By Mary Hall, Deborah Mbofana, Merryn Ekberg, and Mitch Harper
The concept of emergency preparedness is based on the need to act rather than plan, to be able to pick up and run with a ready prepared, detailed plan. In the UK, the Emergency Preparedness and Emergency Response and Recovery sections of The Civil Contingencies Act (2004) provide a framework for preparing and responding to civil emergencies. Pandemic flu has been regarded as one of the most ‘severe natural challenges likely to affect the UK’ and its detailed emergency plans have formed the basis for the UK’s response to the Covid-19 pandemic.
The coordinated response to Covid-19 has seen emergency plans kick in and a dependence on command and control structures of quick, responsive decision making down the chain of command. However this is an unprecedented situation; plans have had to be changed or adapted on an almost daily basis as new scientific evidence becomes available. Regular changes in guidance have created a scramble of local activity with little or no time to think, plan or reflect on critical decisions being made. The opportunity for robust ethical decision making becomes at risk of redundancy, a casualty of the emergency response.
This is particularly true for those working in the health sector. Professional bodies have recognised the potential impact on staff and developed supporting documents for medics, nurses and allied health professionals but these still require local adaptation and adoption that incorporates a reflective, reasonable and justifiable approach.
In Northamptonshire we set up an Ethics Advisory Group to provide key decision makers an opportunity to incorporate ethical considerations into their decision-making process. Rather than being viewed as a luxury, there was acceptance of the need for a structured, reasoned and ethically informed approach to the critical decisions needing to be made. Not least, there was recognition of the exceptional demands being placed on key staff and the need for reassurance and backing regarding individual daily decisions.
The group was set up by the Public Health team of Northamptonshire County Council. Senior level support was apparent from the start with representation at a Director, Chief Executive or senior decision maker level from the local acute trusts, community trust, district and borough councils, adult services, HealthWatch and the University of Northampton.
The group has been very clear that it is not a decision making body. It uses an ethical framework to provide advice and ethical consideration on issues or questions that have been raised by organisations across the social care, health and local government system within Northamptonshire. It does not consider individual ethical issues or complaints but has provided advice on ethical considerations of, for example, allowing hospital or care home visiting or re-deploying staff. National guidance is used as a starting point for discussions, but often local issues need further consideration and nuance than that available in guidelines. The ethical framework successfully enables this to happen.
The group meets weekly, dependent on issues raised, and despite the immense workload of all members, there has always been a regular and high attendance level. This is not seen as a burden, but, rather as an opportunity to contribute to a local and global emergency. There is reassurance in the fact that local decision making can be supported by considered, ethical advice even at a time of crisis. The multi-disciplinary nature of participants means that issues are considered from all angles including that of the resident, their relatives, staff and the community from different organisational perspectives. This is important when disseminating advice and conclusions.
Emergency preparedness enables us to react and respond to emergencies quickly and with minimal need to develop new plans. Ethics and the time for ethical consideration could be a casualty of this emergency response. Yet this is a time when ethics is critical: we need to be able to say, in the coming months and years, that the decisions we’ve taken and the actions we’ve done are ones based on sound reasoning and judgement that benefit most and harm fewest whilst maintaining respect for autonomy. Ethical decision making is not a luxury but a necessity. In setting up, and making space for an Ethics Advisory Group, we have accepted our professional responsibilities and obligations.
Authors and affiliations:
Mary Hall, Consultant in Public Health, Northamptonshire County Council
Deborah Mbofana, Public Health Practitioner, Northamptonshire County Council
Dr Merryn Ekberg, Senior Lecturer in Bioethics, University of Northampton
Mitch Harper, Public Health Officer, Northamptonshire County Council
Competing interests: None