Ethical road map through the covid-19 pandemic

Dear Editor

I am sorry to read that so many doctors are desperate for a road map.

There have been plenty of epidemics before. There will be many more.

There will be deficits of equipment. There will also be deficits of humanity, of common decency, of truthful reporting to the higher levels of the hierarchy.

I have known “authority” wanting only to serve “good news” to 10 Downing Street. But you, the doctor, are ethically bound to serve truth. Which means bad news many times.

The ministers, the Prime Minister, will always be able to claim they were “guided by science”, that they were never told that there was not enough equipment, that there were not enough staff.

The solution is simple. The clinical staff (doctors and nurses at the patient level) should tell us - the public - about the shortages, in so many words. If they say “we are just managing", they will be told - go on managing.

On the matter of ethics when treating or withdrawing treatment: this is nothing new. All of us have had to decide when to stop treatment. HM Coroner will interrogate the doctor and anyone else involved in the treatment. If he is informed that there was a lapse in the care or in equipment, he will be obliged to investigate.

I recall one Coroner, about half a century ago. He always asked two questions :

Doctor, could anyone have done anything to save the deceased’s life?
Doctor, did he suffer at the time of death?

The Prime Minister will choose the science he wants to follow. He should NOT be given the opportunity to do so. Therefore it is vital that the Chief Medical Officer should be truthfully seen to be the sole adviser to the Secretary of State (The CMO can consult SAGE and any other body or individual, including the Chief Scientific Officer.)

Dear Editor

Fritz et al’s article looks at ethics in the Covid-19 era, and states “we must follow the ethics, not just the science.” (1)

However, while they go on to say that “….every institution and organisation involved in the response must follow ethical principles, uphold ethical standards,”(1) and while governments tackling Covid-19 regularly state they are “following the science,” (2) there has been no specific discussion of what could be a key area of relevance, namely the very old but still all too relevant relationship between ethics and politics.

The Polish historian Adam Michnik said “Politics and Ethics belong to different worlds.” (3) But, true as that bleak view may be, should we simply just accept that as a reasonable state of affairs?

16th century renaissance diplomat Niccolò Machiavelli advised his Prince to learn “..how not to be good” (4). Retaining power was all that mattered. Such a stance may have represented a sensible coping mechanism for a leader during Machiavelli’s time, when every Italian city was like a little nation-state by itself, each suspicious of the others and eager to rid themselves of competitors, and while the Italian peninsula was regularly under the threat of invasion by large foreign powers such as France, Spain, and Habsburg Austria.

Also, the late 19th century/early 20th century German sociologist Max Weber rejected the idea that politics could or should be built on ethical foundations. (5) According to Weber, a politician should seek to balance an “ethic of moral conviction” with an “ethic of responsibility,” and some scholars do in fact recognise in Weber’s work “…a preference for the ‘ethic of responsibility’ as the most appropriate ethical approach in politics.” (6) They consider that, for Weber, a pragmatic approach to dealing with a problem is preferable to a situation where an approach is chosen for the reason that it is considered “morally good” in its own right, even if the taking of that approach carries with it a risk that the subsequent outcome may not be as helpful or desirable as one would want. This ethical stance, known as “deontological ethics,” holds that “…at least some acts are morally obligatory regardless of their consequences.” (7)

There is a serious debate to be had here.

Today in the 21st century, as the Covid-19 emergency unfolds and we all find ourselves threatened by something that we still do not have a complete knowledge of, do we want politicians to be taking decisions that are based principally or even exclusively on what they perceive to be the most acceptable ethical stance or not? Unlike during Machiavelli’s and Weber’s lifetimes (although, ironically, Weber died of Spanish 'flu'), one could perhaps argue that our current period on history is truly exceptional – after all, the world is currently living through a once-in-a-century pandemic – and this gives greater emphasis to the deontological ethic of moral conviction. Has the time now come for the vision of the World Health Organization (WHO), that “everyone should have access to the health services they need, when and where they need them, without suffering financial hardship” (8) and according to which view effective medications and vaccines for Covid-19 (once they emerge) should be made available worldwide and affordable to all, to become the universal guiding principle for all, including politicians? It is certainly difficult to find easily defendable arguments against this.

And yet, what is ethical here? Is it funding an endeavour in the short term to deal with a terrible but temporary health emergency and save lives? Or, should we be funding free healthcare provision to everyone at all times, regardless of whether or not there is an on-going emergency, which would also save lives? Recent debates in the USA on “Medicare for All” suggest that currently not everyone in that country is yet ready to embrace such an ethical stance. (9) Governments do tend to be concerned with short term-management, with funding going to wherever an emergency manifests itself, and prefer not to invest speculatively in something they consider might never happen. (10).

Returning to the current pandemic, in 2015 the UK government published a National Risk Register of Civil Emergencies and assessed the likelihood of pandemic influenza to be between 1 in 20 and 1 in 2, with an overall relative impact score of 5 on a scale from 1 to 5. (11) In hindsight, it is easy to say “I told you so” and that we should all have prepared for this possibility in a better way. But, without the perfect knowledge that this was going to happen, committing resources to it proved to be difficult for political and other reasons. In fact, at that time the world was more preoccupied with other emergencies, and other possible risks were identified, such as coastal flooding and widespread electricity failure. The retrospectoscope always has 20/20 vision. (12)

It is certainly laudable and prudent to have a broader approach to national security, one that encompasses all identifiable risks to human life beyond foreign invasion. These would include terrorism, cyberwarfare, tsunami, volcanos, rogue states, massive asteroid strikes and much else besides. Beyond that, there is always something needing taxpayers’ money spent on it. It is accordingly important to recognise that finding strategies to achieve perfect security is difficult: finding ways to achieve a balance between behaving ethically and taking a responsible approach to averting or minimising possible risks is timelier than ever.

References

1. Fritz Z, Huxtable R, Ives J, Paton A, Slowther AM, Wilkinson D. “Ethical road map through the Covid-19 pandemic.” BMJ 2020: 369 doi: https://doi.org/10.1136/bmj.m2033 (Published 21 May 2020).
2. “Britain’s government says it is ‘following the science.’ Which science?” Economist, 9 May 2020. https://www.economist.com/britain/2020/05/09/britains-government-says-it...
3. Michnik A. “Letters from Freedom: Post–Cold War Realities and Perspectives.” Editor; Gross IG. Publisher: University of California Press, 1998. ISBN 0520922492, 9780520922495. https://books.google.co.uk/books?id=nzwkpInLEJMC&pg=PR27&lpg=PR27&dq=Ada...
4. Ramsay M. “Machiavelli: good to be bad.” New Statesman, 3 December 2007. https://www.newstatesman.com/blogs/the-faith-column/2007/12/machiavelli-...
5. Starr BE. “The structure of Max Weber’s ethic of responsibility.” Journal of Religious Ethics 1999; 27, 407-434. https://onlinelibrary.wiley.com/doi/abs/10.1111/0384-9694.00025
6. De Villiers É. “Revisiting Max Weber's Ethic of Responsibility.” Volume 12 of Perspektiven der Ethik. Mohr Siebeck, 2018. https://www.mohrsiebeck.com/uploads/tx_sgpublisher/produkte/leseproben/9...
7. “Deontological ethics.” Encyclopaedia Brittanica, 21 May 2020. https://www.britannica.com/topic/deontological-ethics
8. Ghebreyesus TA. “Health is a fundamental human right.” World Health Organization, 10 December 2017. https://www.who.int/mediacentre/news/statements/fundamental-human-right/...
9. Nichols J. “Last Night’s Debate Produced a Clear Winner: Medicare for All.” The Nation, 31 July 2019. https://www.thenation.com/article/archive/dnc-debate-2020-medicare-sande...
10. Green ST, Cladi L. “Cassandra’s curse and covid-19: why do governments listen to businesses over doctors?” BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1852 (Published 13 May 2020)
11. “National Risk Register of Civil Emergencies.” The Cabinet Office, 2015 edition. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
12. Cladi L, Green ST. “To defeat COVID-19, the global community must work together.” Jandoli Institute (USA), 2 May 2020. https://jandoli.net/2020/05/02/to-defeat-covid-19-the-global-community-m...

Dear Editor,

Care of patients in mental health units during the COVID-19 crisis: Ethics or Legality?

The NHS is currently facing its biggest challenge yet with the rise of the COVID-19 pandemic. As a result of this, we as mental health practitioners, have felt it necessary for attention to be drawn to the existing legal frameworks governing our practice and reflect upon the ways in which infection control measures are being implemented on inpatient psychiatric wards.

We have seen rapid implementation of infection control measures, reorganisation of our services and keeping up with the local and national COVID policy changes has become a challenge to organisations and individuals. There is a pressure to maintain and expand acute services managing the most severe mental health illnesses and to reduce the burden upon acute physical health trusts. Our mental health workforce is upskilling in many areas including physical health and infection control training. Resources of personal protective equipment have been slow to arrive, and training has not been offered to our workforce.

The management of COVID cases has been challenging, particularly on wards where single rooms are not readily available. Cases are allocated one member of staff each shift to provide essential support only, to minimise the spread of infection. This raised concerns by the ward staff who felt the isolation management to be uncompassionate. Communication is at the heart of everything we do as mental health professionals, however in these circumstances we are instructed to limit communication and contact to a bare minimum. Much of our working day is spent trying to create a therapeutic environment, encouraging our patients to spend time together, not apart. In psychiatry it is common knowledge that isolative behaviours are harmful and concerning, and yet here we are insisting our patients stay in their room and avoid all interaction with others.

Furthermore, the potential risk of infection spread from those in the community to the ward has resulted in a ban on all visitors as well as all leave from the ward being postponed until further notice. Trials of leave and staged discharges have not been possible due to the social isolation measures impacting negatively in our patients’ progress.

The high volume of people sharing the ward environment, multiple staff presence and frequent new admissions to the ward exposes our current patients to COVID 19 risk compared to isolation in their homes. We have been offered limited access to COVID testing for our inpatients in the psychiatric wards as supplies have been reserved for acute physical health admissions. Symptomatic management is employed; should our patients develop a fever or persistent cough, we are compelled to implement isolation for the protection of others for 7 days under the national COVID management guidelines.

For cases of suspected and confirmed COVID in those individuals with acute mental illness, their capacity to engage with the necessary social distancing measures may become significantly impaired. As practitioners we are cautious in implementing powers to detain and isolate under the Mental Health Act. We consider the least restrictive measures to ensure patients and others’ safety and must consider patients’ and staff safety alongside the best interests of the patient.

The patient’s right to maintain their liberty and freedoms to access areas of the ward and beyond would be difficult to refute or manage under the legal framework of the MHA. In these circumstances the population restrictions outlined under the Coronavirus Act 2020 may be applied and the authorities may enact the ‘requirement to remain’.

We have a duty of care to our patients and should not therefore impede their progress with mental health recovery. Equally our duty of care extends to the vulnerable others in the ward. We may consider therefore that this individual is best discharged from the mental health setting. We must also consider that after discharge individuals re-entering the community and their homes may then spread COVID to members of their household including community care workers. Contact can be made with family and carers, who if able to weigh up the risks and make informed decisions, may accept the person back into the household, some however may not have a safe destination for discharge.

The implications for the ward and management extend beyond the COVID symptomatic individual. others on the ward, who have been sharing direct contact (in a living environment), should be quarantined for the two-week period. However, some of those individuals may be reaching the end of their detention and be ready for discharge. Without enough risks and mental health reasons, we cannot detain under then under the MHA. Conclusive testing of symptomatic individuals in the mental health inpatient setting may give more weight to implementing powers under the Coronavirus act.

Seclusion for the purpose of infection control remains unusual in the acute mental health setting. There has been interests to produce a guideline governing such decision making, to avoid mistakes born of uncertainty, particularly out of hours. With uncertainty around the duration of these unprecedented social isolation measures, we are having to consider best practice and legality of such implementation in varied ward settings case by case. The challenges faced in psychiatry in these uncertain times are unique and the lack of guidance around the legality of isolation in mental health units needs to be addressed before we are presented with an entirely different crisis.