Ethics in a time of COVID

Ethics is, in normal times, one of those topics we brush up on occasionally, regarded perhaps as a nice ‘soft’ way to get some CPD points, but really not up there with the benefits of the new videolaryngoscope or the breaking news on ultrasound-guided nerve blocks. But here we are, suddenly in a new world, and the subject of ethical delivery of healthcare has been pushed to the very top of the agenda, where it is likely to remain for some time to come.

Standard teaching on medical ethics always begins with Beauchamp and Childress’s four principles: beneficence; non-maleficence; autonomy; and distributive justice. Of these, autonomy has held top trumps for many years, but now, in a situation where equitable allocation of increasingly scarce resources is the topic on everyone’s lips, it’s all about distributive justice. ‘Fairness’ is perhaps a term that is more user-friendly, and it is the key principle adopted by the Royal College of Physicians (RCP) in their very welcomed document “Ethical Dimensions of COVID-19 for Front-line Staff”, endorsed by the Royal College of Anaesthetists (RCoA). Particularly praiseworthy is the emphasis that any decisions or policies regarding, for example, access to ICU and ventilation should be “accountable, inclusive, transparent, reasonable and responsive”. There are some useful comments around topics like ensuring equitable care for COVID and non-COVID patients, working outside of specialty and, particularly thought-provoking for old codgers like me, protecting staff who are elderly or have co-morbidities. 

Ethical advice, by its very nature, has a habit of being non-directional, and often carries a rather woolly, bien-pensant tone which, on the front line, might be regarded as unhelpful. “How do I deal with this specific problem, in front of me right now?” is not a question which ethicists, figuratively stroking their chins and puffing on their pipes, are inclined to address with incisiveness and speed. The RCP guidance follows the trend in this regard and is a bit light on the knotty question of allocation of scarce resources. Clinicians will want to have access to decision-making tools at times of crisis, so where then to turn?

Emanuel and colleagues, in an insightful article in the New England Journal of Medicine, have put together a set of ethical recommendations which at least partly fill the gap between principle and practice when it comes to resource allocation. I personally find recommendation two, which advises prioritising front-line healthcare workers for access to critical COVID therapies, a rather uncomfortable read; it could easily, if inaccurately, be portrayed as doctors arguing that doctors should be first in the queue for ventilators. Nonetheless, those looking for practical advice will find this a useful source.

The RCP guidance makes it clear that it will not cover everything and that individual colleges will develop tailored ethical specialty-specific advice for their own members. The RCoA’s COVID group has a team of ethical advisors for such eventualities, and we are happy to try to address any queries that members may have during the pandemic. As an example, recently, we’ve been considering the very specific issue of anaesthetists being asked to provide services to independent hospitals or other facilities offering to take urgent non-COVID NHS surgical patients. We’re hoping to share our thoughts about this on the website shortly.

Rather coincidentally, and before COVID appeared on the scene, the RCoA had decided that it would benefit from a more structured ethical framework, and its Council had confirmed that an Ethics Committee would be established. As well as advising the College, this body will respond to requests from members and public bodies for guidance on ethical issues relating to anaesthesia, critical care and pain medicine, and act as an educational resource. Hopefully then, we can carry on this dialogue in happier times.

Please stay safe and well, and be kind to yourselves and each other. 

David Bogod