Ethics: Under pressure

NHS STAFF are adept at managing pressure. They train for it. Most accept it as part of their role. Some may even thrive on it. Yet recent months have seen the discourse shift in relation to pressure. The news has been dominated by stories of ‘crisis’ and ‘chaos’. Individual clinicians have written, often moving, accounts describing the impact of juggling increasing demand in an overburdened system. Politicians have opined on, and disagreed about, the extent of and solutions to pressure. Both doctors and patients have shared, sometimes painful, experiences of how pressure influences the care they provide and receive.

Throughout this period in which pressure has been a recurrent theme, I have been a patient. I have attended overbooked clinics, a visibly stretched chemotherapy day unit and waited for scans in packed imaging departments. I have had early appointments and those scheduled for the evening. I am never alone. The patients, their families and, of course, the clinicians caring for them fill every available chair, cubicle and consulting room. In my not-very-scientific experience, healthcare is indeed under pressure.

What impact or influence does such pressure have on ethical practice? An influential teacher used to describe ethics as “what you do when no one is watching”. Whilst that continues to resonate with me, it does seem that pressure throws ethical choices and practice into sharp relief too.

There are, of course, specific ethical challenges that arise from rising pressure. How to attend to dignity and privacy when there is, quite simply, nowhere to put a patient? Resources are always finite, but pressure distils the hard choices between competing needs and interests to a concentrated dilemma that may be impossible to resolve. Moral distress – the phenomenon whereby a professional is discomforted by being unable to provide care that meets the ethical standards to which he or she holds himself – is more likely and, when it occurs, felt more acutely. For those in training, and those training others, pressure may compromise the education and supervision that can be provided in a stretched system. Pressure may make errors more likely and create conditions that are unsafe.

The ethical tensions that arise in times of pressure are testing. For some, the circumstances prompt moral questions that extend beyond the usual dyadic relationship. To what extent does a professional have a duty to ‘name’ the problem and to speak up when the environment in which they are working is under extreme pressure? If an individual decides that he or she should challenge the circumstances in which clinical care is provided, to whom should that challenge be addressed? What might the consequences – intended and otherwise – be both for colleagues and for patients? What ethical response might a clinician bring to bear when he or she believes care can no longer be provided safely?

Beyond these testing ‘headline’ ethical challenges lie a raft of choices that are equally challenging but perhaps attract less attention. These are the daily interactions that continue with care, commitment and kindness. They are clinical consultations as manifestations of virtue and values. This is ethical practice that is never more remarkable than when it occurs under pressure.

I experienced such ethical practice with the phlebotomist who, having rung a managerial colleague, was advised that she would have to manage the clinic alone because there were no more staff available. She turned back to me after the call and responded to my irrational anxiety about needles with gentle compassion, humour and patience. She knew that there were currently 35 people waiting, all of whom needed blood tests to inform their treatment for cancer, yet she made time to respond to me as an individual.

I experienced such ethical practice when the receptionist in the overbooked clinic offered to come and find me in the canteen when space became available in the waiting room and spent spare moments checking patients were coping with the delay.

I experienced such ethical practice when the healthcare assistant on the chemotherapy unit made the time to re-take my blood pressure because we now know that I have Marsden-induced hypertension and it takes several attempts to obtain a non-scary reading.

I experienced such ethical practice when the oncologist answered my questions and responded to my concerns with generosity, attention and openness betraying no sense of urgency even though we both knew that his clinic was running almost two hours late.

I experienced such ethical practice when the car park attendant charged me less than the amount due because I had been delayed on the medical day unit.

I could go on. There have been so many of these ethical moments in which a stressed and stretched member of staff prioritised compassion, kindness, respect, dignity and commitment to care over pressure. These everyday ethical choices are transformative and never go unnoticed, even in moments of pressure.

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