Clinical ethics in a public health crisis: supporting our clinician colleagues at the frontline

By Rosalind McDougall.

Clinical ethicists around the world are responding to COVID-19 in an effort to support our clinician colleagues at the frontline. The clinical ethics community is compiling resources, developing ethical guidelines, and contributing to hospital policy as the scale of the crisis increases.

The hope is that ethics can offer a structured way of navigating some of the overwhelming choices facing clinicians and other hospital decision-makers. Articulating shared values and a process for ethical decision-making offers some scaffolding for difficult choices.

The pace of change has meant some high-speed work, drawing on the existing body of bioethics literature on pandemics. My own experience was one of being approached by a senior clinician colleague who had identified the urgent need for a shared approach to ethical priorities in her hospital. Increasingly, it was clear that many difficult decisions would need to be made across the hospital over coming weeks. We identified relevant bioethics scholarship, and used the values articulated in this literature to develop focused questions. Essentially, we digested bioethical discussion into a form that was directly usable in a hospital context.  We aimed to guide decision-makers to consider their options in terms of the relevant values, and to make their decision using an ethical process.

The tool adapts a published ethical framework, and guides decision-makers through a structured process to support ethical decision-making. The tool has five parts and asks the decision-maker (or group) to consider:

  • Key information – e.g. current context, urgency, who is making the decision, timing of decision and review
  • Benefits and risks of options, and how the options interact with ten ethical values
  • Whether the decision has been made using an ethical decision making process
  • What is required to implement the decision, and what change in conditions would prompt a review, and
  • What needs to be done to effectively communicate the decision.

This tool, like any ethical guidance, will not take away from the difficulty of making pandemic-related decisions. Each situation will require judgement about how to apply and weight the relevant ethical values. However, the tool aims to support ethical decision-making by asking that decision-makers consider the relevant values, follow a structured process, and clearly document decisions.

This is one small contribution to an enormous and complex ethical situation. Despite the best efforts of the clinical ethics community, profound moral distress for clinicians is inevitable. With these resource pressures, clinicians are unable to provide the level of care that would usually be offered. Further, clinicians are working in conditions of heightened personal risk. All the ethical tools, resources and policies cannot fix this. Sometimes, ethicists might just need to be a shoulder to cry on. Health professionals around the globe deserve our deep respect and ongoing thanks for their skills, dedication and fortitude.

Author: Rosalind McDougall

Affiliations: Melbourne School of Population and Global Health, University of Melbourne, Australia

Competing interests: None declared

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