Marika Warren outlines roles health care ethicists can play in pandemic preparation, response, and recovery

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There is no shortage of incredibly difficult ethical questions arising as health care systems around the world respond to the COVID-19 pandemic. It seems reasonable to assume that when health ethics questions arise, individuals who have expertise as ethicists in health care settings should have answers to those questions.  But the role of health care ethicists is to provide support, not answers – so how can they do that in a pandemic?

Ethicists can best contribute during a pandemic by working to minimize the number of difficult choices health care providers must make and ensuring that when they’re made it’s for the right reasons. This means that the primary role for ethicists is in the process of preparing a pandemic response. By the time dilemmas arise during a crisis, it is often too late for ethicists’ efforts to have widespread benefit. There are nonetheless some unique contributions ethicists can make during a pandemic, and once the crisis has passed there are important opportunities for reflection, analysis, and learning.

The work emerging out of the experience of SARS in Toronto and responses to COVID-19 in other countries suggest that ethicists should focus on early involvement to articulate relevant procedural and substantive values and embed these into response plans. In addition to planning, there’s crucial work to be done in building ethics capacity and developing tools and frameworks that will help health care providers live with the decisions they will face. 

Photo credit: TheDigitalArtist. Image Description: A purple image of a COVID-19 virus.

Evidence from SARS and the 2009 H1N1 pandemic indicates that health care providers want to know that ethical questions have been considered and that the actions they’re taking are ethically defensible in the situation. Ethicists can convey how values have been translated into guidance, supporting health care providers as well as members of the public by identifying the relevant values and principles that will guide responses. They can also explain shifts in how various values are balanced against each other, with increased emphasis on values such as solidarity, the precautionary principle, reciprocity, and least restrictive means.

By engaging ethicists in planning, health care systems can ensure that procedural values are embedded in response plans and that fairness is achieved by identifying relevant substantive values that should be applied in decision making. Involvement in planning capitalizes on ethicists’ expertise in addressing issues of resource allocation.  Lead time allows for considered reflection on ethical values and contextual information. 

In treating specific patients, when clinical evidence should drive decision making in concert with pre-established protocols and frameworks, the role for ethicists in decision making is significantly diminished. Nonetheless, there are supports that ethicists are uniquely able to provide. They can provide consultation support for especially challenging cases. They can clarify values and facilitate the use of relevant ethical decision-making frameworks. They can also provide validation that the decisions facing health care providers are ethically fraught and that no choice will feel like it’s deeply “right.” They can acknowledge that there is no single “right” option and that a range of responses could be ethically defensible. They can confirm that appropriate procedural and substantive values are reflected in processes established to respond to the crisis. They can affirm that the appropriate values are being applied in decision making and explain why those values are defensible. Ethicists can further support health care providers by publicizing the role that ethics has played in structuring responses. They can speak to values that were incorporated in the development of the response and reassure groups and individuals, particularly those with concerns about equity, that their needs and concerns were heard and accounted for in the final plan.  They can also advertise that they are available to discuss ethical concerns and challenges as they arise for those making decisions and providing care.

In the aftermath of a pandemic, there are opportunities for ethicists to be involved in lessons learned processes and for ethical analysis around how best to address ethical issues during a crisis. The process of reflective equilibrium can be employed, using experiences to revise judgments about relevant procedural and substantive values. This work also informs planning and preparation for subsequent crises. Ethicists can also play a substantial role in addressing the moral distress that is likely to arise for health care providers who are directly or indirectly involved with implementing pandemic response plans.

Our collective obligation is to minimize the number of difficult choices that health care providers must make in a pandemic.  Evidence from the COVID-19 pandemic and past outbreaks indicate that planning and preparation are key to fulfilling this obligation. When avoiding difficult choices is not possible, ethicists’ duty is to ensure that health care providers and other decision makers are equipped with what they need to decide and to act. 

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Marika Warren is an Assistant Professor in the Dalhousie University Department of Bioethics @marikadwarren