Dr. Pippa Moss reflects on the unique ethical considerations that may arise in a pandemic.
As physicians, our primary duty is to the patient. We value autonomy, to the point of having substitute decision makers defined for situations where a patient loses the capacity to make their own decisions. A physician is trained to put the patient first.
A pandemic changes that. A utilitarian approach is often taken - ensuring the best possible outcome for the most people. An example of this is expecting a physician to don PPE before going to resuscitate a patient who has a cardiac event, even though the delay reduces the chance of that patient surviving. It is not that the physician as an individual is worth more than the patient in question, but rather the role that the physician fulfills within the medical team, and for society as a whole, is worth preserving. There may be times when it is not appropriate to do CPR because of the risk to the medical team and the subsequent risk to the health care system.
Rationing some medical equipment for defined sections of the population makes sense. For example, most people would agree with the principal that face masks, when in short supply, should be allocated to professionals such as doctors, nurses ambulance crew etc. rather than being simply sold to the most wealthy. On the other hand, prioritizing access to a ventilator to a medical professional only makes sense if that professional is expected to return to health and be able to resume their role within the time frame of the epidemic and ongoing societal need for that role. It is not the individuals inherent value that is taken into account, but their instrumental value - their role in preventing societal disintegration and maintaining societal health.
In making decisions about allocation of resources many societies also take into account the life cycle principal, ensuring equal ability for any individual to experience the various stages of life. This would tend to prioritize allocation of resources to the younger members of society who have not yet had the opportunity to experience life in its fullness.
Ideally a multi-system approach would be taken with public input, when defining our decision making algorithms. Canada is one of the countries where we do have means for public input and to some extent this was done during the last SARs outbreak and for H1N1. The decision algorithms that have been supplied are there for the protection of your health care teams and resources, so that we can care for the most patients and have the best outcomes overall for our community.
Have concerns about an ethics issue? Reference resources are available at: http://www.nshen.ca/index.php/covid-19-resources/
For informal or formal clinical or organizational ethics support during the COVID-19 pandemic, physicians can contact both Ethics NSHA and the Nova Scotia Health Ethics Network (NSHEN) by e-mailing or calling Lisbeth Wittoefft at czethics@nshealth.ca or 902.473.1564.
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