By Joshua Parker and Mikaeil Mirzaali.
COVID-19 is now a global pandemic. As cases rise rapidly, one effect will be to raise deep and troubling ethical issues. If the UK follows Italy, as it is predicted to, one such ethical issue will be an extreme demand placed on healthcare resources, specifically intensive care. Indeed, given differences in ICU beds it may well be that the challenges facing the NHS exceed those seen in Italy. Effective triage is the appropriate response to ensure that in spite of a severe mismatch between supply and demand allocation of resources is fair. In an overwhelmed system with critically unwell patients, doctors must decide which patients get oxygen, intensive care, both, or neither.
Fundamentally, this is a question of ethics and distributive justice. In answering this question Italy has opted for a utilitarian approach: “the principle of maximizing benefits for the largest number”. That allocation must be towards “those patients with the highest chance of therapeutic success”. Indeed, American ethicists have also suggested that utilitarianism in some form is the best response to rationing in the face of coronavirus. Under the circumstances, utilitarianism seems to be the necessary and proportionate response. Whilst this might be the only ethical option, for doctors on the frontlines this represents a paradigm shift in how they practice and carries costs that must be considered over the longer term.
Deciding which patient should take the last remaining ICU bed is a decision for doctors. Rationing and making tough decisions are not unfamiliar; however, doctors’ approach to moral decision-making tends to be deontological in nature. Medicine takes place within discrete interactions between individuals. By this very fact of the doctor-patient relationship, doctors often set aside questions of the greater good emphasising patient-centeredness, the needs of the person in front of them and putting that patient’s interests first. Being the predominate way that doctors interact with their patients, not to mention the way that the GMC admonishes doctors to act, places these values at the core of what it means to be a good doctor. Indeed, these moral values are the heart of practicing medicine and a significant part of a doctor’s moral identity. This is a principally different way of thinking about ethics and the doctor-patient relationship to utilitarian ways of thinking
The decision to shift policy towards the rationing of intensive care based on utilitarianism does not belong to doctors. However, under the circumstances and given their expertise, society will entrust doctors to enact this policy making the hard decisions on the ground. In a certain sense this is simply ‘part of the job’ and no doubt doctors will rise to the challenge and do their best. Nevertheless, these decisions carry immense moral burdens. Burdens which doctors cannot refuse.
The two most important burdens are moral responsibility and moral risk. Taking responsibility for deciding how to best ration your resources at a population level, knowing this will inevitably lead some people to die, is immense. The weight of responsibility and the inherent stresses must not be underestimated. Given what is at stake, it is vital that doctors make the right decision. Nevertheless, the pace of change, working in a busy and overwhelmed system and the vagaries of applying the principle of “maximising benefits for the largest numbers” in the real-world leaves plenty of room for moral mistakes. The costs of these will weigh heavily on doctors. Moreover, these uncertainties might make it ambiguous whether doctors did the right thing for the individuals they are caring for. Again, this may be a source of profound distress for doctors reflecting back on the COVID-19 pandemic.
Moral injury is often understood as a psychological harm caused by transgressing ones deeply held values. We have noted that many of doctors most deeply held values both as people and as professionals are at odds with the demands of a public health emergency. One risk to doctors in tackling the myriad of difficult moral choices that COVID-19 hands them is that of moral injury. Where doctors must make utilitarian decisions at the expense of their more deontological values, the sacrifice of these values has a psychological cost. What this recognises is that by working at the focal point of the pandemic doctors not only risk their physical welfare but their moral character.
Choosing between patients knowing that this may lead to death presents an impossible situation and leaves doctors facing ‘unavoidable moral failure’. Either the doctor performs as a deontologist prioritising the needs of the individual patient in front of them or as a utilitarian maximising the greater good. Either way, important moral principles are violated. Whatever the doctor does, something of moral value is lost. Whilst following utilitarian principles might be all things considered best, and the doctor has little other option, many will still retain feelings of guilt and remorse.
COVID-19 is likely to be a global tragedy. In amongst its wide-ranging effects for patients, healthcare systems and society there will be a cost for doctors. As coronavirus forces doctors to make deep and challenging ethical decisions it may also ask healthcare professionals at the coalface to sacrifice their fundamental values for the greater good. There will be a great human cost to COVID-19, however we must not overlook the moral cost in our response to this public health emergency.