The covid-19 pandemic brings ethical decision-making to the forefront of clinicians’ minds. Most of the discussion to date has been focused on issues they may face individually, such as decisions about ventilator support when resources are scarce. [1] For those directly providing care this will be a crucial issue, and guidance is available. [2] What has been neglected however, both from government, and from professional bodies, is an overall ethical framework for managing the health service response to the covid-19 pandemic. This is needed in order to provide a structure for institutions—locally, regionally and nationally—to manage the crisis. Here we aim to address this gap. 

What is best for an individual patient has to be placed in the context of what is best for others. Such issues are never entirely out of sight. But a pandemic brings them to the forefront for two reasons. First, the pressure on scarce resources becomes much greater and more acute, and second, we are dealing with an infectious disease, easily transmitted to others. The two obviously interact: if clinical staff are infected by covid-positive patients, this is not only a direct tragedy to those affected, but reduces the resources available; if infection within the community is not reduced, or nosocomial transmission occurs, the demand on those resources goes up. So an effective response to the pandemic must address broader social health needs and show how they can be reconciled with patient-centred treatment.

There are substantial ethical consequences for organisational decisions—such as how to prevent nosocomial infection—which have not been publically discussed to the same extent as resource allocation of ventilators. [3,4] The  government’s “coronavirus action plan” offers a national strategy for the pandemic but falls short of providing a clear set of objectives for desired patient and population outcomes which can be adopted by institutions and professional and patient bodies. [5]

A clear ethical framework on which to base such objectives is also lacking. The Department of Health produced a  “pandemic preparedness ethical framework” in 2007, which was renewed in 2017 and on which other documents have been based. [6,7] This framework provided a list of eight “core principles,” which ran together ethical goals of the policy (e.g. treating people fairly and with respect,) with the executive virtues that are needed to achieve those goals (e.g. making reasonable decisions, being flexible). 

We propose another approach, building on the primary ethical requirement that we—the healthcare community—need to achieve the best possible health outcomes.  This applies to several groups, and so leads to four objectives for the health service. 

These are to achieve the best possible health outcomes: 

1. for those infected with covid-19; 
2. for those suffering from non covid-19 related illnesses and long term conditions; 
3. for the workforce looking after all of these patients; 
4. and for future generations of patients that the health care system will need to continue to look after. 

To this ethical requirement and the four objectives that fall from them two further fundamental ethical principles are added: 

Treat people as equals 

Treat everybody as equals, deserving of equal consideration and equal care. This does not entail giving everybody equal treatment. And it does not just apply to considering those with and without covid 19: people’s needs and situations will differ. But any decision to treat people differently must be justified on morally and legally defensible grounds. 

Treat people with respect 

Treat people as autonomous individuals with values and concerns of their own. 

From this falls a fifth objective:

5. People—at both 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 (for example in decisions about admission to hospital or ICU or the risks of visiting infected relatives); and their views about their treatment and care should be appropriately respected. [8]

Sometimes these principles may pull against the requirement of achieving the best health outcomes. In many cases, however, giving due consideration to how we might treat individuals or populations equally and with respect will help us to improve health outcomes. 

Recent weeks have seen unprecedented transformation at the local level in terms of commitment and ingenuity, both by clinical staff and by the wider community. It has also seen a plethora of sometimes contradictory covid-19 related ethical and clinical guidelines from national and international specialist bodies and advisory groups. 

Clinicians and politicians efforts and thoughts are being pulled in many directions. We suggest advocates are appointed for each of the articulated objectives at both local and national levels, in order to ensure that efforts are not overly concentrated in one direction. 

An articulated ethical framework and nationally shared objectives will help organisations make coordinated population-level decisions and provide leadership in the time of a pandemic. 

Zoë Fritz, Cambridge University Hospitals NHS Foundation Trust and THIS (The Healthcare Improvement Studies) Institute, University of Cambridge.

Richard Holton, Faculty of Philosophy, University of Cambridge

Jonathan P Fuld, Cambridge University Hospitals NHS Foundation Trust

Contributors and sources

Zoë Fritz and Richard Holton reviewed existing ethical guidance relating to pandemics and worked together to develop a tangible framework from which clinical objectives could be derived. Jonathan Fuld and Zoë Fritz developed the objectives and recommendations. All three authors worked together on the manuscript. 

Acknowledgements

Members of the Cambridgeshire and Peterborough CCG Ethics committee and Cambridge University Hospitals NHS FT helped refine and develop the ideas presented here. 

Patient involvement

There is lay representation on the CCG ethics committee, who contributed to the ideas expressed in this paper.  

Conflicts of Interest

We have read and understood BMJ policy on declaration of interests and have the following interests to declare:  Zoe Fritz is on the executive committee of the Resuscitation Council UK and chairs the subcommittee for ReSPECT. She is also a member of the education group for the institute of medical ethics. Her research is funded by the Wellcome trust. Richard Holton has none. Jonathan Fuld has received funding from the MRC

References:

1. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020.
2. Physicians RCo. Ethical dimensions of COVID-19 for front-line staff 2020 [Available from: https://www.rcplondon.ac.uk/file/20551/download.
3. McMichael TM, Clark S, Pogosjans S, Kay M, Lewis J, Baer A, et al. COVID-19 in a Long-Term Care Facility – King County, Washington, February 27-March 9, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(12):339-42.
4. Nacoti M, Ciocca A, Giupponi A, Brambillasca P, Lussana F, Pisano M, et al. At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. Catalyst non-issue content. 2020;1(2).
5. Government U. Coronavirus Action Plan. 2020.
6. Care DoHaS. Ethical Framework for Pandemic Preparedness 2017 [Available from: https://www.gov.uk/guidance/pandemic-flu – ethical-framework.
7. Care DoHaS. covid-19 ethical framework for adult social-care 2020 [Available from: https://www.gov.uk/government/publications/covid-19-ethical-framework-for-adult-social-care/responding-to-covid-19-the-ethical-framework-for-adult-social-care.
8. Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017;356:j813.