27). Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19): https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf