ABSTRACT
There is an urgent need for an ethical framework to help us address the local and national challenges that we face as clinicians during the COVID-19 pandemic. We propose four key commitments from which a practical and consistent ethical approach can be derived. These commitments are to articulate the needs, rights and interests of the different stakeholders affected by any policy; to be accountable and transparent, recognising that people are autonomous individuals with values and concerns of their own; to consider the impact of our actions on the sustainability of the NHS, infrastructure, service demands and staff welfare; and to treat everybody equitably, with all deserving of consideration and care. Implementing these commitments will require a number of specific actions. We must put in place frameworks enabling clear advocacy for each competing objective; communicate policy and practice effectively to the public; promote integration of decision-making among social, primary, secondary and tertiary care and reduce or stop unnecessary or inefficient interventions; minimise health inequalities; and build spare capacity into the system.
In this article, we expand on these actions, and note the legal context in which this would be delivered.
Introduction
The 3 months from March to May 2020 saw what we had hoped would be the highest peak of the COVID-19 pandemic in the UK. Many papers have already been written about this extraordinary period: the logistical, clinical and emotional challenges we have faced; the inequities which have been unmasked; the difficulty of prioritising among patients and among different care settings; the lack of integrated care; the focus on ventilator allocation and construction at the expense of care homes; the presence – and lack – of ethical guidance.1 As cases rise again we need to think about how to create a framework which will provide the structure to address future challenges.
There is also an opportunity to improve ways of working beyond the needs of this pandemic. The last few months have seen rapid changes in clinical practice, with institutions and individuals trying new approaches to the delivery of care that would in normal times have involved multiple bureaucratic steps. Although these are for the most part operational changes, they all have ethical aspects which need to be considered. And while, in some respects, people are keen to return to work as before, we must not lose the positive changes that have come from this time of unrest: the shared goals that have led to better collaborations and to more integrated thinking.
A pandemic shifts emphasis within clinicians’ ethical and professional frameworks. For example, the General Medical Council's Duties of a doctor states: ‘Make the care of your patient your first concern.’2 In a pandemic, population-level concerns are more explicitly articulated, alongside greater awareness of the importance of looking after staff wellbeing.3,4 In truth, we should always be thinking about the patient, other patients and staff, and public health. The pandemic has simply required us to think more carefully about balancing and prioritising the legal and ethical interests of all these groups, and about extending them to future groups.
So what ethical framework should we use, and how should it be applied? Working together in our System-wide Ethical Committee and extrapolating on work done by Fritz and Cox,5 who in turn draw on Rawls and Scanlon, we propose four principles from which a practical and consistent approach can be derived.
First, we must make a commitment to articulating the needs, rights and interests of the different stakeholders affected by any policy. In this pandemic, the needs of those infected with COVID-19 conflicted with the needs of those suffering with non-COVID-19-related illnesses and long-term conditions; we needed to make and enact policies which achieved the best possible health outcomes for both groups. Alongside these groups, we needed to protect the workforce looking after all of these patients and to sustain a health service which would be able to look after future generations of patients. As we move on, different groups will be identified whose perspectives must also be articulated.
Second, we must make a commitment to be accountable and transparent, recognising that people are autonomous individuals with values and concerns of their own. This means that people – at individual and population levels – should be kept as informed as possible; they should have the chance to express their views on matters that affect them; their views about their treatment and care should be appropriately respected; and ultimately decisions taken that affect them should be reasoned and open.
Third, we must make a commitment to consider the impact of our actions on future generations: we must make decisions which are sustainable, ensuring adequate training and support of our staff, and national investment in infrastructure.
Last but by no means least, we must make a commitment to treat everybody equitably, with all deserving of consideration and care. This does not mean giving everyone equal treatment; it means that decisions to treat people differently must be justified on ethically and legally defensible grounds (see Box 1 for more on the legal context).
The legal context
Recommended actions
Implementing these commitments will require a number of specific actions, which we outline below.
Put in place frameworks enabling clear advocacy for each competing objective
These need to be established at local, regional, and national levels. Where decisions are being made, conflicting demands (eg among different patient or staffing groups, or across care settings) should be identified and considered. This is not the same as ensuring there is representation from each group: it means documenting all of the different groups affected, and assigning individuals as ‘leads’ for each group. We do this for patients who lack capacity in appointing an independent mental capacity advocate (IMCA), and we should do this to ensure that those groups with less power, and less strong voices, are heard in discussions about policy. It also helps to prevent inappropriate weight being given to the objective that is most prominent at any given time. This will be important as we make ongoing decisions about distribution of personal protective equipment (PPE), the prioritisation and order of reopening services, and all the other pressing decisions to come (see Box 2 for more on the deliberative citizen process).
The deliberative citizen process
Communicate policy and practice effectively to the public
We should produce lay summaries and updates of policy and practice across local, regional and national health care groups. Well-placed trust from the public needs to be earned; to do this, there should be access to deliberations, and publication of key policy decisions and key information. This may provoke some anxiety in the short term but will reduce the spread of disinformation and strengthen trust, and may improve health outcomes.14 Accessible information is needed about the reasons for shielding (or stopping shielding), the validity of tests, the level of nosocomial infection and the likely waiting times for resumption of normal services. This will respect individuals’ autonomy and allow them to make informed decisions about their own behaviour and how to look after each other and to know what to expect when coming to hospital. In addition to being transparent about processes, we need to be transparent about outcomes (and make sure we choose measurable outcomes with direct relevance to patient care and experience). These include those measures already established in healthcare that have been upended by the cessation of almost all routine care (such time-to-treatment and quality of life measures in chronic disease). In addition, COVID-19 brings specific risks to patients and healthcare environments; new quality indices such as mortality from ICU admission and hospital acquired infections may be needed. These agreed measures need to adopted and implemented at scale so that organisations struggling to support their communities can be helped to provide better outcomes.
Promote integration of decision-making among social, primary, secondary and tertiary care and reduce or stop unnecessary or inefficient interventions
This is essential to ensure inequalities are addressed and inefficiencies diminished. We need to learn from the reactive overemphasis placed on the availability of ventilators at the beginning of the pandemic, while avoidable deaths happened due to inadequate planning in care homes, with failures including insufficient PPE and inappropriate discharges to make hospital beds available. It is possible that this occurred because the voices in the acute trusts were louder, or more visible; we need to ensure all aspects of care provision are balanced. As we restart services, we should also be honest with ourselves – and the public – about which ones are needed. Many services that have historically been provided by the NHS are not shown by evidence to be of sufficient benefit,15 ‘grommets’ being a classical example.16 As an integrated community we can do this better. We should not simply aim to return to providing treatments or performing investigations just because we did before, but should use this ‘reset’ opportunity to ensure that we do the activities that are most worth doing. There can be no better time to seize this opportunity; swathes of services have stopped or adapted, few people use NHS time unnecessarily and all care environments are pressured. NHS leaders can support systems to capitalise on this extraordinary situation to better match our health provision to the needs of the populations they serve.
Minimise health inequalities
As services are restarted it is imperative that the opportunity is taken to reduce existing health inequalities, rather than allowing them to worsen. Drawing on Rawls’ difference principle,17,18 services should be preferentially restarted in more disadvantaged areas, or where the beneficiaries are less advantaged. Consideration should also be given to equalities in staff deployment, to ensure the extra load does not land on the worst paid.
Build spare capacity into the system
To maintain a sustainable health service – and one which can respond flexibly to change in demands – we need to build ‘spare capacity’ into the system. The NHS, in response to financial pressures, has been operating on a ‘lean’ model with no surplus material, and a supply chain – of staff, beds and equipment – which is only just adequate to deal with usual demand. While this model may work for a car manufacturer, it leads to inefficiencies in a health service even without a pandemic. We are all familiar with the routine of ‘winter pressures’, and the often desperate efforts to identify empty (or to clear) hospital beds. If we struggle to cope in normal times, what hope is there of responding well to a pandemic? It is possible that this lack of spare resources may have been fatal to some; there are likely to be many reasons why Germany's mortality per million population is so much lower than ours, but one set of factors is that they have many more hospital beds, intensive care beds and doctors per 100 population than we do.19 They did not therefore have to reorganise hospitals and stop non-COVID-19 procedures to the same extent that we did, nor was their nosocomial infection rate as high. Making policies which ensure we have some ‘crisis resilience’ would prepare us not only for medical crises, but may also improve the sustainability of the workforce in other ways – by improving training, protecting mental health, creating the ability to work across sectors, and in fostering greater understanding of competing needs. Other emergency sectors work like this: most fire engines are not used for most of the time, and certainly (thankfully) our military are not fighting most of the time.
Conclusion
We believe that the recommendations given above are necessary to guide our approach to the next stage in the pandemic. They set some practical ground norms through which we can work out the many, more specific issues that will arise – for example, how to prioritise recipients for a vaccine, how to ensure protection of staff with PPE while reducing plastic consumption,20 and how to manage visiting in hospitals and care homes. Ensuring advocacy (including for those with less powerful voices) for all of those affected, and, as a group, considering each of the principles listed5 will help to ensure decisions are equitable, transparent, and sustainable.
We welcome public debate on what additional conditions might be needed, and how we can reach consensus on non-political principles to ensure that healthcare and disease prevention are safely delivered to all those that need them throughout the next stages of the pandemic. Once agreed, these principles will help us respond logically and ethically to the next challenges we face.
- © Royal College of Physicians 2021. All rights reserved.
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