How should patients presenting with Covid-19 be prioritised if there is a lack of ITU beds or ventilators? What is a doctor’s duty to treat when that individual may be in a high-risk category? When should a family member be allowed to visit a patient on a ward or a person in a residential care home? …
There were many such questions being posed in the media, by our citizens and by local clinicians, particularly in the early days of the pandemic. Surrey Heartlands responded by looking at the ethical issues raised on a whole system basis.
Writing a Surrey Heartlands Ethical Framework for decisions
The first step was to ensure we had the right ethical framework and ethical support in place for those working on the front line and facing difficult clinical decisions. Adapting a framework developed in the London system, a small team quickly put together an Ethical Framework Document[i]. This, scoped around firm ethical principles, guides clinicians through the decision-making process, offering an appropriate best practice approach across our system and setting out the support available.
Although initiated as a response to the pandemic, the framework is not limited to the ethical challenges of Covid-19 and has potential application to any difficult clinical decisions that the system might be faced with. The Framework will continue to evolve as we work through new challenges.
Creating a Surrey Heartlands Clinical Ethics Committee
An Integrated Care System Clinical Ethics Committee (ICS CEC) was established in April 2020. From Surrey Heartlands its members include: the medical director or other senior clinician of each of our four acute hospitals and our mental health provider, a representative for Surrey County Council social care, a Palliative Care Consultant with Princess Alice Hospice, the CCG Chair providing the primary care perspective, the ICS Medical Director, Dr Mark Hamilton, as Deputy Chair, and myself Jonathan Perkins as the Lay Chair.
We also felt we needed wider perspectives on clinical ethics and subsequently invited an academic ethicist, Professor Ann Gallagher of the University of Surrey. We were also joined by the Chair of Healthwatch Surrey to provide a patient viewpoint.
At the height of the pandemic the committee was meeting on a weekly basis. This subsequently reduced to fortnightly and meetings now take place monthly to reflect the fact that a framework and a network of supportive relationships is in place.
Defining our ethical principles
What ethical principles do we apply? We decided that our overall goal should be: To achieve the most for the most and to do so with transparent, consistent and equitable decision-making support.
We then defined the ethical principles to be applied as follows:
- Equal Respect: Equal need should be treated equally. Unequal need must be treated unequally. Equity does not mean every patient is treated equally, as needs differ; though people have an equal chance of access to clinical resources according to the nature of their need / their likelihood to derive benefit.
- Fairness: Equal need will not always be able to access equal treatment when rationing limited resources; where resources are insufficient and if facing an equivalence of need, this forces an impossible choice, in line with appropriate best practice an unbiased and pre-agreed allocation process may be needed as a default guide to clinicians. A possible positive variance occurs where the equal need includes a health care worker, where ’the greater good’ / utilitarian argument favours preferential treatment (e.g. allowing front line staff to continue to care for others, payback for dangerous work, staff morale); however, this decision would need to be balanced against other ethical principles (e.g. duty-based and virtue ethics) and will require broader, non-healthcare-based endorsement, as any decision made by a body of health care workers about preferential treatment for health care workers would potentially not be deemed acceptable.
- Duty to care – Fundamental obligation of healthcare providers to provide appropriate care for patients. This incorporates the concept of both beneficence and non-maleficence (i.e. doing and promoting good and preventing and removing harm respectively). Clinicians will consider whether the treatment proposed has a reasonable chance of being successful weighing this against the need to avoid subjecting patients to invasive and resource-intensive treatments where, if the prospect of benefit is limited, such treatments would unlikely to be wanted (informed refusal), could cause net harm to individual patients (to mean that unfortunately we cannot offer it) and / or it may represent too high an opportunity cost (to jeopardise the care of too many other patients) such that at that point we are not able to offer it.
- Fair resource stewardship – A plan for resource allocation, to support the decision-making of front-line providers who “already bear a disproportionate burden in an emergency” by providing appropriate resources and represents a responsibility to both patients and health care staff.
- Fair allocation of resources – The socially just allocation of resources. Applying appropriate best practice in order to maximise the benefit to all patients and society, while emphasising equality, fairness and impartiality in the allocation of the available resources at any given point.
- Transparency – Robust efforts to promote transparency are important and require broad input (i.e. internally and externally representative) and parallel public education / involvement and communication to foster shared understanding. Importantly best practice must reflect respect for patient autonomy and shared decision-making whenever possible.
What ethical issues have we considered?
As the questions set out at the start of this article indicate, there are a wide range of ethical considerations which arise from the pandemic. The issues considered also have shifted as the response in Surrey (and nationally) became more mature (e.g. as availability of PPE became less of a concern more focus was on the wider impacts on healthcare workers and the need for individual risk assessments).
As well as keeping the Ethical Framework Document up-to-date, other examples of the ICS CEC’s work include the following issues:
- The equitable and clinically appropriate distribution of PPE across Surrey should a shortage in stock occur;
- How should cancer surgery be maintained during the initial weeks of the pandemic?;
- The application of visiting restrictions in different settings;
- Reviewing the Surrey Local Outbreak Plan; and
- Reviewing the impact of national policies relating to Covid-19;
It should be stressed that the committee’s role is not to draft policy or to take operational decisions. It exists to bring senior clinicians and others together to consider the impact of policies on our staff and patients, and to try to help the system make decisions which are ethically sound. There are Local Ethics Committees within provider organisations and each ICP to consider issues for that place, which may include specific issues for patients and staff. Primary care is also now involved in these local committees. Where the Chairs of these local committees consider an issue is relevant across the system, such issues can then be brought to the ICS CEC.
Substantive discussion and adding to the international debate
Ethical issues are, by their nature, not capable of easy solutions. There can be a number of opinions and heathy discussion. Sometimes this can lead to providing our views to a wider audience than just in Surrey.
One of the issues we considered in great depth is the duty of care to patients requiring resuscitation in circumstances where the appropriate PPE might not be available. The committee considered national guidance from regulators and professional bodies which did not agree in all respects. It also analysed a BMJ Blog in May 2020 on the theme of ‘The duty to treat: where do the limits lie?’. [ii]
This situation regarding resuscitation led the ICS CEC to consider ethical aspects of healthcare professionals’ responses to the need for resuscitation during Covid-19. Members agreed that professionals should, ideally, have the level of PPE required for an aerosol generating procedure. However, there was no consensus regarding professionals’ duty to care when this is not available. On the one hand, it was agreed that the casualty/patient’s interests regarding resuscitation should be prioritised due to professionals’ contract with the public and professional privilege. On the other hand, risk thresholds during the pandemic were perceived as relevant to individual decision-making and professionals’ duty to care.
All agreed that decision-making should not be influenced by rewards or reprimands which could follow from resuscitation attempts or refusals to resuscitate. It was agreed also that decisions to resuscitate should not be considered as moral heroism or supererogatory (that is doing something which exceeds what is expected or required) – regardless of PPE availability – but rather as ‘minimally decent’. We agree that it may be acceptable for professionals, with good reasons, to opt out of resuscitation attempts and these should be reflected on and discussed before the event.
We summarised our views in an article “Resuscitation During the Pandemic: Optional Obligation? or Supererogation?” published in July 2020 in Clinical Ethics Journal.[iii]
What next for the Ethics committee?
The ICS Clinical Ethics Committee will continue with its work looking at system issues. Two of our number are also members of the South East Region Ethics Committee and are therefore able to contribute at this level as well. As our services in Surrey Heartlands are stepped back up with our Restoration and Recovery work and as we look towards winter pressures and immunisation programmes, there will no doubt be plenty to consider.
For anyone who would like to refresh their knowledge of clinical ethics, or (like myself), wants to understand some of the techniques involved for the first time, there is an excellent free online course on Ethical Decision-making in Care, designed by Surrey University and led by Professor Ann Gallagher on the Future Learn Platform.[iv] Date of the next run of the course to be announced.
Lay Chair, Surrey Heartlands ICS Clinical Ethics Committee and Lay Member and Deputy Chair Surrey Heartlands CCG
[i] This document is available on the Surrey Heartlands website here: https://www.surreyheartlands.uk/about/ethical-framework/
[ii] Sheather J. and Chisholm J. (2020) BMJ Blog ‘The duty to treat: where do the limits lie?’ https://blogs.bmj.com/bmj/2020/05/12/the-duty-to-treat-where-do-the-limits-lie/
[iii] Resuscitation during the pandemic: Optional obligation? or supererogation? Clinical Ethics Journal, first published 30th July 2020, Authors: Jonathan Perkins, Mark Hamilton, Charlotte Canniff, Craig Gannon, Marianne Illsley, Paul Murray, Kate Scribbins, Martin Stockwell, Justin Wilson and Ann Gallagher.https://journals.sagepub.com/doi/full/10.1177/1477750920946684
iv] Ethical Decision-Making in Care, Future Learn https://www.futurelearn.com/courses/ethical-decision-making-in-care2