At the height of the pandemic, as the reproductive rate of SARS-CoV-2 reached its peak, and with many hospitals reaching capacity, healthcare facilities changed their policies regarding visitors; their presence was considered both a risk to others and to themselves. There was also a concern that visitors would increase the spread of covid-19 into the community. This policy continues in some hospitals, and it presents many healthcare professionals with a complex ethical dilemma. Policy makers argue that it was necessary from a public health point of view, in order to prevent spread. Yet, for many clinicians and patients, being without visitors has been debilitating. For those patients with dementia, learning difficulties, or those who are dying, having family, friends, and carers, to visit, can be a vital part of any patient’s care. Framed slightly differently: At what point is it no longer ethical to sacrifice the individual care for the benefit of the public good? At what point does being a humanitarian require allowing family visitors?
Many clinicians have experienced their patients with rapidly worsening hypoxia, and felt torn about how to engage families. For many family members with dying relatives, empathy over the phone has not been enough: they need to see their loved ones. It can be a lonely and frightening existence, secluded in a side room, perhaps proned, perhaps on maximal oxygen therapy. For relatives it may be a lonely, but also a helpless experience, and one with potential psychological impact for years to come (especially if bereavement is involved). And, for doctors, the absence of relatives makes their job harder: harder to treat patients with dementia, harder to update families, harder to break bad news. Families are part of patient care, and in their absence has been left a void.
These issues raise many questions. We might ask for what purpose are these encounters: for the patient or for their relatives? And as patients deteriorate and are ventilated, what ethical framework should we follow in terms of allowing physical (or virtual) visits to patients? Deciding on a framework to work through these issues is vital, because they bring up many questions: how unwell should someone be to allow a relative to visit in person; who decides when they should visit; if a patient improves, are visiting rights rescinded; if a patient dies during a virtual visit, when is it appropriate to hang up the call. Covid-19 has thrown up unprecedented questions.
One ethical framework to develop would be the same as that of treating patients. Just as patients can refuse treatment, but cannot demand it, we might apply the same system to patient visits. If they do not want virtual visits, patients should be allowed to refuse them. And, if patients are unconscious, we might choose to act in their best interests (as we would with treatment), and allow a family visit. In fact, if we see family visits as a form of treatment ―it is well documented that emotional wellbeing affects physical health―as clinicians, we might insist on this treatment, regardless of policy makers’ intentions. [1,2] I, and many of my colleagues, have watched as the most vital thing to a patient―their relative―is denied to them.
This framework seems particularly salient because, as I experienced on my ward, there are not enough mobile devices (nor nursing staff with time to operate them) for all the patients to talk to relatives at the same time, and many patients require carers as part of their treatment for dementia. This issue of justice, the rationing of such a valuable thing as talking or seeing relatives, is an emotionally charged one. Fundamentally, where is the Rubicon at which public health policy can no longer take precedence over individual needs? If an overwhelming number of patients require patient visitors for their wellbeing, could that supersede the focus on the community? One might argue that dying patients should have preference, for example. It becomes apparent that the ethical issues facing healthcare professionals in this fraught environment are not only those of drugs and machines.
It is important to consider the broader socioeconomic disparities such a system brings to the fore. It is well documented that minority ethnic groups have fared the worst in this pandemic; it is precisely those groups who are least able to advocate for their rights and desire to visit their families. [3] Conversely, it is also those groups who potentially would benefit the most from the public health policy, designed to prevent spread of covid-19. Additionally, just as covid-19 has disproportionately affected certain groups, it may be older or more vulnerable people who cannot visit due to restrictions on the age of visitors, or reduced access to virtual visits. Those without internet access, or with limited computer skills, may be excluded from such attempts at human contact. And unconscious bias by healthcare professionals might lead to disparity in access to these services (or inequality across different hospital departments).
Finally, we should consider what a virtual visit entails. A video call is not the same as a physical encounter. Human communication requires interpretation of far more than voice; it is the slight turn of the head, or a nuanced intonation, which defines much of human contact. Often, a video conversation is fraught with the difficulty of expressing oneself, because it is challenging to feel present in the conversation. In the same room as a person, you can be, forgetting the surroundings, but a virtual conversation has a feeling of artificialness. To borrow a term from philosophy, video calls lack the aura that personal contact has. An awareness of the camera or microphone precludes a feeling of togetherness. Patients often report a feeling of both physical and emotional distance during the calls, even if it is a welcome reprieve from their solitariness.
We are all someone’s relative; we have all visited someone in hospital outside of our healthcare role. They may be dealing with serious illness, and we can try to understand their situation. However, we are necessarily differentiated from them; to love them is to understand that we are not experiencing the same thing, and in that distance we empathise with them. Our patients need our empathy in this time of distance more than ever before, and we must explore new ethical frameworks to ensure we continue to do so.
Michael Blank, junior doctor in infectious diseases, Northwick Park Hospital, Harrow
Competing interests: None declared
References:
- Naylor C, Galea A, Parsonage M, McDaid D, Knapp M, Fossey M. Long-term conditions and mental health. King’s Fund [Internet]. 2012;1–32. Available from: http://www.kingsfund.org.uk/publications/long-term-conditions-and-mental-health
- Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med [Internet]. 2017 Dec;195:42–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0277953617306639
- Pan D, Sze S, Minhas JS, Bangash MN, Pareek N, Divall P, et al. The impact of ethnicity on clinical outcomes in COVID-19: A systematic review. EClinicalMedicine [Internet]. 2020 Jun;23:100404. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2589537020301486