By Hui-Siu Tan
Malaysia is going through the emergency phase of the COVID-19 pandemic. The marked surge of cases and deaths sees recent drastic measures from the government with the nationwide movement control order and a declaration of a national emergency the king this week. The democratic implications of an EO are worrying to many However, 85% of the 200,000 polled felt that an EO could halt the pandemic’s progression by stabilising the political undercurrents allowing the Ministry of Health to do their job better. This job includes the on-going persuasion for private healthcare providers to expand their roles to manage suspected or COVID-19 patients.
For almost a year now, COVID-19 cases have been managed in public healthcare facilities. Private hospitals, the “commercial sector” of the Malaysian healthcare system, have been assisting in the screening and managing non-COVID-19 patients, as some of their specialists express concerns in treating suspected or COVID-19 patients, citing safety, costs, and quality of care reasons. More critically, they said, the inability of the current insurance pre-existing schemes to cover expenses related to the management for COVID-19, particularly in testing, PPE, and treatment, has become the major hindrance to COVID-19 care and might cause hospitals to close. However, a few felt distressed with the barriers to accept and holistically care for their suspected COVID-19 patients, especially when COVID-19 is just a small part of a patient’s medical or surgical needs.
Ethical Dimensions
Private hospitals cover a quarter of the hospital beds in the country and house half of the total number of clinical specialists in the country, many of whom were the nation’s top brains and earners. The expanded roles they will play in off-loading the currently overwhelmed public systems during the worst time of the crisis will be impactful to the country. Thus, it is time to revisit some of the concerns about healthcare professionals’ competing obligations and safety during a pandemic and steps that could be taken.
The competing obligations of healthcare professionals during the pandemic include duties to care for patients and maintain personal safety. Healthcare professionals must don full PPE during high-risk procedures such as intubation or resuscitation. Without adequate safety measures, they should not perform high-risk procedures, even if it might delay saving a patient’s life. Impact on patients could be mitigated by anticipatory preparation and adequate training. It is a less risky encounter, such as the physical examination of a patient with respiratory symptoms. Only strict hand hygiene and good protective barriers (mask, face shield, and apron) are needed. Clearly, healthcare professionals could fulfil both the obligations towards the patients and themselves, except those with pre-existing heart conditions, age, and pregnancy, of which the significant risk for COVID-19 complications should not be ignored.
The phenomenon of conscientious objections (CO) among healthcare professionals to treat certain patients due to personal values or philosophy is widely debated. CO protects moral integrity but may also jeopardise care without anticipatory planning and transfer of care in place. During a pandemic, CO may be relevant for value-laden triaging processes but not the prima facie duty to care. Healthcare professionals cannot object from treating a patient in an emergency and when the specific care cannot be provided elsewhere, as in the case of a pandemic crisis. For a novel and unpredictable virus, healthcare professionals can learn fast from scientific evidence and others’ clinical experiences. They have a moral obligation to perform at the highest level of competencies when public health is in crisis; if not, who else? If it falls within the contract with the private healthcare facilities or professional regulatory bodies, they are obligated to fulfil that responsibility stipulated in the agreement.
Recommendations
Refusal to care may not be absolute or fixed and must consider all the contexts mentioned above. Nevertheless, the notion that this pandemic affects every human across the board and that our lives and health are interlinked must be emphasised in these desperate moments. Private healthcare professionals must step up as it is no more a provision of care on a voluntary basis. The public will be watching closely and decide whom they could trust during this crisis and beyond. They could have more choices for their care (have we asked them?), the interruption of care could be prevented, and their co-morbids managed more wholesomely.
On the other hand, it is the reciprocal obligations of (any) healthcare institutions to support healthcare professional if they were to provide care for COVID-19 patients, performing beyond the call of duty (outside of usual specialty with heightened risks to personal health and moral distress) during a crisis or “supererogatory acts.” Safety measures must be in place, equipment and drugs adequate for healthcare professionals to do their job smoothly, especially when the number of cases becomes overwhelming and harsh bedside triaging decisions may be needed. Healthcare professionals should not need to worry about patients’ costs. The government and insurance companies should relieve these burdens from managing clinicians’ shoulders. Healthcare professionals should provide care based on ethical principles (respect for autonomy, beneficence, non-maleficence, and justice), the latest evidence, and sound clinical judgement. Mental health should be monitored, and moral distress during difficult decision-making is addressed through appropriate bioethics support and guidance.
Private healthcare facilities’ capacity to manage outbreaks and have established infection control protocols given limited experience must be addressed. Training must be in place, accepting improvisation to physical space and clinical management. Identifying designated private hospitals for this purpose would be safer and more effective. Clear pathways to manage cases based on private healthcare facilities’ capacities will ensure better co-managing for COVID-19 and other patients. Any new agreement between the government and private healthcare providers must be reached as soon as possible. Any form of payouts should be deemed secondary to public lives. There should not be delay in the implementation of any part of these agreements. All stakeholders’ voices, including end-users, the people, must be heard. A COVID-19 advisory group is welcomed, and bioethics input should never be left out.
Conclusion
All must be committed to a shared responsibility principle and work as one. Without collective efforts, there is no way that the transmission will halt, regardless of the duration of a lockdown or even the presence of an emergency ordinance. We shall be seeing more casualties among both COVID and non-COVID patients in the next several months. The pandemic curve’s exponential trajectory will be a nightmare unless all healthcare professionals in Malaysia come together and “ask what we can do for the country”.
Author: Hui-Siu Tan
Affiliations: HS serves at a public hospital in Selangor, Malaysia, currently of the worst-hit COVID-19 red zones. She hopes more will read “The Fight Against Uncertainty: Hospital Services Journey in Combating COVID-19” to know more about Malaysian pandemic efforts.
Competing interests: HS has no interests to disclose.