By Michael Dunn, Mark Sheehan, Joshua Horden, Helen Turnham and Dominic Wilkinson.
As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles to which staff are being allocated in the ITU and ED are riskier than they are used to. In our experience, policies for staff reallocation are causing distress and uncertainty.
One initial ethical issue here is the scope of the obligation to treat COVID-19 patients. As Udo Schuklenk has argued on this blog, and has been discussed elsewhere, it is difficult to argue that health professionals have an ‘obligation to treat’ when the exercise of that duty conflicts with other obligations that they have – to themselves and to family members. At the heart of the practical questions around reallocating staff, therefore, is an ethical bind: pandemic treatment needs to be provided, but no individual in a health care role is specifically obliged to provide it.
The aim, clearly, is to achieve the best outcomes for all patients at a time when the pandemic is causing asymmetries of need across a health service. Any ethically justifiable approach to allocating staff requires: i) an overall assessment of the nature of patients’ needs, ii) a de-prioritisation process in which staff are freed from their established responsibilities, and iii) articulating a redeployment process.
In the redeployment step, we are concerned with the question: how should we determine which health professionals are redeployed?
There are three sub-questions here:
- What constitutes a justifiable process for deciding which staff are chosen to be reallocated?
- What reallocation models for making these choices are fair and justifiable?
- What is owed to those reallocated to high-risk clinical roles?
This whole process, including engaging with each of these three questions, needs careful analysis, and we have sought to provide this analysis in a full paper on this topic (available on this link shortly). Here we focus on the second question. There are a number of viable reallocation models.
1. Volunteering
A volunteering model is an ‘opt-in’ process to select staff for redeployment. Potential volunteers would need to be provided with full information about the possible roles the associated risks and the rationale behind the redeployment.
This model allows health professionals to decide in line with their own assessment of the relative risks. Here, people remain in control of their professional role and they have the opportunity to contribute to the broader endeavour to the extent that appropriately balances their own commitments in their professional and personal lives.
Even if there are enough volunteers to meet clinical demand, there is a still a question about fairness and the distribution of risk. For example, out of a pool of 100 eligible anaesthetic staff, 50 volunteers agree to be deployed in intubation teams. Assuming risk correlates with exposure, these volunteers will be exposed to a risk of infection that is twice the risk they would have faced if the task had been divided evenly. Those not opting-in will face no additional risk and might be taken to be freeriding.
2. Lottery
Randomly allocating staff for redeployment is an alternative which directly attends to the intrinsic unfairness of the volunteering model. A lottery gives everyone an equal chance of being exposed to additional risk. Of course, this approach leaves the allocation entirely to chance, and so does not enable staff members to retain control over the configuration of their working lives.
3. Equal sharing of risk
A final model of distribution tries to share the risks equally between all, rather than randomly allocating. On this model, a rota might be set up which ensures that each eligible member of staff is broadly exposed to the same amount of risk. This model, like the lottery, removes individual control and specific choice in favour of fairly sharing the risks.
The key difference between equal sharing and random allocation is how we handle our knowledge of the risks and where they are likely to be incurred. Where we reasonably think that the risk to staff is higher when intubating COVID-19 patients, it makes sense to use this knowledge to improve the distribution of that risk.
Adopting this model ensures that those redeployed into high-risk roles do not face inequitable exposure to risk. Roles should be devised and scheduled in a flexible way such that those who are allocated share the responsibility.
Whichever model of reallocation is adopted, there are residual duties owed to those who are identified for reallocation. Those redeployed to high-risk roles should be i) provided with appropriate acknowledgement and proper compensation (perhaps a financial payment or professional recognition in light of the fact that their new roles carry special demands), ii) sufficiently prepared to undertake the responsibilities of their new roles, and iii) prioritised (additionally or equally) to other health professionals for access to critical care if required.
Authors and Affiliations
Michael Dunn, The Ethox Centre and Wellcome Centre for Ethics and Humanities, University of Oxford. Twitter: @ethical_mikey
Mark Sheehan, The Ethox Centre and Wellcome Centre for Ethics and Humanities, University of Oxford. Twitter: @mark_sheehan_ox
Joshua Horden, Faculty of Theology and Religion, Harris Manchester College, Oxford Healthcare Values Partnership, University of Oxford.
Helen Turnham, John Radcliffe Hospital, Oxford. Twitter: @HelenTurnham
Dominic Wilkinson, John Radcliffe Hospital, Oxford, the Oxford Uehiro Centre for Practical Ethics, University of Oxford and Murdoch Children’s Research Institute, University of Melbourne. Twitter: @NeonatalEthics
Competing interests: All 5 authors are members of Clinical Ethics Advisory Groups providing support to NHS Trusts within the south-east of England. This includes, at the present time, on providing advice on the issues discussed in this blog post.