Balancing the greater good with individual care

Pandemics—and public health emergencies more generally—reinforce approaches to ethics that emphasise or derive from the interests of communities, rather than those grounded in the claims of the autonomous individual. The response has been to draw on more public health focused ethics, ‘if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual's need will give way to decisions about how to maximise overall benefit’.2 Alongside this, effective control of pandemics requires that we all adopt strategies to reduce disease transmission such as the lockdown measures instituted by governments worldwide. Individual liberties are curtailed for the greater good.

Together, these factors shift the weighting of ethical concepts to emphasise the individual within a community.3 4 For many years, public health ethicists and practitioners have drawn attention to the importance of the health of the whole community5 and the broader determinants of health, including the built environment and the way that society is structured.6 7 Public health emergencies, such as COVID-19, demonstrate our mutual dependencies and highlight the need to prioritise the interests of the community. The difficulty of balancing these tensions between the interests of the ‘wider community’ and the patient as the ‘first concern’ has been well rehearsed. In the reset period, how to further the public good is contested; should health services prioritise the response to COVID-19; or should we now be trying to give equal or greater priority to providing non-COVID services? It has been argued that the response to COVID-19 will produce much greater detrimental effects on population health than the disease itself, including the impact of those who need healthcare for non-COVID conditions not receiving treatment.8 9 Thus, in the current pandemic, how to promote the public good is by no means clear and which wider community’s interests should be prioritised needs careful ethical consideration.

Attention also needs to be paid to relationships between healthcare professionals and patients, as elements of non-verbal communication are inhibited by wearing masks; the calming and reassuring gesture of touch is prohibited or distorted by the use of personal protective equipment (PPE); and patients have to attend appointments on their own without any support, no matter how difficult or traumatic the consultation is expected to be.10 This raises important ethical questions about how the demands of infection control should be balanced against the need for personalised, dignified and supportive care. Responding to these competing demands can result in moral distress for healthcare professionals who feel ill-prepared or unable to pursue ethically appropriate actions.11 COVID-19 has created new and uncertain circumstances that continue to disrupt our understandings of what ‘good care’ looks like and, in so doing, shifts the underpinning values or assumptions on which care is based, raising new ethical considerations for day-to-day decision making.

Resource allocation

Resource allocation is a perennial problem in health systems and the persistence of COVID-19 will magnify concerns about National Health Service (NHS) resources long after the first wave. With the suspension of many non-Covid services from March 2020 in the UK, the backlog of demand for non-Covid services has grown, and the pressures on healthcare services are even greater. At the same time, healthcare is necessarily less efficient because of COVID-19 infection control precautions. Each healthcare interaction takes longer because of the time it takes to clean equipment and the treatment area, don and doff PPE, and patients cannot be left waiting in shared rooms but must be tightly scheduled.

In the first wave of the pandemic, the analysis focused on resource allocation between patients with COVID-19.12 In this reset period, attention must now turn to how to allocate resources between those with COVID-19 and all other patients, including those whose conditions are not life-threatening and these kinds of decisions need focused ethical scrutiny.