• Ethics

Many countries are looking back at the pandemic and reflecting on what could have been done better. The UK COVID-19 Inquiry rumbles on1 and other influential groups such as the British Medical Association have already reviewed the British response to the pandemic and made recommendations about what should happen in the future.2 The UK is not alone in looking for lessons from the pandemic with a view to preparing for the next one. Countries with a very different COVID-19 experience, such as Australia and New Zealand, have also commenced national inquiries with a view to becoming better prepared for the next pandemic.3 4

While many of the issues revolve around public health and government responses, there are also profound ethical issues that demand reflection on the conceptual resources we use when responding to new ethical challenges. The Journal of Medical Ethics (JME) covered many of the pressing ethical issues that emerged in the heat of the pandemic. Some of these revolved around issues that have been debated before, such as vaccine challenge studies, and earlier ethical analysis5 could be drawn on for the issues presented by the COVID-19 pandemic.6

The pandemic presented ethical challenges that exposed existing problems and highlighted the need for new or modified ways of framing relevant ethical issues. The health inequities that exist in all healthcare systems were exposed and amplified in many countries, and that has highlighted the importance of medical ethics attending to equity and the social determinants of health.7 8

However, there is also a need to explore other ethical concepts so as to frame the ethical issues presented when acting within a difficult context. In this issue of the JME, Tomkow et al consider the ethical challenges of healthcare professionals (HCPs) working with asylum seekers during the pandemic.9 As they point out, ‘moral resilience’ and ‘moral suffering’ are ideas that we might expect to be central for HCPs working in difficult times, but are they adequate concepts for analysing and framing ethical practice? After interviewing HCPs working with asylum seekers, Tomkow et al argue that ‘moral resilience’ has limitations as an ethical concept, and that if we are to articulate and engage with responses to practising within a difficult context, we should move beyond theorising ‘…moral discomfort as being a morally inert state, instead… working within environments that challenge morality can be transformative.’ So rather than seeing maintaining one’s moral orientation in difficult times as central, we should also acknowledge ‘…collective resistance, especially how to develop theory to capture this and enable working conditions to support it.’

While access to abortion services has liberalised in some jurisdictions, in some others, most prominently the USA, legislation has become more restrictive. The JME has published a number of articles over recent years analysing conscientious objection, which is an important response for HCPs practising within a jurisdiction that they find overly permissive about abortion. Writing in this issue of the journal, Hersey et al propose an ethical approach for those working within jurisdictions that have become more restrictive about access to abortion.10 They claim that their account is grounded in a ‘shared, normative framework of clinical medical ethics’. To make good on that claim they draw on and supplement Beauchamp and Childress by considering ‘reproductive justice’ which…

…arises from the lived experiences of people historically excluded from healthcare spaces and centres individuals and their specific reproductive needs. It is not only a lens to understand how patients interact with their providers, but requires provider engagement in addressing unjust or violent social structures which preclude patients from accessing the reproductive care they need.

The contexts in which we need to act ethically will change, and there are always existential threats, the current challenges of climate change, pandemic risk, conflicts and the pernicious spread of misinformation are an invitation to think creatively and carefully about ideas that can shed light on being ethical during difficult times.