In the past week, there has been a change in the way my colleagues end their emails. The usual “Cheers” and “Best wishes” have been replaced by a new phrase, both a wish and a warning: “Stay well”.
As the coronavirus pandemic sweeps across the globe, questions are being asked about when, how and who to treat. These questions are not just clinical, but moral. Medical ethics can help our NHS make the tough decisions it will need to in the coming weeks and months.
Pandemics bring into tension two important forms of medical ethics: public health ethics and clinical ethics. Public health, with its population-level focus, favours a utilitarian approach, emphasising the needs of the many over those of the few. Clinical ethics, on the other hand, favours the individual, focusing on how best to support the patient’s right to choose treatment that reflects their individual values and beliefs.
In a pandemic, both approaches must be considered. As we have seen in the past few days, liberties may be curtailed to help protect the health of others, even if we ourselves are healthy. But decisions about our own health are for now still largely up to individuals. It is a confusing situation, one in which individual wants and needs may not match up to the measures needed to address the pandemic. In extreme circumstances, it may become necessary to make decisions about who we can treat and who we cannot (see Italy’s strict treatment cut-offs); to restrict freedom of movement, patient choice and even medical treatment.
So how do we make these decisions?
Unfortunately, medical ethics does not offer one answer to that question. It is not very good at adjudicating between competing theories, as must be done during a pandemic. However, it is possible to approach decision-making in a way that considers the big picture of the population’s health, while remembering that what makes up that population are individuals.
When making medical ethical decisions during a pandemic, a few basic principles must be followed. First, consistency is key. Measures must be put in place to ensure that throughout the crisis, ethical decision-making can be made and sustained. This means that any guidance for healthcare decisions made during the pandemic must be implemented nationwide. A treatment decision made in Cardiff must be made in the same way in Norwich, Belfast or Glasgow.
Second, decisions need to be inclusive. This means they should be taken with the views of all stakeholders in mind. Here the stakeholders are the patients being treated, but also the staff caring for them.
Third, decisions need to be transparent. How, why and by whom they are made must be known, but also defended, to the public, or decision-makers risk losing the public’s trust. If and when we come to a time when difficult decisions are being made about treatment, those criteria, how they are used and who uses them, must be clearly communicated to the public.
Fourth, decisions must be reasonable. But this is not an arbitrary criterion. Reasonableness requires decisions to be evidence-based, and consider principles and values developed with stakeholders. Decisions must meet health needs, but in a way that is credible, and made by people who are accountable for those decisions.
Finally, decisions must be responsive. This crisis has demonstrated just how quickly things can change. As such, any ethical decision-making must incorporate opportunities to revisit decisions in light of new information. This requires mechanisms to address complaints, too. We should not assume we will always ‘get it right’ in a pandemic.
How Covid-19 will shape our present and future, and one day inform our global history, is yet to become clear. What is clear is that by ensuring our response is ethical, we will be able to tell future generations that we did our best. Stay well.
Dr Alexis Paton chairs the committee on ethical issues in medicine for the Royal College of Physicians. She has led the Royal College of Physicians’ contribution to forthcoming national ethics guidance for the treatment of patients during the Covid-19 pandemic.
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