Throughout the Covid-19 pandemic, health and care services continue to function under unprecedented pressure. These trends are likely to produce scenarios which challenge clinical decision-making.
Medical ethics and ethical decision-making should inform all aspects of clinical practice. Concerns over the way decisions are taken in the current crisis have led to high levels of public anxiety, and some of the guidance issued by professional bodies has caused confusion amongst clinical services with conflicting priorities. Open dialogue and a sound understanding of morally defensible principles are essential to avoid poor decision making, both during the current Covid-19 crisis and as we emerge from lockdown. Some of the decisions that must be taken to avoid nosocomial infections will require radical restructuring of services.
For many years, clinicians have been taught the principles of medical ethics as originally described by Beauchamp and Childress which have been very influential since they were first formulated. In summary, these principles are based on autonomy, non-maleficence, beneficence and justice, and they remain fundamental to understanding the approach to ethical assessment in health care in the current COVID-19 situation, in which there are no clear-cut answers to the complex situations encountered clinically and across all sectors of society. They involve:
Recognising the importance of considering and respecting as far as possible a person’s wishes and feelings, while ensuring they do not adversely impact on the rights of others.,
Weighing up the need for an intervention or support against the ability of the person to benefit from it, while ensuring that the individual does not suffer disproportionate harm in the process from whatever is offered.
The just allocation of scarce resources assessed in proportion to the needs of all. For the individual, justice requires that the person receives the best care possible within the resources available.
While the principles identified can be taken to reflect current thinking on medical ethics, they should not necessarily be treated as being of equal value. For example, in other scenarios involving applied ethics, such as decisions made by judges about end of life treatment, one would not value flexibility in itself (identified in guidance issued by governments in England and Wales during the COVID-19 crisis), because that could produce uncertainty and result in inadvertent widening of scope – sometimes referred to as the “slippery slope” issue.
Every decision has to consider the risks, as far as they are known, and other relevant factors, and the legal rules which have developed in the light of ethical principles state that patients should, as far as possible, be involved in decisions about their treatment. Over the past two decades stronger policy orientation towards patient-centred care has emerged gradually, reflecting developments in social and cultural attitudes. Despite this, in the present crisis, the pre-eminence of individual autonomy as an overriding principle has given way to a realisation of the importance of relational autonomy across society. Our interdependence on each other and the integrated functioning of society has come to the fore, with a heightened emphasis on fair distribution. This is seen in the way leaders at all levels have become aware of their reliance on others.
Within the concepts of ‘avoiding harm’ and ‘doing good’ other practical issues have emerged, including an awareness of the importance of meticulous attention to detail, and of accurate data and scientific analysis to inform decision making. This is visible in the frameworks for difficult decision-making that recognise the complexity of individual needs and the balancing exercise to be undertaken in weighing these against the necessity to provide care to a population whose needs outstrip the resources available.
In this crisis, a commitment to care has been seen as a core value at every level, with staff supported by compassionate local leadership. Examples range from the way in which scarce PPE supplies have been used, the engagement of volunteers in supporting some community services and innovative support provided to relatives who were isolated from the bedsides of loved-ones while they were dying. This re-balancing of priorities and values has resulted in the publication of a great deal of high-quality guidance, much of which is cross-referenced in the resource guidance document.
With the passage of time the world will reflect on the COVID-19 crisis and seek to identify lessons that can be learned from the way in which governments handled it. Ethicists may conclude that the predominant emphasis on individual autonomy gave way to recognition of the intrinsic value of each human life, however vulnerable, and the powerful interconnectedness of human relationships.
Meanwhile, those faced with tough decisions need rapid access to support to guide their thinking. This resource, with links to a wide variety of expert opinions and decision support tools, is a reference source for decision-makers. As we emerge from lockdown and face a rapidly changing and potentially fragile future, the delicate nuances of careful decision making will be more important than ever.
About the authors
Baroness Ilora Finlay of Llandaff, Bevan Commissioner, Honorary Professor of Palliative Medicine, Cardiff University, Chair of the National Mental Capacity Forum and Crossbench Peer
Vivienne Harpwood, Emerita Professor of Medical Law and Ethics, Cardiff University, Chair of Powys Health Board and Chair of Welsh NHS Confederation