Covid 19 Ethics Resources

Ethics forums of various sorts are being called upon to support ethical deliberation and supply advice and guidance during the Covid 19 outbreak. This page shares resources that groups or individuals may find useful. It includes links to official policy, professional guidance and selected research.  It will be updated at least every two days. (This page is intended as a repository of advice and guidance for decision making. The Nuffield Council on Bioethics now has a page with a wider remit and range of media including journalism, podcasts etc.)

Thank you to @DrCicely and @JonathanIves4 who started me off by putting me onto very welcome resources.

Professional body & official guidance 

  • The Royal College of Physicians has published ethical guidance that has been developed by a collaborative of medical Royal Colleges and reviewed by the GMC. See Ethical Dimensions of Covid19 for Front Line Staff. It makes an important statement regarding fairness in decisions surrounding escalation of care:
(Ethical Dimensions of Covid19, p4)
  • The BMA has also published guidance for doctors Covid19 – ethical issues which builds upon the ethical principles for pandemic influenza revised by the DHSC in 2017 (see below). On resource allocation, it states
BMA Covid 19 Ethical issues p.3
  • NICE has slightly revised its COVID-19 rapid guideline: critical care (most recent update 30th March) including a one page critical care admission algorithm. (Thanks to Priya Singh at GSTT for the link). This is the key national guidance for ensuring that access to critical care gives most benefit to those who need it, and that it is allocated fairly and consistently.
  • Following news that groups of elderly, frail and chronically ill patients were asked to complete DNAR forms, the CQC, BMA RCGP and Care Providers Association have issued a joint statement making clear that this practice is unacceptable. (It is clearly unethical.)

“In particular, on the topic of potential ‘triage by resource’ (declining a patient on the basis of capacity rather than the usual triage by likely outcome/benefit), the following apply:
> External: nobody should triage until everybody triages (which should be a national decision). We are a networked service and until the last bed in the last hospital is occupied, there are always options.
> Internal: no one should make capacity-related admission decisions alone. Trust systems such as ‘three wise people’ should be deployed for mutual multidisciplinary support.

  • NHS England recently published this important guide to caring for people with learning disability or autism (or both) during the outbreak. It notes that “in 2018/19 at least 41% of people with a learning disability who died, died as a result of a respiratory condition. There is therefore, strong reason to suspect that people with a learning disability may be significantly impacted by the coronavirus pandemic.” The guidance is directed at clinicians who may have limited experience of managing the care of this group of patients.
  • The Royal College of Psychiatrists has a developing suite of resources including a summary of ethical issues and principles, emergency amendments to MHA 1983, risk stratification in community mental health, and remote consultations. Emergency legislation in the Coronavirus Act introduces significant changes to the Mental Health Act (NOT YET IN FORCE, 30th March). These include changes to rules on length of detention, formal admission, and administration of medication without consent.
  • The British Geriatric Society has published guidance Managing the Covid19 pandemic in care homes. It has notable ethical reminders around visiting, alternatives to restraint for residents who ‘walk with purpose’ (wander), the need for advance care planning, being clear why admission to hospital may be apt or inapt, and accepting residents back on discharge from hospital.

Governance and strategy for leaders & ethics forums

  • The UK Clinical Ethics Network which supports clinical ethics committees (CECs) now has a regularly updated page on its website giving access to Covid ethics resources and assistance to CECs.
  • The DHSC document ‘Responding to Covid 19: an ethical framework for adult social care’ sets out principles that are equally relevant to providers of mental and community health services. It sets out eight principles: Respect; Reasonableness; Minimising harm; Inclusiveness; Accountability; Flexibility; Proportionality; and Community. It states Respect and Reasonableness are fundamental, and that otherwise the principles carry equal weight.
  • In 2017 the Department of Health published a revised ethical framework for pandemic influenza planning, tweaking one developed in 2007. It appears to have informed the 2020 DHSC ethical framework for adult social care (see above). The ethical framework can be found within this longer document.
  • Information Governance. NHSX has published guidance on information governance during Covid19, including provision for sharing patient information for public health purposes.
  • The Hastings Centre (US) has issued a useful guide to strategic ethical considerations, PDF here and at The Hastings Centre
  • Will providers or clinical staff face potential legal liability for non standard care under pandemic conditions? This statement from NHS Employers explains how the Clinical Negligence Scheme for Trusts will continue to indemnify staff.
  • The Nuffield Council on Bioethics (UK) has published a policy briefing. PDF here. They emphasise “People should be treated as moral equals, worthy of respect. While individuals may be asked to make sacrifices for the public good, the respect due to individuals should never be forgotten” and  “Solidarity is crucial at the international level between countries, by businesses in how they exercise their corporate social responsibility; and at the individual level in the way we all respond to the outbreak in day-to-day life.” 

Caring for staff and understanding their perspectives

  • An important article by Greenberg and others in BMJ addresses minimising moral injury in care staff during Covid19. Key messages: managers need to proactively take steps to protect the mental wellbeing of staff; must be frank about the situations staff are likely to face; support staff by reinforcing teams and providing regular contact to discuss decisions and check on wellbeing; once the crisis begins to recede, actively monitor, support and where necessary offer treatment to staff. Importantly, they advise that “Single session psychological debriefing approaches should not be used as they may cause additional harm”.
  • Research article by Ives et. al. Healthcare workers’ attitudes to working during pandemic influenza: a qualitative study (Open Access) The researchers asked staff what would motivate them to go or not go to work. In summary, it is worth paying attention to the following factors (besides staff being ill themselves).  Practical aspects: caring responsibilities (children, spouse, parents etc) and whether a substitute carer can be found or provided; perceived level or risk to self & also to those for whom there are caring responsibilities; transport availability, particularly when less transport is running and for night shifts; availability of appropriate personal protective equipment; availability of on-site or near-site accommodation. Psychological factors Staff anxiety about having to make rationing decisions and adapt treatment protocols, with their fear of subsequent litigation exacerbated by lack of authoritative guidance; positive motivating factors of loyalty to team, professionalism, being useful; and an expectation of reciprocity – if I put myself out for others, will I be looked after by the organisation?

Mental health law, disability rights, human rights

  • Coronavirus and the Mental Capacity Act. A thoughtful blog on the implications of the MCA 2005 in pandemic circumstances, when large numbers of people who may lack capacity to consent require urgent treatment.
  • Mental Capacity Law and Policy is a web page maintained by leading barrister Alex Ruck-Keene. It currently (26th March) contains pretty much all that is anticipated about how the Coronavirus Act 2020 will affect duties owed under the Mental Capacity Act. Note that the Coronavirus Act changes will not come into effect until triggered by order.
  • Disability, coronavirus, and international human rights. This web page is maintained by Doughty Street Chambers to promote the interests of all people with disabilities, including cognitive disability and mental ill health. Links to UN and WHO sources, and draws attention to need to consider people with disabilities in prison.
  • Advance decision resources for individuals. Many people assume partners or family members will be asked to make decisions about their care when they are too ill to do so themselves. But that is not the case – while those close should be consulted, they will not have the final say. However, individuals can make a binding advance decision or give power of attorney to another person to make decisions. Charity Compassion in Dying helps people through the process with structured information, forms and a helpline.

Caring for the deceased

How can the dead be truly dead when they still live in the souls of those who are left behind? (Carson McCullers)