Clinical Ethics During the Covid-19 Pandemic
Clinical Ethics During the Covid-19 Pandemic
Consequentialism: Act vs. Rule
Fundamental Principle: Maximizing the good.
Act Consequentialism: Focuses on evaluating each action on a case-by-case basis to maximize good.
Rule Consequentialism: Argues that following "secondary" moral rules (established for general good) is better than constantly evaluating individual actions.
Quote: "a consequentialist should not try to compute the probabilities of all possible outcomes before each and every action" (p.32).
Example (Utilitarianism): Utilitarians believe that telling the truth and keeping promises generally supports the main principle of maximizing overall benefit.
Analogy (Traffic System): "Imagine a traffic system with just one law or rule: Drive your car so as to maximize benefit" (p.33), illustrating the impracticality and potential chaos of pure act consequentialism.
Individual Liberties vs. Public Good
Dilemma: States must intervene with stringent public health measures to save lives and protect people, but these interventions (like lockdowns) cause huge losses and suffering, especially for the poor and marginalized (p.612).
Difficulty: Achieving a balance between individual liberties and rights versus the public good is extremely challenging in such situations.
"Missing the Trees For the Forest"
Phenomenon: During the pandemic response, so much attention was given to macro-issues (e.g., lockdown, physical distancing, isolation, quarantine, travel bans, public health measures) that their impact on the individual was neglected (p.612).
Ethical Application: Ethics during this period needed to be applied to two groups:
People with Covid-19.
People with "non-Covid-19" illnesses.
Clinical Medicine and Public Health Divergence
Clinical Medicine:
Cares for individuals after the onset of illness.
Emphasizes the alleviation of suffering, pain, psychological, and emotional distress.
Public Health:
Works with healthy populations to prevent illness and the spread of infection.
Priority in a Pandemic: Public health takes precedence.
Means to an End: Individual actions like testing, isolation, detection, and treatment become a means to the greater end of keeping the numbers of infected persons down.
Shift in Principles: The foundational tenets of clinical ethics, including respect for the individual patient's rights, values, preferences, care for individual needs, avoiding unnecessary harm, and discrimination against infected persons, all "take a back seat during such emergency situations" (p.613).
Infection Control Supersedes Clinical Care
Hippocratic Oath Reversal: The traditional ideal, "Cure sometimes, treat often, comfort always" (Hippocrates), saw "comforting the patient" become the least of the three priorities during Covid-19.
Duty Shift: The primary duty to care for individual patients is put aside in favor of public health strategies.
Healthcare Worker Experience:
Healthcare workers had to resist desires to help patients in isolation and put aside desires to provide greater support, prioritizing public health.
The ability to connect with and care for patients was significantly curtailed by the need to eliminate human contact.
Examples: Infrequent patient visits, full PPE making workers look like "faceless robots," the use of robots to dispense food and medicine.
Touch, an important mode of communication and comfort in healthcare, was prohibited.
Moral Distress in Healthcare Workers
Autonomy Subordination: The autonomy of healthcare workers was put aside in favor of the public good; their own desire to treat patients and protect themselves was seen as secondary to their duty toward the public good.
Impact: This had a significant toll on their well-being and caused moral distress.
Definition of Moral Distress: The suffering caused by being forced to face unresolvable moral dilemmas and conflicts between moral principles and duties, often resulting from not being able to act in accordance with one's core values.
Examples:
Watching a patient die alone without their family and being forced to prevent family from visiting.
More generally, not being allowed to provide comfort.
Working With Uncertain Evidence and Unproven Therapies
Crisis Situation: The challenge of having a crisis with no proven therapies.
Ethical Questions:
Is it appropriate to take the risk of giving a therapy that cannot be confirmed as effective, especially when there are known serious side effects (e.g., hydroxychloroquine running the risk of cardiac arrhythmia)?
Is it better to take no action and let the disease run its course?
What do you tell the patient? How does truth-telling fit into this scenario?
There is a risk that patients and the community may mistake unproven therapies for definitive treatments.
Moral Distress: Uncertainty creates moral distress, generated by the tension between wanting to provide evidence-based care and having insufficient evidence to provide adequate care. This highlights a connection to the concept of competence in care ethics.
Duty To Care Versus Right To Protection
Dilemma: Do healthcare providers (HCPs) have a duty to care when the health system does not protect their health and safety through adequate provisions of Personal Protective Equipment (PPE)?
Measurement: How is "safe enough" measured or defined in such contexts?
Multiple Duties During Pandemics
Healthcare Provider Duties: HCPs have multiple duties, including:
Duty to care for their patients.
Duty to protect themselves from getting infected so they can continue to provide care.
Duty to protect their families, neighborhoods, and colleagues (including covering for them when they are sick).
Duty to society at large.
Notable Omission: The text does not explicitly mention a duty toward their own welfare, beyond remaining productive and in action throughout the pandemic period.
Professional Obligations
Unique Services: Healthcare providers possess unique and specialized skills, acquired over years, that must be put to maximum use during pandemics.
Moral Obligation: There is a moral obligation based on a "social contract between the healthcare provider and society that the provider will deliver healthcare services in time of need" (p.615).
Question: When one has committed their lives to healthcare, how does this change the line between duty (what is required) and supererogation (actions beyond the call of duty)?
Categorical Imperative (Second Formulation)
Question Posed: Was the categorical imperative (second formulation: "Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end") violated in the treatment of healthcare workers during the Covid-19 pandemic? (p.12)
Autonomy in Healthcare
Professional Guidance:
General Medical Council (UK): Recommends that doctors "must not refuse to treat patients because exposure will endanger their lives" (p.615).
American Medical Association (AMA): States that "physicians should balance the immediate benefit to the patients with their long-term ability to serve many patients" (p.615).
Medical Council of India: "States that no physician can refuse to treat a patient during an emergency" (p.615).
Missing from Specific Guidance: These particular sources make "no specific mention of duty to care vs protection of self" (p.615).
Reciprocity
Emerging Consensus: The duty to care during pandemics and emergency situations must be voluntary and must be associated with reciprocity from the health system, the government, and society to protect providers.
Examples of Reciprocity: (p.615)
Enough PPE.
Hours providing adequate time for rest and recuperation.
Comfortable rooms to stay when separated from family and loved ones.
Adequate monetary and non-monetary compensations or incentives.
Recognizing the distress caused by fear, anxiety, and guilt of transmitting illnesses to loved ones.
Rationing Scarce Resources – Triage and Utility
Ethical Challenge: Clinicians are pushed into making "morally contentious decisions on allocation of beds, ventilators and medicines" (p.615).
Allocation Principles: Scarce resources are allocated based on criteria such as:
Ability to save most lives.
Ability to save most life years.
Priority to those who are likely to make significant contributions (e.g., healthcare providers).
Decision Algorithms: Algorithms for selecting patients may consider factors like age, presence of comorbidities, and contribution to society.
Example: Potentially letting someone's elderly parent die in favor of saving a healthcare professional who, once recovered, can save other lives.
Community Involvement: Local communities also have a duty to understand "community perspectives, values, and priorities" to ensure that rationing decisions are "relevant and acceptable to the community" (p.615).
Dignity in Death
Loss of Dignity:
Patients dying alone without giving family members a chance to say goodbye.
Formalities of disposing of the body without contamination restrict traditional rituals around burial and death, potentially dehumanizing the dead and stripping them of dignity.
Impact: This situation creates significant distress for both healthcare providers and the families of patients.
Philosophical Connection: These issues relate to both consequentialism (negative outcomes like distress, lack of closure, and psychological harm) and deontology (potential violation of inherent rights and dignity of individuals, even in death, regardless of consequences).
Denial of Care for Non-Emergency Conditions
Resource Reallocation: In an effort to effectively allocate resources toward the pandemic, basic clinical services were suspended.
Affected Patient Groups: This significantly impacted the quality and availability of clinical support for patients with various conditions, including:
Mental health conditions.
Those dependent on alcohol.
Chronic noncommunicable diseases (e.g., diabetes, hypertension, cardiac diseases, and chronic lung diseases).
Tuberculosis and HIV.
Chronic kidney disease (needing dialysis) and those with cancer.
Those in need of reproductive and child health services.
Ethical Issues in Clinical Care of "Non-Covid-19" Patients (Page 18 Summary)
Suspension of non-emergency services.
Deaths due to lockdown and isolation.
Lack of access to emergency services.
Denial of care.
Mental health issues, including suicides.
Lack of transport services.
Worsening of existing health conditions.
Alcohol withdrawal and illicit alcohol use.
Scarcity of resources.
Interruption in non-communicable disease (NCD) treatments.
Interruption in chronic disease medications (e.g., for TB/HIV).
Lack of reproductive and child health services.
Were the Lockdowns Justified?
Considerations against Lockdowns (Ethical Issues Raised):
Increased propensity for mental health issues.
Supply chain interruptions.
Reduced access to emergency services.
Ethical issues facing the treatment of non-Covid-19 patients.
Ethical issues facing the treatment of healthcare workers.
Underlying Trade-off: Lockdowns involved "choosing utility over autonomy, public health over clinical duty to care for individuals."
Continued Moral Distress
Core Conflict: Ethical issues "emerge from the conflict between their responsibility to the individual patient versus responsibility to the public during a public health crisis." Such conflicts cause severe moral distress among healthcare providers.
Whistleblowing Dilemma:
Should healthcare providers become whistleblowers about issues such as lack of PPE, unreasonable duty timings, and the suffering of vulnerable populations due to the non-availability of non-Covid-19 services?
Consequences: They could face punitive action and lose their jobs.
Political Responsibility: What is their political responsibility in agreeing with public health measures, especially when disagreement (and potential non-compliance) might lead to more deaths?