By David Shaw

Covid-19 raises dozens of fascinating ethical issues, but you might not know it from looking at the narrow focus of many ethics papers published since the pandemic began. Most of these papers have focused on the issue of allocating scarce resources in intensive care units, because of the anticipated pressure on these units because of the number of people experiencing complications of Covid-19. This has led to other important issues being neglected. In this blog and linked paper I suggest that ethicists have a duty to triage ethical issues and help set the agenda, rather than flocking to a few issues that health and public health professionals regard as deserving priority.

When the pandemic began, it soon became apparent that even with lockdown, intensive care units might come under a great deal of pressure. Doctors and ethicists began to develop guidelines and research on what should be done in extreme emergency situations where patients are competing for ventilators. At the time, this might have seemed like the right thing to do; ethics input to clinical guidelines can be important, and there was a perceived need to prepare for difficult dilemma situations.

However, there may have been an overemphasis on the issue of triage. For example, in the month between mid-May and mid-June, almost half of the new papers on Covid published online in the JME concerned triage in intensive care. Furthermore, there was already a massive literature on the ethics of scarce ICU resources, and the actual ethical issues involved in triaging Covid-19 patients were not novel. Therefore, the new guidelines and papers to some extent reiterated in a new context what had already been said. This is perhaps not the best use of ethical expertise, particularly when the envisaged dilemmas generally did not materialise, except in northern Italy which was hit earlier. (The focus on thought experiments in the ICU also runs the risk of ignoring clinical realities, and it is wrong to assume that ICUs simply flip from normal operation to extreme emergency triage.)

Furthermore, this focus on the ethics of triage in a worst-case scenario meant that many other important ethical issues were neglected. For example, part of preparing hospitals for the envisaged onslaught of coronavirus patients was emptying patients from ICUs and other wards, which had substantial costs for non-Covid-19 patients; the number of excess deaths among other patients may exceed the death toll among those killed by the virus. Organ transplantation came to a virtual halt, increasing mortality among those waiting for organs, and some cancer screening services stopped entirely. Hardly any papers covered these important topics, or the increased risk of death among ethnic minorities and socioeconomically disadvantaged communities. This failure to tackle other, less ‘sexy’ issues was one criticism levelled at ethicists during the Ebola epidemic.

Of course, many ethicists were asked by doctors to contribute to these guidelines, and to research on this topic. As such, they were responding to a need that was perceived as important. But ethicists are experts in identifying important ethical issues, and in joining the avalanche of triage discussion, they contributed towards its momentum – momentum that drew attention away from other important ethical issues.

I think that ethicists have a duty to triage ethical issues in order to maximise benefit during a public health emergency. How can this be done? First, they should not simply respond to the expressed needs of others, but survey the ethical landscape – in this case of Covid-19 – and identify the different ethical issues. Second, they should consider which ethical issues are most urgent, which are neglected and which are most ethically complex and thus require substantial ethics input. These factors are interrelated and it will sometimes be difficult to triage topics accurately, but it is necessary to try. Having triaged the ethical issues, ethicists can then go to work. And of course, as days and weeks pass, new medical and ethical evidence will emerge, changing the relative urgency and degree of neglect of different issues.  (I explain this system in more detail in the paper.)

Applying this system will ensure that the diverse ethical issues raised in a crisis like this will each receive adequate care and attention according to need. Here is an example: let’s compare the two ethical issues of triaging Covid-19 patients and suspending cancer screening services. Triage may be complex, but the issue is certainly not neglected – many papers came out very quickly, and as already mentioned the issues were not really new. There was perceived urgency, but that was probably overstated, particularly given that good frameworks and evidence already existed. In contrast, the suspension of cancer screening services was unprecedented, and there is no ethical literature on that subject. It might not seem urgent now, but millions of cases of cancer may have been missed, which may become an urgent issue very soon. On balance, the second of these two ethical issues seems more deserving of treatment.

In The Lion, the Witch and the Wardrobe, Aslan chides Lucy for lingering over her brother after she has given him a lifesaving medicine because other people need attention. By lingering over her first case, Lucy does not benefit him any further, even though she has a personal interest in staying there. Similarly, ethicists should not linger on one case for which effective treatment has already been provided when there are others that have not yet received any care. Ironically, by overfocusing on the ethics of triaging coronavirus patients, ethicists have neglected the importance of triaging ethical issues.

Author: David Shaw

Affiliations: Institute for Biomedical Ethics, University of Basel; Care and Public Health Research Institute, Maastricht University

Competing interests: I wrote about the ethics of randomization and prioritization during the Ebola epidemic, but have tried to diversify during the Covid-19 pandemic. I would probably have written more papers and blogs on neglected ethical issues, but had to triage research with homeschooling three kids (who seem to be fans of the trolley problem).