Ethics in clinical practice

Dealing with challenging circumstances

As we look at the rising number of cases and the escalating death toll from the COVID-19 pandemic, it is hard to not feel despair.

Surrounded by death and suffering, and facing uncertainty, many health professionals experience moral distress, particularly because of the feeling of being unable to meet the needs of patients and colleagues. These feelings can also raise profound moral dilemmas.

This distress has also been fueled by feelings that healthcare systems have not been prepared for the pandemic and that patients and healthcare professionals have been put at an unnecessary risk. For many, the highly politicised global health environment has been a barrier to collaboration and sharing. In many parts of the world, public health services have not received adequate investment, leading to insufficient resources to deal with this increasing problem.

As communities and nations around the world confront the COVID-19 pandemic, the ethical issues raised pose potential challenges to individual patients, health care workers, communities and organizations, contributing to deep ethical conflict, for example:

• rationing of limited health care resources
• imposing restrictions on individuals
• the use of digital surveillance, and
• the sense of professional duty to treat in the face of personal danger.

For those severely affected by the virus, profound respiratory effects and the impact on multiple organs has led to many being admitted to the intensive care unit. Beyond the immediate issues around equipment, there are crucial questions on whether intubation and ventilation is what the patient would want. This underscores the importance of advance care planning.

The unnecessary death and suffering of both patients and healthcare workers is of profound concern to many. In the times of pandemics and emergencies there is often a delicate balance of benefits and burdens.

The scale of the COVID-19 pandemic clearly rises to the level of a public health threat that could justify restrictions on certain rights, such as those that result from the imposition of quarantine or isolation limiting freedom of movement. However, human rights principles such as transparency and respect for human dignity are important to foster and monitor. Under the International Covenant on Economic, Social and Cultural Rights, which most countries have adopted, everyone has the right to “the highest attainable standard of physical and mental health.” Governments are obligated to take effective steps for the “prevention, treatment and control of epidemic, endemic, occupational and other diseases.”

According to the International Covenant on Economic, Social and Cultural Rights, the right to health is an economic, social, and cultural right and is a universal minimum standard to which all individuals are entitled. This right stipulates that health facilities, goods, and services should be:

• available in sufficient quantity
• accessible to everyone without discrimination, and affordable for all, even marginalized groups
• acceptable, meaning respectful of medical ethics and culturally appropriate, and
• scientifically and medically appropriate and of good quality.

In response to global challenges, the World Health Organization has issued a document drawing our focus to health and human rights considerations with regards to the COVID-19 pandemic. This document also draws our attention to key considerations in addressing stigma and discrimination, prevention of violence against women, support for vulnerable populations, as well as considering the impacts of quarantine and restrictive measures and shortages of supplies and equipment.

For many of us, this is the first time that we have been confronted by a serious shortage and restrictions in our workplace.

• What are the immediate challenges and restrictions you have been forced to put in place, or follow yourself?
• How has this made you feel?