The many ethical dilemmas confronting healthcare workers – including triaging, moral distress and unrealistic public expectations – under the spotlight at the 16th annual International Conference on Clinical Ethics and Consultation (ICCEC), just held in South Africa.
Chris Bateman writes:
The conference, hosted by the Stellenbosch University Centre for Medical Ethics and Law, featured seamless cyber-streamed and in-person expert speakers, thus overcoming last-minute travel Omicron virus restrictions imposed on travellers to South Africa. Some 70 delegates attended in person, with 250 registered on the virtual platform. It was the second attempt at hosting it after a COVID surge forced its cancellation in April last year.
Dr Nida Shamsi, a family medicine consultant in Pakistan, presented cases of patients admitted to hospital suffering from various non-COVID conditions a few days before the pandemic was declared a health emergency. CT scans and biopsies were cancelled due to the sudden flood of COVID admissions, and patients had to be discharged prematurely. In response to one such fatal case she said: “It was a big blow to the clinicians who brought it to the Clinical Ethics Committee (CEC) for discussion, one of many such cases involving justice and equity between COVID and non-COVID patients. Is restricting medical care to non-COVID patients medically and ethically sustainable in the long run?” she challenged her peers.
Shamsi said COVID-19 posed “formidable and unprecedented” challenges to resources, medical equipment, diagnoses, therapeutics and work shifts, the work environment and continuity of care, besides causing moral distress to healthcare staff.
Dr Janine de Snoo-Trimp, a post-doctoral researcher on Ethics Support at Amsterdam's Vrije Universiteit, said determining what was “futile care” for each patient depended on the personal values and experience of the healthcare giver, with each decision a balance between the individual and the collective. Non-medical value judgments were made about the patient’s quality of life and what was an acceptable threshold for the chances of recovery. While COVID fundamentally changed the "normal" hospital situation, patients should ideally all be treated identically, although with COVID-19, “the collective weighs a little more”, she said.
In a presentation entitled, “Comrades in arms in the COVID War,” Dr Shannon Odell, a palliative medicine specialist and GP in Cape Town, said world leaders and the media used “unhelpful” war metaphors to describe the pandemic. “From Trump declaring himself a ‘wartime president’ to France talking about ‘general mobilisation,’ and even Time Magazine using war metaphors, they framed the context for how we think about COVID, influencing emotions, behaviour, and perhaps even ethical thinking. This justifies exceptional measures, with some like Trump even extending it to construct enemies by talking about 'the Chinese virus'.”
While initially conveying urgency and perhaps boosting morale and resilience in preparing for hard times, war talk led to the curtailing of liberty and free speech while healthcare workers were described as “soldiers redeployed to the front line”, military language totally foreign to them, confusing duty with consent.
Odell displayed a World War 2 picture of a helmeted soldier, captioned, “How my grandfather saved the world”, juxtaposed with a young man slouched on a couch at home during lockdown, entitled, “How I saved the world”. Ironically Germany proved the exception to this global war talk, its chancellor, Angela Merkel talking instead about COVID being, “a test of our humanity”.
Odell said war-talk inferred casualties and “bad deaths” (as opposed to compassionate palliative care), while those breaking social distancing were labelled “traitors and deserters”. Some burnt out doctors were even refusing to see unvaccinated patients, all of which left the war metaphor, “falling rather flat”. She added: “We can’t adopt military ethics for triage because it differs hugely, prioritising patients according to country of origin, military status or their ‘value’ .”
In a war, treatment priority was given to “comrades”, while nationalism was currently being used to justify grossly unequal vaccine distribution. “It’s paternalistic and authoritarian. War talk involves anxiety, stigmatisation and endorses the legitimacy of political violence with false promises of victory and the oversimplification of complex issues. It can also lead to xenophobic nationalism. South Africa mercifully avoided this, our political and scientific leaders using the metaphor of a veldt fire and talking about ubuntu. We cannot emerge from this stronger and healthier if our neighbours do not emerge strong and healthy,” she added.
Fielding questions later, she challenged the widespread practice of calling healthcare workers “heroes”, questioning whether it had not put more pressure on them to perform in often impossible circumstances with government lauding them instead of providing a more supportive policy framework.
Professor Valerye Milleson, manager of Clinical Ethics in Ascension St Thomas Hospital in Nashville, Tennessee, described moral trauma as “acts that transgress deeply held moral believes and expectations”, saying COVID was accelerating burnout among healthcare workers. She cited pre-pandemic figures showing that up to 45% of nurses suffered from moral distress. Since COVID however, associated conditions such as anxiety, burnout, insomnia and post-traumatic stress disorder (PSTD) had soared.
“We have a professional duty to protect ourselves – the impact of COVID-19 on healthcare workers is an identifiable threat to patient safety – nobody can be expected to do the impossible,” she added.
Addressing the tension between individual liberty and population health benefits, Dereck Soled, Advisor, Special Operations Team at New York City’s Department of Health and Mental Hygiene, said physicians had to obtain informed consent before any medical intervention, especially when a patient insisted on treatment a physician did not believe was valid.
“Individual decision-making can be steered without coercion, and you can nudge them in the right medical direction. How you frame the choices will ultimately affect what the patient decides and influence the outcome,” he advised. He said one analysis he conducted concluded that physicians did infringe on individual liberties, despite limitations, but were ethically justified in subtly manipulating patient choice when there was a “clear public health benefit”.
A lively debate ensued with delegates raising questions and proposing alternate views on the various topics under discussion.
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