John Milton’s sonnet “On his blindness,” expresses the sense of powerlessness, frustration, and even guilt that many feel in responding to situations beyond their control, where their ability for active participation to act from the common good is limited. [1] We applaud and respect the considerable efforts and sacrifices made by those who provide public services in the face of covid-19 especially those frontline workers in health and social care roles. 

There have been heartfelt expressions of support and solidarity e.g. volunteering initiatives such as transporting patients, delivering drugs and equipment, telephone support, community responses or simple acts of kindness. [2] In this situation where so many are trying to help what part might ethical and spiritual services play?

As well as physical, social, and economic effects, pandemics and our responses to them, provide ethical challenges. The latter pose risks of moral distress, either with individuals knowing the right course of action, but constrained by lack of resources or with conflict over what course of action is right. [3] If the negative effects of exposure to morally distressing situations is prolonged and cumulative as during a pandemic, moral injury may result, and has been correlated with compassion fatigue and burnout. [4]

The causes of moral distress are numerous, but a major factor on the healthcare response to pandemics relates to the changing ethical imperatives that providing care for large numbers of sick people brings. In most healthcare systems, professional duty is defined by the principle of making the care of individual patients the primary concern. [5] In pandemics, there are tensions between this individualised approach based on clinical need and duties to the wider population in terms of minimising harms and maximising benefits. Deciding on what care is provided shifts from consideration of an individual’s needs, to whether s/he is likely to especially benefit from the intervention. This tension creates moral dilemmas when resources (staff, beds, equipment) are limited, yet urgent and frequent existential decisions have to be made, with the usual uncertainty over outcomes. These decisions are challenging, but nonetheless necessary, with some professionals needing to act out-with their usual areas of expertise.

Consequently, a number of professional bodies have provided ethical frameworks for policy making and decision-making, some specific to covid-19. [6,7] As helpful as these may be at the meta policy-making level, they do not usually indicate what practical support ethics and spiritual care may provide. A traditional view on ethics support is that it has the role of a chorus in a Greek tragedy by offering advice history and support for the protagonist: “Its virtue is its presence and its sympathy and its clear meditation on his or her predicament in a social and historical context.” [8] It may also function as a moral memory to be recalled in future events. This important reflective, but largely reactive, role has been superseded and the practical input from ethics and spiritual services in alleviating moral distress and preventing moral injury are increasingly recognised.  

The need for a later return to a healthcare profession not broken by the experience of covid-19 has been underappreciated as yet.

In terms of local more individualised responses to the covid-19 pandemic, ethics support services can:

• Assist development and facilitation of frameworks for ethical decision-making
• Provide retrospective (“have I done the right thing?”) and prospective/”hot” (“am I doing/about to do the right thing?”) case analysis, discussion commentary, advice.
• Exhibit moral empathy (Greek chorus function)
• Protect patients from discrimination, overt or subconscious, and help ensure hard decisions are consistent with the best moral standards and compatible with the law
• Develop and test techniques to alleviate moral distress and help initiatives to prevent moral injury e.g. input to facilitated discussion on ethical practice, participation in Schwartz rounds.
• Develop/assist programmes to build and strengthen moral resilience and spiritual values.
• Provide reassurance that tough decisions are necessary, occasioned by events and neither they nor their consequences are necessarily and wholly the fault of those charged with making them

Since religion and spirituality offer, for many, the foundation of moral and ethical decision-making, spiritual support should be provided for all who would like it. This includes ensuring its practical provision for patients, their families and professionals within the constraints imposed by covid-19 measures. The role of faith and spiritual care for staff, particularly those struggling with decisions made and their results, is imperative and should be actively offered by multi-faith/non-faith Chaplaincy/Spiritual Care teams.

While those providing ethical and spiritual support may not be numbered among the “Thousands at his bidding speed and post o’er Land and Ocean without rest,” their role is attracting wider recognition as France’s establishment of regional multidisciplinary ethics support indicates. [1,9] Surely, they fulfil Milton’s ultimate message of hope for humanity in that “They also serve who only stand and wait.”

Vic Larcher, retired paediatrician, Paediatric Bioethics Centre, Great Ormond Street Hospital for Children NHS Trust

Jim Linthicum, deputy director & lead chaplain, Paediatric Bioethics Centre, Great Ormond Street Hospital for Children NHS Trust

Joe Brierley, director and intensivist, Paediatric Bioethics Centre, Great Ormond Street Hospital for Children NHS Trust

Competing interests: None declared

References:

1. John Milton. Sonnet 19: When I consider how my light is spent. Available at:https://www.poetryfoundation.org/poems/44750/sonnet-19-when-i-consider-how-my-light-is-spent.  (accessed 09/04/20)

2. NHSE Volunteers website Available at: https://www.england.nhs.uk/participation/get-involved/volunteering/nhs-volunteer-responders/ (accessed 08/04/20)

3.Morley G What is “moral distress” in nursing? How, can and should we respond to it? J Clin Nurs. 2018 Oct; 27(19-20): 3443–3445.

4. Rushton C & Carse A. (2016). Towards a new narrative of moral distress: Realizing the potential of resilience. Journal of Clinical Ethics, 27(3), 214–218.

5. GMC Good Medical Practice. Available at https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor. (accessed 09/04/20)

6. Department of Health and Social Care U. Guidance. Responding to COVID-19: the ethical framework for adult social care. 2020.

7. BMA Covid-19 Ethics. Available https://www.bma.org.uk/advice-and-support/covid-19/ethics/covid-19-ethical-issues (Accessed 09/04/20)

8. King N. The ethics committee as Greek chorus. HEC Forum 1996; 8, 6: 346-5

9. Covid-19: Can France’s ethical support units help doctors make challenging decisions? Available at: The BMJ https://www.bmj.com/content/369/bmj.m1291 (accessed 09/04/20)