Healthcare Ethics During a Pandemic

Xavier Symons is a Lecturer in the Institute for Ethics and Society at the University of Notre Dame Australia. He will be completing his 2020 Fulbright Future Postdoctoral Scholarship at the Kennedy Institute for Ethics, Georgetown University. He recently completed a PhD on the ethics of healthcare resource allocation.

How has COVID-19 affected your day-to-day life?

The COVID-19 pandemic has led to some fairly radical changes in my life. Last month I had to self-isolate for two weeks after returning from a trip to Oxford, and, like most people, I’m now working from home. I work for a research institute at the University of Notre Dame, and we’ve had to completely readjust our 2020 calendar. As part of my work, I organise regular seminars on ethics in social and professional life. Most of our upcoming events, however, have been postponed or cancelled. There’s even a possibility that I may have to delay the start date of my residency at the KIE. I’m slowly adjusting to several hours a day of teleconferences, and getting used to instant coffee rather than heading to my favorite cafes.

But perhaps there’s a silver lining to the solitude of the current situation. I’m an ethicist with a background in moral philosophy. And many of the great philosophers wrote their best work while on retreat in the countryside or in front of the fireplace at home. Who knows, maybe the next few months may be more productive than I’m anticipating.

What are some of the ethical challenges that decision-makers could face in the coming months? Culturally-speaking, how does Australia typically respond to these challenges?

Ethics is always relevant to life, even when it’s business as usual. But ethical reflection is particularly important during a crisis such as the current COVID-19 pandemic.

One issue that I’ve written about recently is the ethics of healthcare resource allocation during a pandemic. ICU physicians in countries like Italy, France, the UK and the US are being forced to ration precious resources like ventilators as their wards are overwhelmed by critically ill coronavirus patients. These rationing decisions raise a number of complex ethical questions. For example: Is it permissible to ration health care on the basis of age? How can we obtain maximal benefit from healthcare resources while not discriminating against people with disabilities? And should people with important social and political roles (such as healthcare workers and politicians) receive priority access to scarce resources?

Rather than having to face these agonising ethical questions, Australian authorities have sought to “flatten the curve” through aggressive social distancing measures. Current modelling suggests that this strategy is working.

Culturally, I think that Australia’s response to the pandemic reflects a sense of solidarity with society’s most vulnerable. State and Federal Governments have made minimising loss of life their primary priority. I think this is a laudable approach, and one that gives due importance to the value of each human life.

It’s also important to note that the risk of burnout for clinicians is heightened in a time of crisis, and so healthcare professionals must be given adequate time off during the coming months. Patients are put at risk when they are being treated by a clinician who is on the verge of a breakdown. In this sense, burnout and fatigue become ethical issues.

In your recent ABC interview, you spoke about the ethical issues surrounding critical healthcare rationing during public health crises, and concerns over a fundamental shift in how decisions are made regarding emergency medicine following the end of this pandemic. Can you briefly explain your concerns?

The area of resource allocation ethics has come into sharp focus in the current crisis. New guidance for the COVID-19 pandemic was recently published by the Australian and New Zealand Intensive Care Society and the Australasian College for Emergency Medicine. These documents, however, are fairly general, and leave scope for individual ED and ICU departments to decide how they will assess and triage patients. Fortunately, new government modelling suggests that we may not face the surge in hospital admissions that was originally expected.

Like many ethicists, I think we need to take a balanced approach to resource allocation. I don’t want to be alarmist, but I do think there’s a risk in adopting an avowedly utilitarian approach to healthcare rationing. Guidelines recently published by the Italian Society for Anesthesia, Analgesia, Resuscitation and Intensive Care, for example, focus not just on the possibility that someone will survive the coronavirus, but also on someone’s overall life expectancy. Yet an approach like this will be to the disadvantage of persons with a life-limiting disability, as well as older persons. We should, therefore, be cautious about including long-term life expectancy as criterion for rationing in our official guidelines.

Some governments have said that they may extend the current COVID-19 lockdown for several months until a vaccine is available. Other health analysts have suggested an alternative herd immunity strategy which would allow for an easing of social distancing measures, albeit with much higher rates of infection. What do you think of these competing strategies?

Several commentators have published articles recently arguing for implementation of a herd immunity strategy for managing the coronavirus. Herd immunity is a term usually used in the context of child vaccination for diseases like measles. When a sufficient number of children have been vaccinated for a disease, this provides a degree of protection for those persons who are unable to be vaccinated. In the context of the coronavirus, some people have argued that governments should ease social distancing measures and allow the virus to spread in the community, while ensuring that those who are most vulnerable (such as older people and people with disabilities) remain isolated.

It’s stimulating to read different perspectives on the aggressive social distancing measures that governments are enforcing around Australia. But in the end, I fear that a herd immunity strategy would have disastrous consequences. Epidemiologists estimate that approximately 60% of the Australian population would need to contract the virus before we achieve herd immunity. This would include massive rates of hospitalisation and also a very high death rate. Despite the economic benefits that may come with easing the social distancing measures, and I’m not sure this is a wise approach all things considered.