Ethical road map through the covid-19 pandemicBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2033 (Published 21 May 2020) Cite this as: BMJ 2020;369:m2033
All rapid responses
I am reacting to Dr Anand’s rapid response (Ref 1) in which he wrote about the potential divide between (known) science and political decisions by leaders.
It reminded me of the following closing statements by Hannah Fry on BBC Two’s “Coronavirus: A Horizon Special: Part 2” broadcast on 19 May 2020 to UK audiences (and only shown to Australian viewers some 3 weeks later); fortunately her conclusion is still very much relevant to a fast evolving topic:
“Science is centre stage like never before, with politicians all around the world telling us they are guided by it at all times.
But that implies there is a single scientific solution.
But listen carefully to the scientists and you’ll hear them wrapping their answers in uncertainty, reminding us of how much we still don’t know, that science doesn’t trade in absolutes and rarely gives a black-and-white answer.
Science can’t weigh up the trade-offs we have to make.
It has no moral compass.
But when its limits are understood, it’s the most powerful tool there is to inform the decisions we face.”
The UK’s chief scientific officer Patrick Vallance’s claim that public health expertise on Scientific Advisory Group for Emergencies (Sage) was represented by PHE employees demonstrated “extraordinary ignorance about public health” according to some public health specialists. (Ref 2)
“These are mostly microbiologists. They are vital but it’s not the same as having expertise in communicable disease control”, one prominent expert commented.
“Reports have also suggested that Sage members fear they may be used by government ministers as “human shields” at a future public inquiry.” (Ref 2)
Such is the concerns about the secrecy and lack of transparency involving the activities of the SAGE committee, the Independent SAGE (iSAGE) was convened in response “as a group of preeminent experts from the UK and around the world. The aim of the Independent SAGE was and is to provide robust, independent advice to HM Government with the purpose of helping the UK navigate COVID-19 whilst minimising fatalities.” (Ref 3)
Now the public faces 2 potentially different (and conflicting) recommendations from 2 scientific committees, a situation which could have been easily avoidable.
“Scientists and doctors in advisory positions face a dual obligation to the state and to the public. But what happens when the government’s integrity no longer matches your personal or professional integrity, when your public accountability seems greater than that of the politicians you advise? Do you fight from within? Do you speak out, and even resign? What of the leaders of medical organisations working closely with the government? Regrettably, questions of conscience and duty must now be addressed.” (Ref 4)
What is the potential role of the GMC if registered practitioners are found to have knowingly not act to protect the interests of the public by standing behind a political decision against prevailing scientific evidence or not speaking out against a policy they do not support professionally or ethically?
No reasonable person during normal times (much less during a pandemic), would expect a categorical and absolute guarantee of any kind from anyone about anything, particularly about health care. Any scientist or clinician who do so would have boxed themselves into the playbook of movements who selectively use minute uncertainties and rare occurrences to the contrary to chip away the foundation of science that builds our modern society.
Unfortunately politicians like to deal with absolutes and make claims to that effect, even if many people do not trust them.
If there are enough scientists co-opted to support any official government narrative, however misguided it may turn out to be, then the trust of the society in the scientific community and its integrity would be greatly diminished, and will suffer the same fate as the fourth estate as it faces the “fake news” crisis.
Science may very well go back to the dark ages, supported and tolerated by the elite when it suits the current political narrative of the day.
Competing interests: No competing interests
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.)
Competing interests: Might be caught by the Virus
One way to describe ethics could be to say it involves doing the right thing, preferably at the right time and optimally in the right way for the right reason. As such it is always responsible effective and humane. To posit a rift between being responsible and effective and being moral as Lorenzo Cladi suggests in his last sentence implies a misunderstanding of ethics or what constitutes a good result. Good ethics by definition always has a good result because it respects the person and the intrinsic laws of nature - the natural law. You could ask what caused the financial collapse in 2008 and the answer is bad ethics; what caused the hiding of early warning data about Covid and it also was bad ethics; what exposes minorities to heavy viral loads may be bad ethics or poor resources. Ethics as such is crucial to prevent crises occurring and essential when crises do occur. It is not a Cinderella activity to be engaged in when there are no real stakes, but a high stakes activity underpinning the justice and humanity of governance and management of people. Without a solid ethical basis the enterprise will fail no matter how Machiavellian and smart the politics and decision making are.
Des O'Neill laments the lack of ethical education among doctors and this could also be echoed in the houses of Parliament among decision makers. An ethics that obeys the laws of nature is always successful because it respects human dignity and refuses to cross this line. The biggest human disasters always stem from bad or no ethics - lack of accountability, transparency and justice and honesty. There has been an industry in ethical leadership courses and books since 2008. Let's hope we won't have a similar response after the pandemic.
Competing interests: No competing interests
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.
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...
Competing interests: No competing interests
Re: Ethical road map through the covid-19 pandemic: Continuing Professional Development in ethics for clinicians also needed
The call for an ethical road-map is timely in view of the explosion of ethical statements of very variable quality, overt and occult bias, and at times obscure provenance during the COVID-19 pandemic (1). A missing element in the proposals was that of ongoing continuing professional development/medical education (CPD/CME) in clinical ethics among doctors and other healthcare professionals. A lack of ethical fluency and articulacy has been notable in many settings, including a failure to recognize appropriate standards of attribution of authorship and bias. For example, the conflicts of interest process and editorial oversight of a Sounding Board in the New England Journal of Medicine promoting prioritizing saving more years of life for scarce medical resources (effectively age-based rationing)(2) failed to signal the deeply negative views espoused by the first author about ageing and the value of life after the age of 75(3).
In an illustrative national context, the Irish Department of Health published two documents on ethical frameworks for COVID-19 with no attributions as to authorship or consultation, and with no appreciable bibliography or reference list(4, 5). These documents contain a number of contentious elements, including supporting life years saved (militating against older age groups) as a factor in prioritizing medical and critical care (5), as well as supporting advance care planning carried out over telephone or videophone for nursing home residents (4).
A measure of the ethical inarticulacy of clinicians as a group was the lack of any apparent commentary or expression of concern from Irish postgraduate medical colleges, or other professional bodies for standards and training in healthcare, as to the content, process or anonymity of these documents which had the potential for a significant impact on practice and outcomes.
Clinical ethics is field which has developed considerably over several decades, acquiring sophistication and nuance to a degree comparable to other disciplines, yet rarely featuring as an element in CPD/CME (6), with the emphasis on ethics in undergraduate medical education not replicated during clinical working life(7).
This creates a major challenge for engaging with policy and practice, posing a challenge not only to meaningful engagement with non-clinician ethicists in clinical ethics committees, but also to furthering a discourse as to the cultural and clinical appropriateness of this form of consultation process (8).
If doctors do not develop an articulacy in ethics through an emphasis on incorporating the discipline into CPD/CME to an extent comparable with other evolving aspects of medical care (9), they run the risk of becoming unequal partners the challenge of developing appropriate ethical frameworks for optimal care of patients and fostering due congruence between ethics and clinical practice.
1. Fritz Z, Huxtable R, Ives J, Paton A, Slowther AM, Wilkinson D. Ethical road map through the covid-19 pandemic. BMJ. 2020;369:m2033.
2. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine. 2020.
3. Emanuel EJ. Why I hope to die at 75. The Atlantic. 2014;17.
4. Department of Health. Ethical Considerations Relating to Long-Term Residential Care Facilities in the context of COVID-19. Dublin: Department of Health; 2020 4 June 2020.
5. Department of Health. Ethical Framework for Decision-Making in a Pandemic. Dublin: Department of Health; 2020.
6. Kenny N, Sargeant J, Allen M. Lifelong learning in ethical practice: a challenge for continuing medical education. J Contin Educ Health Prof. 2001;21(1):24-32.
7. O'Neill D, Kelly B, O'Keeffe S, Moss H. Mainstreaming medical humanities in continuing professional development and postgraduate training. Clinical medicine (London, England). 2020;20(2):208-11.
8. Whitehead JM, Sokol DK, Bowman D, Sedgwick P. Consultation activities of clinical ethics committees in the United Kingdom: an empirical study and wake-up call. Postgrad Med J. 2009;85(1007):451-4.
9. Russell C, O'Neill D. Developing an ethics of competence, care, and communication. Ir Med J. 2009;102(3):69-70.
Competing interests: Chair of Working Group advising on developing Clinical Updates in Medical Humanities and Ethics for the Royal College of Physicians of Ireland
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.
Competing interests: No competing interests
The development of an ethical plan for national strategy, the formal implementation of such ethical guidance and research to guide its formulation could only be of great help. That said, the scope of this must be debated. Although it would be possible to develop such a strategy for healthcare decisions, the integration of this into the field of population policy may be met with more hesitancy. Although ethical guidance may advise policymakers, this guidance is unlikely to have a smooth transition into implementation. This is especially the case in a climate where health concerns are being pitted against economic forecasts (the UK experienced a 35% fall in GDP in the second quarter of 2020), while it is unclear where public opinion lies. An independent body researching how to weigh up such decisions may find its guidance overlooked by government, yet may be of great support for policy makers, and ought to be supported whole-heartedly.
 ‘Coronavirus analysis’, Office for Budget Responsibility. https://obr.uk/coronavirus-analysis/ (accessed May 25, 2020).
Competing interests: No competing interests