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    Issue 14

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    Doctors’ ethical dilemmas during COVID-19

     
    Susan Hertzberg Headshot

    Dr Susan Hertzberg

    MBBS, MHealthlaw, MBioethics, FACEM

    Senior Medical Adviser - Professional Conduct, NSW, Avant

     
    new script

    As the COVID-19 pandemic reached breaking point in Lombardy, a bioethics group1, released a document to guide doctors’ ethical decision-making when the number of critically-ill patients exceeded available resources.

    The document’s general principle was that patients with the highest chances of survival — the young and healthy — get priority rather than the traditional first-come, first-served basis. Upon its release, both the document and bioethics group faced scathing criticism from colleagues for “God-playing.”

    Australia prepares

    Doctors in Australia watched the disaster unfold in Europe and the US, with an impending sense of doom that they may face a similar situation. While Australian doctors have fortunately not yet had to face the same serious ethical dilemmas, the pandemic has posed some important ethical questions.

    The goal with clinical ethics support is to enable clinicians and health service decision-makers to think more clearly about complex ethical questions...


     

    Dr Linda Sheahan, Clinical Ethics Consultant, South Eastern Sydney Local Health District (SESLHD) and a staff specialist in palliative care, says while the Lombardy situation was very confronting and traumatic for doctors around the world, it highlights the importance of embedding clinical ethical frameworks in healthcare delivery to help doctors navigate complex decisions and reduce their moral burden on the frontline.

    “The goal with clinical ethics support is to enable clinicians and health service decision-makers to think more clearly about complex ethical questions and provide a structured approach to tackle really difficult and/or more unusual ethically complex situations,” Dr Sheahan, an Honorary Associate with Sydney Health Ethics at the University of Sydney, says.

    Once it became clear the health services were being overwhelmed in Lombardy, the SESLHD Clinical Ethics Service reviewed the relevant bioethics literature related to pandemic response and created a framework which included a question-based tool for decision-making.

    “We developed a statement of organisational values that are relevant in the context of a public health emergency such as stewardship, reciprocity, duty to provide care, equity and fairness, individual liberties, privacy, proportionality, protecting the public from harm, solidarity and trust,” she says. “Each value had a list of questions that could be used to address each of those values in how they are thinking about organisational decision-making.”

    Developing a clinical ethics framework encompasses two main components, Dr Sheahan says. Firstly, deciding together on what is important and how to prioritise, and secondly, a decision-making process aligned with procedural justice principles which involves stakeholder engagement to come to a consensus on what action is relevant and appropriate in each circumstance.

    “The whole idea about ethics is you can defensibly come to different answers to the same questions. What’s relevant is that you have thought about all the important pieces and you’ve got good reasons and good process for deciding on a particular path of action,” she says.

    “One of the things we got off the ground early was the triage modelling around ICU because of the issues that were happening in Lombardy,” Dr Sheahan says. “At each of the hospitals, for example, we pulled together key stakeholders and facilitated discussion around how a triage model might look in our specific context, and what are the defensible pieces we might use to make decisions about people who might be appropriate for ICU if there was a resource scarcity situation.”

    PPE shortage raises moral scruple

    As the pandemic hit Australia, doctors’ concerns over a shortage of PPE were palpable. Our COVID-19 Member Survey found 88% were ‘very or somewhat concerned’ about catching COVID-19 from a patient, and 64% did not think healthcare workers would have access to enough PPE. This raised a profound moral scruple – to what extent should doctors attend to suspected or confirmed COVID-19 cases if appropriate PPE is unavailable? What if the situation is an emergency? Is it okay to say no to clinical interactions when PPE is not available? With a career predicated on ‘the patient comes first’, these questions were novel to many doctors.

    Commenting on the PPE issue, Dr Sheahan says while doctors fundamentally accept they have a duty to provide care in a pandemic, striking a balance between competing duties, such as their legal duty of care, their professional duty to care, and duty to their family and loved ones, can be difficult.

    Are we obligated to provide care regardless of our own personal safety or not?


     

    “The PPE issue really threw a light on those potential tensions because I guess this idea about professional duty is contested isn’t it? Are we obligated to provide care regardless of our own personal safety or not?” she asks. “And I think from an ethics perspective the answer is ‘no’”.

    “What happens in a pandemic is you are asked to park that individual patient focus, and decision-making is broadened out to think of all the individuals involved in the pandemic, so the priorities and values may shuffle around,” she says. “That creates a lot of tensions, particularly for clinicians, when their ethical framework, if you like, is so moulded to that individual patient claim component.”

    Legal standpoint on PPE

    Our advice to members, from a medico-legal perspective, is they are not required to treat suspected or confirmed patients with COVID-19 if they don’t have access to the appropriate PPE.

    In terms of doctors’ professional obligations to provide care in an emergency in the context of PPE, doctors should consider their own safety. The Medical Board of Australia’s code of conduct says, “Good medical practice involves offering assistance in an emergency that takes account of your own safety, your skills, the availability of other options and the impact on any other patients under your care; and continuing to provide that assistance until your services are no longer required.”

    The value of ethics

    As for the way forward, Dr Sheahan says an important ethical issue in the future will be how usual standards of care are being impacted by the pandemic response.

    “Potentially, the gold standard of care for non-COVID-19 patients in the context of this pandemic, may in some circumstances have been compromised,” she says. “That’s a huge ethical issue that we now need to look at – for example, how this pandemic response has impacted patient groups who are now presenting later or have had delayed surgery.”

    Now Australia has ‘flattened the curve’ and concerns that demand for healthcare will outstrip resources has subsided, Dr Sheahan believes it’s important to keep up the momentum by continuing the work on clinical ethics frameworks.

    “What struck me when I got into that ethics literature was a very strong sense that there was some solid momentum happening post the last pandemic, and then everything just stopped. That once you got out of the woods, the work got shelved,” she says. “I think clinical ethics tools and frameworks can be used not only in future pandemics, but in usual care to create some rigour around how we make resource allocation decisions in our healthcare system.”

    On the bright side, Dr Sheahan also believes the pandemic has highlighted what clinical ethics support brings to the table.

    “One of the side-effects of the pandemic, is clearly demonstrating to clinicians and organisations, who may or may not have experienced or hold an understanding of clinical ethics support, that this is how clinical ethics services can really be value-added when things get complicated,” she says.

    References

    1. The Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

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