Marika Warren compares her expectations going into the pandemic with the actual ethical challenges that arose.

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As a practicing healthcare ethicist who has been involved with pandemic response, I am spurred by this fall’s rise in COVID-19 cases to reflect on some of the things that surprised me while providing ethics support during the pandemic.  At the outset, I expected to be focusing on how to allocate scarce resources such as ICU beds, personal protective equipment (PPE), and eventually vaccines. That was certainly part of the work, but there were several other questions and concerns that I did not anticipate, even after experiencing previous infectious disease emergencies such as SARS in 2003 and H1N1 in 2009.

During the COVID-19 pandemic, much more so than in previous pandemics, everyone had significant skin in the game.  It was like being behind a veil of ignorance; you knew you’d be affected somehow at some point but not how or when.  We were trying to manage a novel pathogen as it affected our work lives while we were also loved ones and caregivers and community members and all of those roles were radically altered.  There was no neutral “view from nowhere” from which policy responses could be considered impartially. Being embedded in the crisis influenced decisions.  It is useful for us to ask as we look back whether the fact that everyone was affected made for better policy.  Policy makers and practicing healthcare ethicists recognize the importance of bringing lived experience to decision making, as seen in increasing collaboration with patient and family advisors in recent years.  That said, there were voices and perspectives that were still not present during policy making and we can look to our COVID experiences to inform policy development processes that are responsive to the full spectrum of interests and identities that are affected by policy decisions.

Photo Credit: Engin Akyurt/pexels. Image Description: An N95 mask.

Another set of unanticipated questions arose around access to information.  These questions arose within health organizations trying to learn about and respond to a new pathogen as well as for governments faced with a public that was trying to manage and mitigate the risks they faced.  And questions of who could access information and what information could be released to the public were especially salient in the early days of the pandemic when case rates were relatively low in many jurisdictions, COVID-related stigma and fear were high, and information was an extremely scarce and valuable resource in making what felt like high-stakes decisions about how to act and where to direct resources. Members of the public were trying to manage risk to themselves and loved ones, researchers were trying to determine infectiousness, lethality, and susceptibility, and health care leaders were trying to decide whose care needs could and could not be met.  

But as is always the case in ethics work, context matters. The pandemic coincided with increasing reliance on data and analytics to direct health care strategy and care delivery, which further raised the perceived value of information.  And as the potential benefit of information increased so did questions about whether our values related to privacy and personal health information needed to shift in this context given potential insights into disease course, transmission, and susceptibility that could only be gleaned from personal health information.  

I also did not anticipate that ethical challenges that arose as we relaxed restrictions and increased levels of service would be more complex than those encountered when widespread restrictions and cancellations were instituted at the beginning of the pandemic. These challenges required much more nuanced thinking and weighing of values and priorities.  In addition, that weighing was being done in a context where there was more evidence about the benefits and burdens of restrictions as well as increased fatigue and decreasing solidarity among the public, patients and families, and health care providers.  Similarly, it was at this point that the most difficult resource allocation questions arose. Resource allocation is a perennial challenge in health care, and problems and limitations that long pre-dated the pandemic were made significantly worse as supply (especially of human resources) decreased and demand increased. Pre-existing processes were not well-suited to direct system-wide redistribution of resources.

Many of these challenges were foreseeable, but none of them had been a significant factor in ethics responses during previous pandemics so they weren’t on my radar. Going forward into a future pandemic, I feel more prepared as a practicing healthcare ethicist to expect the unexpected and less likely to assume that prior experience or planning will provide specific guidance. Over the course of the COVID-19 pandemic I have certainly developed an appreciation of the way that fine-grained details about local epidemiology, disease pathology, and social and political environments will deeply affect decision-making.

In retrospect, some of these concerns feel less pressing, in part because some of the deep uncertainty of those early days has been resolved and in part because we now have the benefit of perspective as the sense of urgency has faded.  At this point, though, we are left with deeper challenges than when we went into the pandemic, and we still need the contributions of ethics guidance to navigate these challenges. That said, we also have an increased appreciation of our collective ability to be creative, innovative, and collaborative as we adapt to new circumstances.  I hope that, collectively and singly, we take this opportunity to reflect on our experiences and use what we’re taking away from our pandemic experiences to build a more equitable and resilient health care system going forward.

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Marika Warren is an Assistant Professor in the Dalhousie Department of Bioethics.