Intended for healthcare professionals

Letters Feeling safe working on front line

Covid-19: Difficult decisions require reciprocal understanding among decision makers

BMJ 2021; 372 doi: (Published 22 February 2021) Cite this as: BMJ 2021;372:n462
  1. Woody Caan, retired professor of public health
  1. Duxford CB22 4PA, UK
  1. wcaan{at}

Ethical practice is certainly challenging “in an almost impossible position.”1 When rationing care in an out-of-control pandemic, individual clinicians might decide to provide or withhold care from an individual patient. This might be based on their clinical judgment about which patients will benefit most from a scarce resource, but people under pressure tend to show their unconscious biases (such as investing less care in older people or in people with learning disabilities).234

Younger readers might be surprised to learn that treatment “contracts” between clinicians and patients, with explicit treatment aims, used to be encouraged. This was based on the assumption that a therapeutic alliance was improved by writing down the aims of treatment and often the targets that should be achieved. In one cancer service I evaluated, the dedicated, caring, and all female nursing team supported many women to achieve their aims, but no male patient achieved a single chosen aim over two years. The team was unaware and truly shocked at this finding.

Public health experience across patient populations can shape guidelines and decision aids. My favourite approach, across hospital and community settings, was having a health benefit group5 to plan a range of linked services and share out resources—in “commissioning for outcomes,” for example. But clinicians in acute settings were very reluctant to accept epidemiological approaches that included groups of patients that they, personally, never saw. Looking back, I think that lack of trust might have been related to the different ethics of caring for individual patients and planning for populations with health needs.

In 2021, the more difficult the choices that need to be made, the more important it will be to have reciprocal understanding among the decision makers: in healthcare management, in clinical teams, and in population health.


  • Member of the Faculty of Public Health special interest group for ethics.

  • Competing interests: I used to include professional ethics in my public health training and used to be a learning disability champion.

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