‘What are the healthcare ethics in a global crisis?’

With the limited health care resoures and that too in the case of unprecedented demands (COVID-19), the decision making authorities face challenges in healthcare ethics.

It is imperative to understand the healthcare ethics and its importance in dealing with difficult crisis.

• There are more than 150 COVID-19 vaccines currently in development and an estimated 10 billion vaccine doses eventually will be delivered around the globe. 
• Now, at this critical juncture of global vaccine shipping, healthcare ethics has taken the centre stage. 
• All healthcare resources are limited – staff, equipment, drugs, space and time can all run out.
• Decisions about the use and allocation of scarce resources are regularly made in medicine. These usually proceed on the basis of those with the greatest medical need being given priority.
• But the way these allocation decisions are made in crisis situations differs.
• The current unprecedented health crisis is testing our ability to make appropriate choices and health decisions.
• These decisions are not limited to an individual but have an all-encompassing influence on the broader population. Therefore, these health decisions have to be moral and ethics based.

The ethical dilemma

From resource allocation and priority-setting, physical distancing, public health surveillance, health-care worker's rights and obligations to conduct of clinical trials, the COVID-19 pandemic presents serious ethical challenges.

• Prioritizing people over people: Decisions on how to allocatesuch limited resources are made in the full knowledge that hospital staff must prioritise some people over others – and that not all lives will be saved.
  • Decisions will likely be simplistic – such as
    • age of the patient
    • health conditions
  • Concerns regarding end-of-life support: Furthermore, the crisis raises ethical concerns not only surrounding triage and withdrawal of life support decisions, but also regarding family visits and quality of end-of-life support.
  • Risk of ‘sacrificing’ vulnerable patients: Faced with a massive influx of patients and extreme scarcity of ICU beds, the risk of “sacrificing the most vulnerable patients” shakes ethical convictions. 
  • Discrimination: It could lead to disadvantaged groups being systematically discriminated against.
  • Disposal of dead bodies: Disposal of dead bodies is a big concern.

What are the challenges faced?

• Maximum number of people or greatest number of years: It might be interpreted as simply the number of people saved or it might be interpreted as the greatest number of years of life saved. And if maximising the number of people whose lives are saved is the overarching ethical goal, governments and medical staff need to establish how this is best achieved.
• Ventilator occupancy: Lifesaving ventilation is offered on a basis of prioritising those who will be most likely to survive as a result of the intervention. This may also be combined with the likely speed of their recovery – as this would free up ventilators for others sooner. This combination reflects the ethical goal by offering the highest probability that the greatest number of lives will be saved overall.
• Discrimination against disadvantaged group: But in high-pressure situations, any such approach will likely be simplistic – such as an algorithm based on the age of the patient and any health conditions. This could lead to disadvantaged groups being systematically discriminated against.
  • The elderly and those with underlying health conditions, for example, could be unprioritised because they will be less likely to survive or take longer to recover.
  • Even if additional considerations are added to the process – such as the potential quality of life or subsequent length of a person’s life – these groups are likely to fare badly.
• Healthcare workers: There is an ethical consensus that healthcare workers have a prima facieduty to work. However, the obligation of healthcare workers to show up for their jobs is not absolute.
• Males over females?: Another major ethical challenge revolves around gender. Males have been found to be at a greater risk of progressing to severe disease and even dying compared with females.

Why evaluation of ethics is important?

• Ethics is shaped based on the ingraining of values in subjects and the society in which they are inserted, and, from this set, each one proposes their actions.
• That being said, it is necessary to valuate to intervene.
• It is worth noting that the medical field assigns a different value to life, according to age, providing distinct care to children, adults, and the elderly.
• From this perspective, the ethical values necessary to ration healthcare resources in an epidemic have high prestige.
• It can converge into some proposals based on fundamental values, such as
  • maximizing the benefits produced by scarce resources
  • treating people equitably
  • promoting and recommending instrumental values
  • giving priority to critical situations

What needs to be done?

• Positive discrimination: Strict adherence to the overarching moral goal of maximising lives saved might also require aspects of positive discrimination. If, for example, the patient is a highly-skilled, older medic, then prioritising them might result in more lives overall being saved.
• Maximize benefits: The priority of limited resources should aim at saving as many lives as possible and maximizing improvements throughout life post-treatment. This premise is consistent both in the perspective of utilitarian and non-utilitarian ethics.
• Privacy: There has to be a balance between protecting a person’s right versus safeguarding public interests.
• Clear ethical basis: When it comes to life and death prioritisation, to be justifiable, these decisions must be made from a clear ethical basis.
• Fair distribution/allocation of resources: Hospitals must consider how they can distribute the resources they have fairly.
• Effective evaluation of gaps and challenges: Given the economic, societal, and operational ramifications of the COVID-19 pandemic, healthcare leaders should consider which aspects of their business models are resilient and which will face challenges as value pools shift. 
• Innovation: The high human and economic costs associated with COVID-19 make it essential to rapidly accelerate and scale medical innovations, while ensuring that patient safety and quality of care remain central. 

Conclusion

Both government and healthcare workers need to be open, public and clear about the basis of selective prioritisation. It also needs to be made clear that criteria will be revisable as information and situations change. Such an approach would also need to be systematically enforced – so that universal and applied to all. Without such clarity and fairness, confidence, trust, solidarity and support for health systems would become irreparably damaged in the longer term.