COVID-19: nursing in a pandemic and how to apply ethical decision-making in practice
A respiratory nurse and an ethics in care professor discuss how nurses can approach ethical dilemmas
I am a nurse working in a respiratory ward, and a PhD student. Like other nurses, I am anticipating the consequences of an increased number of patients with COVID-19.
I have a longstanding interest in ethics and was keen to discuss how to prepare for the ethical challenges that will arise. Here, I pose some questions to Ann Gallagher, professor of ethics and care at the University of Surrey.
What might it mean for nurses to be prepared for ethical decision-making?
Ann Gallagher (AG): Nurses and other healthcare professionals make ethical decisions every day and are accountable for them, having to provide reasons for their actions and omissions. For example, should I always tell the truth to patients? Ought I withhold information that may cause distress to patients and/or families? Might it be acceptable to share confidential patient information when a relative phones to enquire about a patient’s diagnosis or prognosis? How should I allocate my time when busy?
Such questions are ethical in nature and nurses have resources to draw on to help think about and prioritise the values and evidence that will help them make decisions they can justify.
Nurses need to be reflective and morally resilient in the values they profess, and as far as possible, identify the values that underpin their practice and enact them. This means ‘walking the talk’ and this can be difficult.
Moral preparedness involves being able to think well, drawing on ethical values and decision-making frameworks to underpin arguments. This enables nurses to participate confidently and competently in ethical decision-making in their everyday practice.
What ethical decisions will have to be made during a pandemic?
AG: Some of the issues I’ve mentioned will relate to decisions to be made during a pandemic. However, there are many others.
We are in new territory with COVID-19. It is a global emergency, spreading across continents and cultures, causing illness and death with no vaccine yet. New ethical issues relating to public health are familiar to all of us as a result of the lockdown. Ethics is not an optional extra and the preserve of professionals, it’s a matter for everyone. Each of us is aware that slowing the spread of COVID-19 requires individual restraint.
That said, it is nurses and other healthcare practitioners who are engaged in challenging decision-making.
What ethical challenges are likely to arise?
AG: The main one will be balancing limited resources with increasing need, for example in the matter of insufficient ventilators or, as Georgina Morley points out in her helpful nursing ethics blog, not only ventilators but staffing and clinical competence to support them. A central question is: ‘Who gets what resource? And why?’
There are three key components of ethical decision-making about the allocation of scarce resources, such as ventilators. These are consensus, clarity and communication:
1. Consensus must be reached about the ethical values that underpin decision-making
There is general agreement that these values include:
- Respecting people’s choices as far as possible and ensuring information about treatment and care options is available.
- Balancing values of minimising harm (non-maleficence) and doing good (beneficence), including weighing benefits and harms of different interventions.
Values of minimising harm and doing good are central to decision-making when resources are limited. These include saving lives where possible and ensuring treatment is allocated on the basis of a patient’s ‘capacity to benefit quickly’. Doing good involves ensuring nurses fulfil their duty of care including when recovery is not possible and also that organisations fulfil their duty of care to protect staff.
Nurses are best placed to provide compassionate care and to comfort patients and families.
The value of solidarity is also important: we are in this together and gain by helping each other, working together and learning from each other across cultures.
2. There needs to be clarity about the decision-making process
It is agreed this needs to be open, transparent and fair. Experienced clinicians will make decisions about the allocation of scarce resources, in collaboration with nurses and other professionals. Some organisations have ethics committees or advisory groups to help with challenging decision-making, for example, where there is disagreement between professionals and families.
3. Communicate the decision-making rationale
To increase trust and demystify ethical decision-making, the underpinning values and process need to be communicated to the multiprofessional team and, as appropriate to patients, families and communities.
Nurses should check local approaches to ethical decision-making in relation to each of these components.
Clinicians are already trained for ethical decision-making, so what makes the COVID-19 pandemic special?
AG: There is likely to be wide variation in competence and confidence in ethical decision-making across the UK. Some universities, like our own University of Surrey, put a lot of focus on ethical decision-making for nursing and paramedic undergraduates.
What makes now special is that some ethical questions become much more pressing. It has always been the case that some resources are rationed, but the possibility that patients with COVID-19 will not receive what they need is of great concern.
Also, as you know, there is much discussion about the need for personal protective equipment (PPE) and ethical questions arise again: ‘Who gets what? And why?’
These are important questions and need to be considered locally. However, there is an abundance of resources available to assist with pandemic ethical decision-making (see resources).
At Surrey we pioneered a MOOC (massive open online course) with FutureLearn on the theme of ‘ethical decision-making in care’ and the next run of that will be in April 2020. That run of the course will have a section on ethical decision-making during a pandemic.
What resources are available to help nurses weigh the ethical considerations that this pandemic presents?
AG: Professional codes continue to provide sound ethical guidance and there is guidance specific to global health emergencies that is particularly helpful (see resources).
What else can we do to promote ethical preparedness for practising nursing during a pandemic?
AG: The clinical ethics network has guidance on setting up an ethics committee quickly, where no such committee exists, to assist with drawing up policies and to offer ethics support to practitioners and managers.
Nurses can help each other – and other professionals – by remaining calm and holding firm to their professional values, while reflecting on those that are the most critical to prioritise now.
What can we learn from history?
AG: We tend to forget past events and the ways exemplary figures coped. I was reading about the Crimean War activities of Florence Nightingale recently and was reminded of her role in managing uncertainty, building evidence, holding fast to care values and being resilient in the face of enormous challenges.
Finally, what are your views of the ethical preparedness of policy and political decision-makers?
AG: There are, as you know, a wide range of stakeholders and experts involved in discussions about COVID-19 and I’ve been struck by the humility of saying ‘we don’t know’.
This is a time, overall, when we need to hold firm to our values, and challenge practice we consider unethical, while engaging with emerging evidence. There has never been a time when care and kindness to each other mattered more and I am proud to say nurses are ahead when it comes to this.
Duncan Hamilton is a respiratory nurse and PhD student examining the role of Schwartz rounds in supporting professionals
Ann Gallagher is a nurse and professor of ethics and care at the University of Surrey and author of Slow Ethics and the Art of Care
Resources for ethical decision-making during a pandemic
- British Medical Association COVID-19 information
- Georgina Morley blog
- National Institute for Health and Care Excellence COVID-19 information and guidance
- Nuffield Council on Bioethics COVID-19 ethics resources
- Nursing and Midwifery Council COVID-19 temporary registration
- Pandemic influenza preparedness: an ethical framework to guide decision-making
- RCN COVID-19 (coronavirus) resources
- Swiss Medical Weekly guidance for ‘triage for intensive-care treatment under resource scarcity’
- The Hastings Center ethical framework and guidelines
- University of Surrey MOOC