ETHICS: Connected choices

I AM fortunate that when I sit down to write this column, I often have several ideas from which to choose. This time, I feel somewhat overwhelmed by those choices. In a time of COVID-19, there is no shortage of ethical questions.

I had my first inkling of what might be to come in February when I was invited to a meeting to consider the ethical implications of pandemic. It was a fascinating multidisciplinary conversation with a diversity of perspectives, expertise and experiences. It was also a strange meeting with an otherworldly atmosphere. As we talked, London continued its routines seemingly unchanged by the possibility of a pandemic.

When, four weeks later, the country found itself moving into that other world of lockdown and loss, ethics took its place front and centre in a way I have not seen before. Journalists approached me frequently for comment. I have written before about how I decide whether to talk to the media and will not revisit those thoughts here. Suffice to say, I was not convinced my contribution would add much to public discourse in this time of crisis.

More significantly, large numbers of NHS organisations and clinical friends and colleagues contacted me to ask for support, or simply to talk through the ethical dimensions of their changed and changing work. These calls, in the early stages, were heightened conversations. People were anxious and felt the burden of the knowledge they were beginning to have about what this virus could do. They were distressed by the dissonance between what was being said about the safety of their working conditions and their experiences in clinical settings. They sensed that there was an inherently moral character to many of the choices and decisions that they were making. They were individuals caught within a complex system imbued with expectation and uncertainty. It was clinical ethics on steroids: familiar tensions reframed in a context of urgency, pressure and uncertainty that was unknown and perhaps unknowable.

Following these calls, came the emails. There was a recommendation that all NHS Trusts should have ethics committees to consult as they made decisions relating to COVID-19. I was, like many colleagues with ethics in their title, approached several times a day by whomever in the organisation had been charged with setting up ‘the ethics committee’. I worried about these people who had no time and seemingly little support to create a functional group from out of nowhere with a brief that would be demanding both intellectually and emotionally. The way ethics was defined in these emails sometimes discomforted me too: as an organisational salve for moral distress that was complex, deep and likely to endure long after any nascent ethics group had disbanded.

I agreed to chair a couple of ethics groups and to act as support for two clinical teams in different settings. That work has always been challenging and sometimes distressing. However, it has also been a source of hope because of the fundamental connectedness it has revealed. That connectedness resides in the willingness of clinicians, managerial staff and lay members to come together, to listen and to strive to understand each other’s perspectives and experiences. If that sounds ‘cosy’, I have done these groups a disservice. These are searching conversations. Assumptions are noted and intuitions interrogated. Difference is the currency of the discussion with conflicting and contrasting ethical preferences. Yet, each person also shares an ethical disposition which prioritises respect for others, curiosity, commitment to the task and openness to divergent views.

The questions, dilemmas and problems that each group or team brings and considers vary enormously. The much-anticipated ethical questions about resource allocation and impossible choices about who has access to care in an overstretched system have not, in my work, been raised. Rather the questions have included considering the ethical implications of excluding visitors, the imperatives of providing good end-of-life care, indeed of articulating what care means and how to support clinicians experiencing moral distress.

The approach, composition and format of the different committees and groups are distinct. Each one has its own preferences, rhythm and style. However, there is a connection and a commonality in the values that underpin the work, irrespective of the organisation it serves and the type of healthcare setting in which it is located. That connection and commonality reflects and engenders hope. It demonstrates that we will find ways to connect with others, especially through difficult times. It reminds me that whatever the specific question, case or dilemma, the commonality of purpose remains - namely to care and to care well for others. It is grounded in hope that this time will pass, and we will have learned together. It is an acknowledgement that our relationships are as powerful and important as the search for a vaccine.

Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law at St George's, University of London