By Rosalind McDougall, Lynn Gillam, Danielle Ko, Isabella Holmes, Clare Delany

Prior to the COVID-19 pandemic, clinicians in well-resourced healthcare systems usually had the information and resources they needed to appropriately protect themselves while still providing optimal care for patients.  However, achieving both staff protection and high quality patient care has now become difficult in many settings.  Sometimes the two values – health professional wellbeing and patient care – cannot both be optimised.

In our experience as clinical ethicists in Australian hospitals, a range of new ethical questions are arising within hospitals in relation to staff protection during the COVID-19 situation.  These types of ethical questions include:

• What should we do when the PPE available is inadequate for the task?
• Should we alter/decrease the frequency of patient care in order to conserve PPE?
• Should we delay cardiopulmonary resuscitation to don PPE?

Two key values: duty to care and personal wellbeing

Generally in clinical ethics decision-making, choosing between different options involves balancing different values.  For those making decisions about health professional safety, we suggest that the two critical values that need to be balanced are duty to care for patients and personal wellbeing.  Responding to ethical questions about health professional protection requires decisionmakers to weigh up the scope and relative importance of each value in order to find an ethically justifiable balance.

The concept of ‘duty to care’ refers to clinicians’ role-based responsibility to provide care to patients even when this involves some degree of burden or risk to the clinician. The term ‘duty to treat’ is sometimes used.  We prefer the term duty to care, as it encompasses all the aspects of healthcare work that are not specifically the provision of medical treatment. In usual circumstances, the duty to care is put into practice by providing care despite feeling tired or frustrated, or despite finding the patient unlikeable or even offensive. In situations of infectious disease, it means caring for patients even though there might some level of risk to health professionals. However, the duty to provide patient care is not absolute. Like all other ethical obligations or values, it needs to be balanced against other ethical considerations.

In the context of clinical ethics decisions about PPE, staff members’ personal wellbeing is a crucial ethical consideration.  In our view, health professionals’ wellbeing should be understood broadly, as including both physical health and psychosocial wellbeing.  In the COVID-19 pandemic, it is important to protect staff by minimising the risk of infection but also by minimising the emotional burdens of clinical work during this public health crisis.  Processes for sharing challenging clinical ethics decisions are one important part of minimising these emotional burdens. Approaches such as the framework below enable decisions to be structured and shared.

As well as including both physical and psychosocial elements, another way in which health professionals’ wellbeing should be understood broadly is by acknowledging that their family members’ wellbeing has an impact. Concern for their loved ones has a significant impact on health professionals, and should be included in the conceptualisation of their wellbeing.  There is a substantial body of bioethics work recognising the moral value of close family relationships. As one of us (RM) has argued, having strong intimate relationships in a family is an element of individual flourishing. Whether conceived in terms of obligations to family members or intertwined interests of family members, keeping their family members well is an important aspect of health professionals’ personal wellbeing.

An ethical framework

We have developed an ethical framework that aims to guide the process of balancing the two values (duty to care and personal well-being) by facilitating ethical reflection and/or decision-making that is systematic, specific and transparent.  The framework consists of five steps, each with associated questions.  It provides a structure for individual reflection, collaborative staff discussion, and decision-making by those responsible for teams, departments or other groups of healthcare staff.

The steps are:

1. Characterise the degree of risk to staff as precisely as possible.
2. Identify the feasible options for protecting staff, specific to this setting.
3. For each option, identify the degree of protection afforded to staff and the impact on patients.
4. Look for the option or options that would make a meaningful difference for staff protection, without a disproportionately negative effect on patient care.
5. Note the conditions that would prompt a review of the decision.

The full framework – steps and questions – can be found here. The framework applies to issues of PPE in COVID-19, and also has potential to assist decision-makers in other situations involving protection of health care staff.

Paper (under review): Balancing health worker wellbeing and duty to care: an ethical approach to staff safety in COVID-19 and beyond

Authors: Rosalind McDougall, Lynn Gillam, Danielle Ko, Isabella Holmes, Clare Delany

Affiliations:

• Melbourne School of Population and Global Health, University of Melbourne, Australia. (RM, LG, IH)
• Children’s Bioethics Centre, Royal Children’s Hospital, Parkville, Australia. (LG, CD)
• Department of Palliative Care, Department of Quality and Patient Safety, Austin Health, Melbourne, Australia. (DK)
• Department of Medical Education, University of Melbourne, Melbourne, Australia. (CD)

Competing Interests: None to declare

Social media accounts of post author(s): @ethicsros