By Ayesha Ahmad.
When traditional healers heal, they empathise with the pain being endured. The traditional healer is distinguished by their strength and ability to channel the suffering through, and beyond, them. What this shows is that there is a distinction between the person who is a healer and the person who is being healed. There are certain virtues and values that create a distinguished relationship, a relationship between the healer and the sufferer. Abandonment of these virtues and values leads to vulnerability of the sufferer and of the entire meaning of healing.
Health professionals responding to difficult and extreme situations especially during disasters often face personal risk. The site of clinical settings globally as the gathering of patients infected with COVID-19 and a humanitarian crisis, one of many, surrounding the provision of Personal Protective Equipment (PPE) in many countries has exemplified the humanity that is shared between the health professional and the patient. Just like with the traditional healer, health professionals are defined by their moral positioning to be treating patients in response to ethical principles such as to do no harm or to provide compassionate care. The health professional is in a position of elevated ethics; that is to say that there are ethical duties that must be fulfilled for a virtuous healthcare to exist.
The COVID-19 pandemic has shifted the virtues and ethical boundaries of ordinary healthcare professionals in otherwise non-crisis settings. Health professionals, especially in care home settings in the United Kingdom, abruptly were transformed into humanitarian responders to crises that there had previously been no necessity to be trained for. Health professionals who opt to work as part of humanitarian health efforts are prepared and there is a form of agency in choosing such an identity. Such humanitarian health professionals also are part of a collective response; they are not the intervention.
However, the COVID-19 pandemic and the rapid advent of vaccination programmes in society has cascaded the virtues and values of health professionals during non-crisis times to crisis modalities without their participation.
As an academic philosopher and medical ethicist working in global health, specialising in humanitarian and disaster ethics, and a co-owner of a rural 60-bedded care home with acute, complex, palliative, psychiatric, and end-of-life care residents, I liken the situation we are currently amid to a cross-road of crises. We need to respond accordingly. With the advent of ministers including the health and social care secretary, Matt Hancock, recently announcing that COVID-19 vaccinations will be mandatory for care home staff in England, this is a conversation that should have started much earlier in the vaccination roll-out, but it should also have been be framed from a perspective of developing a humanitarian health effort rather than as forsaking individual autonomy.
During an outbreak of COVID-19 in the care home during the winter months, our healthcare staff suffered traumatic demands. Their identities shifted. The typical landscape of peace and stability of an isolated valley with strong community bonds was juxtaposed with the acute level of clinical care being provided, the personal risk of the staff, and the ethical issues arising from scarcity of resources, balancing the clinical needs of residents without COVID-19, and the psychological burdens of bearing witness to such suffering as well as from the impact of making moral decisions in non-ideal circumstances.
The care home was in effect a disaster because of the collapse of the familiarity and challenge to the ways we cared for our residents’ needs. The response required the mindset of a humanitarian equipped to read and interpret the signs of a crisis.
Such was the transformation of the space of the care home that a member of staff expressed during grief “I am used to my happy life, not this”. The situation was unrelatable to any of their experiences. Their life-worlds were shattered. The distinguished relationship between the healthcare staff and residents dissolved, their infallibility on par with the residents. That is the defining of a disaster—the alteration of place.
This is why I am calling for mandatory COVID-19 vaccines for all care home staff. As it stands, COVID-19 vaccinations for care homes in Wales will not be made mandatory and this is extremely concerning for the impact that such a decision will have on inscribing further vulnerabilities into the context of care homes that are already depleted from connectiveness and accessibility to wider healthcare resources. The vaccination is a humanitarian intervention and the decision to mandate COVID-19 vaccines is necessary as a form of disaster preparedness and risk reduction. The humanitarian crisis that we endured form a collective change from individual autonomies to the place of the lives of the residents and staff as a living organism.
To care for our residents, each member of staff fulfils moral requirements that are mandatory to maintain the well-being of all those within the care home. Staff members continuously abide by public health mandates including forsaking autonomies that they otherwise would be able to conduct in society as a member of the public, such as drinking alcohol or wearing non-uniform clothes. Public health regulations have provided specific mandates to the pandemic such as the wearing of PPE, or routine testing for COVID-19 in the workplace. Failure to adhere to these measures subject staff members to disciplinary measures.
A mandatory vaccine is an accepted public health intervention in some clinical settings, such as Hepatitis B. However, the care home is often perceived, by virtue of its identity as a home, as a benevolent setting that is far separated from the discipline of a hospital. The COVID-19 pandemic has revealed the lived realities of residents in care homes—lives that I have had the privilege to observe and be part of since my childhood—and their silence and separation in and from society will continue to be a vulnerability unless their well-being is protected from further disasters related to the COVID-19 pandemic.
We need to treat the mandating of the COVID-19 vaccination as a ‘best interests’ standard for how we treat a place ethically. A care home is a vessel of lives, of the staff and residents. To keep the flow of healing in situ we need to consider ethical principles that foster how we conceptualise the collective autonomy of a space where healing occurs. This is a different space to other places in society and thus there is a shifting in virtues. An individual who refuses to vaccinate is not upholding the ethical virtues of a healthcare professional and is substantiating risk to the place. For example, should an unvaccinated staff member become infected with COVID-19, as well as risking residents’ lives, the infected staff member will be required to self-isolate as well as any ‘direct contacts.’ The threat of such staff shortages is another risk to further disasters relating to providing care.
Ultimately, mandating the COVID-19 vaccine will strengthen an existing structure that will permit the ethical treatment of a care home as a place that needs protecting from disasters, and to ensure transformation from the humanitarian crisis we have solvently endured. The healer, or health professional, is a virtuous agent. The mandatory aspect of the vaccine must be recognised as an emergency intervention, and not as a solution. In an ideal scenario, the vaccine is an individual and voluntary decision. However, we continue to strive to treat our residents in non-ideal circumstances, and the vaccination is a crucial step to create the lives that both our staff and residents are familiar with—in their home.
Author: Ayesha Ahmad
Affiliations: Senior Lecturer in Global Health, St George’s University of London
Competing interests: The author occupies a role as a Responsible Individual in a care home is owned by her family.