Dr James Watts and Dr Carole Pilkington, Consultants in Anaesthesia and Critical Care Medicine at Blackburn Royal hospital, offer guidance concerning ethical decision making during the current pandemic
Medicine is practised within a legal, professional and ethical framework. This framework may not give specific answers in specific situations, but is a general set of principles to which we are expected to practice. These principles are set out in a number of historic and current publications, including the General Medical Council’s (GMC) Good Medical Practice (1). The overwhelming messages contained in Good Medical Practice are that a good doctor will:
- Make the care of the patient their first concern
- Be competent and keep their professional knowledge up to date
- Take prompt action if it is felt patient safety is being compromised
- Establish and maintain good partnerships with patients and colleagues
- Maintain trust in themselves and the profession by being open, honest and acting with integrity
- Despite improvements in treatment, diagnosis and guidance, legal claims and complaints against doctors and the health service in general continue to rise (2,3) associated with a variety of factors, including greater access to information via the internet, social media, and general media pressure.
The main concern for doctors in relation to complaints and possible legal action even in normal circumstances is that medicine is practiced within a world where everything is shades of grey, where a diagnosis may evolve or completely change as more information not immediately available becomes apparent; whereas the scrutiny of any complaint seems to occur in an environment where there is assumed to be only black and white, right or wrong, competence or incompetence. To a doctor in such circumstances, the legal rulings that confirm that while a single clinical incident could be serious enough to reach the threshold of “misconduct” that “mere negligence” on its own does not, unless particularly grave (4), is of little comfort. The Bawa-Garba case has done much to undermine doctor’s belief that regulators and courts will take the context in which decisions were made into account (5).
These anxieties are magnified when the normal systems break down: so-called “compensated major incidents”, where extra resources are mobilised due to the fear that otherwise live casualties will be lost. This may involve the suspension of normal services and the creation of new processes, roles and ways of working. The current Covid-19 pandemic is such an incident, where working practices have been changed due to the health service being at risk of collapse. As a result, doctors are working in unfamiliar job plans, possibly in unfamiliar roles, in a stressful environment when they themselves are at risk (6).
As a result of this concern locally, we were tasked with producing some guidance concerning ethical decision making during the current pandemic. We decided to produce a set of easily digestible bullet points rather than a larger document that would take longer for an individual to review. With a view to helping to reassure others, we reproduce our guidance below.
Introduction
- We are currently working in highly unusual conditions. However, even in testing times we are not being asked to make any decision that we do not make every day under normal circumstances, although we may be asked to make them with reference to different treatment thresholds, or very quickly, or both.
- Adhering to our normal practice, no matter how constrained, is the best way to make a decision that can be justified, based on what the circumstances at the time were
- When the system is under strain, we may not be confident that we have adequate time, information or resources to make the correct decision
- However, it is important whatever the circumstances that we try and ensure that all decisions are equitable and fair, evidence-based and open and transparent based on the information that we have at the time we made them
- It is