The ethics of a pandemic

The coronavirus pandemic has flagged up a number of ethical issues, from whether it was right to put routine healthcare on hold to whether it was wrong take to social media to complain about PPE shortages

The coronavirus pandemic has flagged up a range of ethical issues for healthcare professionals, both in primary and secondary care. As the situation escalated, decisions had to be made as swiftly and effectively as possible, often with limited access to robust evidence. These decisions included supporting people to access healthcare differently, contact tracing, end of life care and advance care plans, supporting people in care homes and appropriate prescribing. Ideas and experience were widely shared through different media. In this article, we discuss how coronavirus has forced us to tackle these issues.

By the end of this article you should be able to:

• Recognise some of the commonly held ethical principles in healthcare
• Consider how these could be applied to the pandemic
• Evaluate the role of ethical principles in pandemic-specific scenarios
• Reflect on whether ethical principles were implemented with regard to your own role during the pandemic

HOW DO ETHICAL PRINCIPLES APPLY TO HEALTH CARE?

According to Beauchamp and Childress, the four bioethical principles are autonomy, beneficence, non-maleficence and justice.¹ Similarly, the Nursing and Midwifery Council’s Code of Conduct, focuses on the ‘Four Ps’ which state that nurses and midwives should prioritise people, practise effectively, preserve safety and promote professionalism and trust.²

HOW CAN WE APPLY ETHICAL PRINCIPLES IN A PANDEMIC?

All of the ethical principles described above have been put under the spotlight of the pandemic, including whether the economy should be prioritised over people, or whether individual freedom was given more consideration than the safety of the population as a whole. Was it ethically acceptable that people were denied the right to make autonomous decisions about the risks and benefits of carrying on as normal versus lockdown, or was it right that we were all simply told what we must do, based on the ethical principle of the greatest good for the greatest number? Should the public have been able to choose to attend hospital or surgery appointments, especially for symptoms of or investigations for potentially life-threatening diseases? Should people with long term conditions that might not have been well controlled have been allowed to come into the surgery for a face-to-face review if they deemed that to be more important than staying away? Anecdotally, there have been reports of young women being unable to get follow up appointments for abnormal smear tests for several months, causing a great deal of anxiety for them and their loved ones, stress which would be a significant burden to their holistic well-being, particularly when compared with the relatively low impact of what would have been a potentially mild disease for many people? Was the bioethical principle of justice served by putting the needs of people with (or at risk of) coronavirus above the needs of others with similarly significant disease?

The pandemic began at the start of the year and once it hit the UK, the numbers of people infected with and dying from coronavirus swiftly increased, from nine in the first week of reported cases to more than 1,000 a day by Easter. This meant that to start with, the information coming through to the public and clinicians alike, was changing on a daily basis. While government tried to balance public health with economic viability, delaying lockdown and arguing that they were trying to ‘follow the science’, doctors and nurses working in hospitals were suddenly seeing people being admitted and dying at an exponential rate. There were arguments about herd immunity suggesting that some lives could acceptably be sacrificed in order to acquire this level of immunity.³ There were accusations that we were inadequately prepared for a pandemic such as this and had based decisions on flawed data, an accusation addressed by Imperial College.⁴ There were also claims that people were dying unnecessarily because of the lack of personal protection equipment (PPE) and disruption of the supply line.

On the plus side, new beds were made available for sick people who needed intensive care and new hospitals were set up at an unprecedented rate. However, with the benefit of hindsight it appears that too much focus was put onto intensive care predictions, based on flawed modelling which relied too heavily on flu statistics, leaving many of these new resources empty and unused. Outside of hospital intensive care units, however, routine care was being cancelled and appointments, including referrals, were put on hold to minimise risk and maximise resource allocation for the COVID-19 wards.

In general practice we saw clinic appointments generally being changed from face-to-face to remote, with only the most essential cases being seen in person. Some nurses in general practice were asked to work from home and others were encouraged to take some time off. There was a rush to support people to self-manage, bringing about a huge increase in a quasi-telemedicine approach to care. It has been said that the pandemic has moved the NHS forward a decade in the space of a few months in terms of its take-up of new technology. In essence, then, although frontline workers in hospitals and other coronavirus-facing roles were having an extremely challenging time, other areas of the hospital and most of general practice were actually much quieter than normal.

ROLES AND RESPONSIBILITIES

As a result of this change in focus and need, some general practice nurses (GPNs) offered to work in acute settings, in the new Nightingale hospitals or in different roles within primary care to support their colleagues. This led to the issue of competency being highlighted with people being reminded not to work outside of their area of competency. Many nurses expressed concerns about people being offered work very quickly in areas outside of their normal practice and being told that they would be ‘probably’ be trained on the job. A colleague was asked to arrive half an hour early for her shift in what was a completely new area of practice for her so she could be trained. Others offered to return to practice but felt inadequately prepared to do so, once they were accepted.

Working outside of your area of professional competency potentially breaches the bioethical principles of beneficence and non-maleficence. If harm is done to a patient because a nurse was redeployed to an area she was ill-prepared for, there is a shared responsibility for any harm that occurs to a patient (or even a colleague) as both the employer and the employee have a duty of care. This could lead to medicolegal issues and a negligence claim. Whilst understanding people’s enthusiasm to help, nurses need to be aware of the medicolegal and ethical concerns that lead to significant potential risk from doing so.

Other ethical principles that are being exposed for discussion, too, include the concepts of ‘the greatest good for the greatest number’.

HEALTHCARE PROFESSIONALS: ALL FOR ONE AND ONE FOR ALL?

In this issue of the journal, Helene Irvine describes the gradual return of some areas of care, following on from her previous article on prioritising workload and how the pandemic had impacted on usual care in general practice.⁵ There is no doubt, when reading through social media groups for GPNs, that some feel that they were left without clear advice as to what they should and should not be doing. Indeed, even as we start to reopen some services, nurses are relating very different experiences with regard to what their GP employers are asking them to do. The need for clear, unequivocal leadership for GPNs was never more evident than during the pandemic, and it may be useful to reflect on where this came from. Although there were gaps at times, nurses also have a duty to seek out information, not just wait to be told. ‘Practise effectively, preserve safety’ says the NMC Code, and nurses should be able to research, analyse and implement knowledge appropriately in order to meet these requirements. Presenting employers with clear, scientific evidence about what should be happening and why, will get better results than comparing poor practice on Facebook. This is leadership at its most effective. If employers refuse to comply with best practice, the situation should be escalated, as it will be the patients who are at risk.

CONTACT TRACING – WHY AND HOW

At the start of the pandemic people with and without COVID-19 were mixed together without testing taking place. This became a major issue in care homes when coronavirus-infected patients were being discharged to their care, which in all likelihood facilitated the spread of the condition. A consultant virologist has launched a judicial review against the Government, after the complainant’s father died of coronavirus. The criticisms include the failure of the Government to take proactive measures to protect residents, discharging patients from hospital without testing, the failure to provide PPE and the disruption to PPE supplies.⁶ Contract tracing and sharing of information about infection rates seems to be an obvious way of tracking the virus, especially with respect to the possible ‘second wave’ but some people have expressed concerns about how the data will be used and how safe it might be. Greenhalgh has been at the forefront of some of the discussions on contact tracing apps and her views warrant consideration – she regularly tweets under the handle @trishgreenhalgh. Implementation of the app has been fraught with delays and errors.

END OF LIFE DECISIONS

The ReSPECT programme was launched to help create personalised recommendations for an individual’s clinical care in any future emergency where they are unable to express their wishes. This is a relatively new approach and has been implemented in some general practices. More information is available at https://www.resus.org.uk/respect/ The programme has been a useful resource during the pandemic but end of life decisions are often challenging and fraught with ethical quagmires. However, the sudden need during the pandemic to clarify people’s wishes may have made the situation a little easier for the future and the public may start to realise how important it is to have plans in place and shared. The importance of getting Lasting Powers of Attorney (LPA) in place for financial and health concerns has become a little clearer too. Although legal help can be useful for setting out the scope of an LPA, it is not necessary, and forms can be downloaded and registered online via https://www.gov.uk/power-of-attorney

PRESCRIBING APPROPRIATELY – WHO DECIDES?

At the start of the pandemic there was a shortage of some medication. Some inhalers, for example, were lost from the supply chain and people with asthma and chronic obstructive pulmonary disease (COPD) had the additional stress of not being able to access their usual treatment, at a time when they needed it most. The main reason for this disruption was a sudden surge in demand, driven by people overordering inhalers, or ordering inhalers which they had not been using for some time – months or years – ‘just in case’. Although this anxiety is understandable, it was down to the prescribing clinician to explain to people why these supplies were not needed and why it was important simply to order as usual. Arguably, then, the shortage was the result of poor prescribing practice. The Brexit situation had already prepared us for the risk of hoarding supplies; with the pandemic we saw the medication equivalent of toilet roll hoarding, which could only be facilitated by prescribers making the supplies available.

THE FOURTH P: A SPECIAL PLACE IN THE PANDEMIC?

The fourth ‘P’ of the NMC Code of Conduct highlights the importance of promoting professionalism and trust. It is interesting to consider how this relates to the pandemic and the issues discussed in this article highlight some opportunities to meet this obligation. However, from an ethical and medicolegal point of view, nurses may also like to consider the role of social media in either augmenting or detracting from the image of the nurse as a competent, trustworthy professional. For example, not everyone is comfortable with the concept of HCPs as heroes and there were some who expressed their conflicted views on the ‘clap for carers’ initiative. Some HCPs expressed concerns about colleagues appearing on social media singing and dancing about coronavirus when a relative of someone they had cared for might see them. It was thought by some that this might detract from the pandemic and make light of the suffering of people who had died as a result. While the Chief Nursing Officer praised the nurse who went viral after weeping about empty shop shelves, others disagreed, and the importance of demonstrating fortitude and resilience was a topic of conversation. While some may have supported public displays of concern from HCPs about the lack of appropriate PPE, others were unhappy at the prospect of these complaints causing further distress to acutely sick people who might decide to stay away from hospitals and surgeries believing that this would put them at greater risk. It is already known that there is an increased death rate from non-COVID-19 deaths, possibly because people were anxious to stay away from what was seen as a hot-bed of infection. Political comment and moral and religious views were expressed in a way that could be seen to breach the NMC Code. Paragraph 20.7 of the Code requires nurses, midwives and nursing associates to make sure they do not express their personal beliefs (including political, religious or moral beliefs) to people in an inappropriate way. This expression may be in any format including though the use of social media. I am often struck, as a trained Expert Witness, by the willingness for nurses to share their potentially controversial views on social media. However, keeping quiet has to be weighed against the importance of free speech and being prepared to act as a whistle-blower where necessary.

CONCLUSION

The pandemic has changed a great deal about how we live and work. For nurses, and other healthcare professionals, there are some fundamental moral and ethical issues which have become a much more explicit part of day-to-day practice. As a result, nurses should be more aware of some of the commonly held ethical principles in healthcare, and should be able to consider how these influence care provision, not just during this pandemic, but for all areas of practice. A useful exercise for revalidation might be to reflect on whether ethical principles were implemented with regard to your own role during the pandemic and to consider what lessons have been learned.

REFERENCES

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford; University Press: 2013

2. Nursing and Midwifery Council. The Code; 2018 https://www.nmc.org.uk/standards/code/

3. Chan TK. Universal Masking for COVID-19. BMJ Global Health 2020;5:e002819. Doi: 10.1136/bmjgh-2020-002819

4. Czyzewski A. Modelling an unprecedented pandemic; 2020 https://www.imperial.ac.uk/stories/coronavirus-modelling/

5. Irvine H. Prioritising workload during the pandemic. Practice Nurse 2020;50(5):7-12

6. Holland L. Coronavirus: Daughter of suspected COVID-19 victim begins legal action against Matt Hancock; 22 June 2020. https://news.sky.com/story/coronavirus-daughter-of-suspected-covid-19-victim-begins-legal-action-against-matt-hancock-12012227