Introduction
The COVID-19 global pandemic placed significant pressure on the U.S. health system due to a rapid increase in cases and a need for protective measures. Almost immediately it became clear that hospitals around the country were facing shortages of personal protective equipment (PPE) for healthcare personnel, necessary when providing care to protect themselves and patients (CDC, 2020). Such shortages placed healthcare professionals in situations of ethical dilemmas as PPE is critical to care provision and safety of everyone, but amid a pandemic, more patients than ever require medical attention. This paper will attempt to explore the ethical considerations of PPE shortages during COVID-19 and potential steps to action that reflect the ethical and professional responsibilities of nurses.
Interpretation of the Situation
Healthcare professionals on all levels are taught a ‘patient-first philosophy in their practice, and any decision made poses the question of implications for the patient. However, the public health crisis with COVID-19 has shifted priorities for the healthcare system towards more utilitarian principles of making the moral choice of maximizing doing the greatest good. Vital healthcare resources including hospital beds and PPE are tightly managed as demand has increased. Any crisis which leads to rising demand requires a rational method of prioritization and allocation of these resources. Locations, where there is a surge of COVID-19 cases and shortage of PPE, may fare differently where the case number is relatively small. Regular standards of disposing of PPE after each patient is the professional and safe aspect. However, when there is a shortage, nurses are faced with the dilemma of providing care with suboptimal PPE (American College of Surgeons, 2020).
Most healthcare professionals want to provide competent care for the patient that they are currently treating, and not think about the hypothetical future. However, this forces nurses to an ethical decision of whether to serve the patient or think of future patients that may have greater needs. As medical professionals, nurses have a moral obligation to provide care to those in need. Nevertheless, the status quo of the pandemic has strongly shifted the dynamics of care, including the shortages of PPE, and nurses must consider their risks as well. In some circumstances, provision of care without adequate PPE may cause more harm. Such as when a nurse is a caretaker of a high-risk individual or they are at high-risk themselves, thus potentially requiring an ICU bed that could be needed by others, as a consequence of an avoidable situation (Brown, 2020).
Morally Ideal Action
Healthcare professionals also have a duty of care for patients. However, in the context of the pandemic, there is an ethical complexity in balancing professional duties and demands with the need for self-protection. Professional codes of conduct may offer guidance, often suggesting that healthcare professionals ensure the personal safety and safety of others when providing clinical care. Healthcare provision follows the four core principles of biomedical ethics that guide decision-making which include respect for autonomy, beneficence, non-maleficence, and justice. Non-maleficence in particular is a critical consideration since no practitioner wants to harm patients, their families, or themselves. The scarcity of PPE significantly undermines the ability to respect this principle. As for justice, from a material perspective, the principles of need suggest that social resources, including those in health care, must be distributed according to need. Since PPE is fundamental to the protection of frontline medical workers and their patients or families, the principle of justice indicates that PPE is required in the context of the pandemic (Maguire et al., 2020).
The AMA has released guidance on the Code of Medical Ethics in this situation. Opinion 8.3 suggests that health professionals in dire situations such as a pandemic must provide urgent care, even in the face of greater than usual risk. However, it is also recognized that the healthcare workforce is not an unlimited resource, thus should be considered in the context of the ability to provide care in the future. Although not specific, the Medical Code of Ethics does discuss the allocation of key healthcare resources based on the urgency of need, such as the role in the institution and degree of contact. Practitioners can decline to provide care with suboptimal PPE based on several considerations discussed above such as risk factors. Therefore, according to the AMA efforts must be made to protect or reduce risk to healthcare personnel to the greatest extent possible when PPE is limited since benefits accrue to the public at large (AMA, 2020).
Deciding What to Do
Amid the SARS epidemic, Thompson et al. (2006) developed a framework for ethical decision-making in the context of a pandemic. The ethical processes consist of:
- Accountability – mechanisms in place to oversee ethical decision-making throughout the pandemic.
- Openness and transparency – the decision must be open to scrutiny, public, and defensible
- Reasonableness – decisions should be based on rationality such as evidence, values.
- Responsiveness – provide opportunities to revise decisions or mechanisms to address disputes as new information emerges during a crisis (Thompson et al., 2006).
Thompson et al. (2006) also identify duty to provide care as a key ethical value, arguing that in the context of a pandemic where resources are overwhelmed, providers have to consider the demands of their professional role to other obligations to own health and those of family and friends. If the circumstances are that all safety procedures are followed but there is not enough PPE, the health professional has the right to consider their duty. Accountability is followed since this approach is recommended by the AMA and other medical organizations. It is a transparent decision that is made public, and others are aware of ongoing circumstances. There is rationality to the decision if the nurse in question or her immediate family member is at-risk for COVID-19. Responsiveness is an element that can be considered once greater PPE resources are present or in the case of a vaccine being developed when it becomes safer to work with suboptimal PPE.
Implementation and Perseverance
From an organizational perspective, proactive conserving critical resources such as PPE while ensuring fair distribution is the best utilitarian approach to creating the greatest good for all patients served. Limited PPE would be distributed in a manner that protects the greater number of healthcare workers based on factors such as the minimal level of protection necessary given the risk of contact, setting, and procedure as recommended by scientific guidelines. Unnecessary PPE use should be minimized by focusing on high-acuity procedures and reducing staff in settings where protection is required. Another, more difficult and controversial approach, likely to be used in most desperate situations, is to provide PPE to those healthcare workers who can provide the most care to the patients. This will likely cause moral distress but will provide PPE to those clinicians who can work rather than those who are at-risk or absent to treat the greatest number of patients. Provided the urgency in making the critical decisions regarding resource distribution, hospitals must develop and implement policies on allocation of PPE, particularly to at-risk healthcare workers. The policies should be scientific and ethical, considering the moral consequences of overarching decisions. No system will be universal or perfect, but elements that consider utilitarianism, reciprocity, and protection of the vulnerable can be inherently ethical (Binkley & Kemp, 2020).
In terms of individual perspective, it is evident that the COVID-19 pandemic has challenged social and professional expectations along with the extent that healthcare workers have a moral obligation to provide care. Although some risk is always integrated into the concept of healthcare provision, there needs to be a distinction between reasonable risks and risks that are outside professionally enforceable obligations. Virtually all health organizations emphasize that healthcare workers, particularly nurses or lower-level support staff are under no ethical obligation to accept unreasonable risks. If circumstances are such that there is good evidence that a nurse should not participate in the provision of care due to serious risk, no matter the good intentions, it would be unethical for them to endanger their welfare and potentially that of others around them such as co-workers and family (“Ethical considerations”, 2020).
Conclusion
The ethical dilemma of PPE availability to healthcare workers during the pandemic is challenging and unprecedented on many scales. Medical ethics views the situation from primarily a utilitarian point of view. Treatment of patients is vital during a health crisis, but medical workers should protect themselves. Having suboptimal PPE provides a strong justification for refusing to provide care, particularly if a nurse is at-risk due to personal health or that of family members, as it would both cause harm, a violation of a principle of biomedical ethics, and would be unjust. Healthcare workers will continue to conserve PPE while supplies are strained, attempting to minimize risk to themselves and patients while providing the best treatment possible in these conditions. Ultimately, it is an individual choice of practitioners as COVID-19 poses risks beyond expected professional obligation and duty, it is necessary to respect the autonomous decisions of individuals. Ethically, the acts are supererogatory, and choosing another course of action to avoid risk would be morally acceptable.
References
AMA. (2020). AMA Code of Medical Ethics: Guidance in a pandemic.
American College of Surgeons. (2020). Ethics of PPE allocation.
Binkley, C. E., & Kemp, D. S. (2020). Ethical rationing of personal protective equipment to minimize moral residue during the COVID-19 pandemic. Journal of the American College of Surgeons, 20(6), 1111-1113.
Brown, B. (2020). Are clinicians without PPE morally obligated to care for COVID-19 patients?
CDC. (2020). Strategies to optimize the supply of PPE and equipment.
Ethical considerations for PPE use by health care workers in a pandemic. (2020).
Maguire, B. J., Shearer, K., McKeown, J., Phelps, S., Gerard, D. R., Handal, K. A., Maniscalco, P., & O’Neill, B. J. (2020). The ethics of PPE and EMS in the COVID-19 era. Journal of Emergency Medical Services.
Thompson, A. K., Faith, K., Gibson, J. L., & Upshur, R. E. (2006). Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Medical Ethics, 7(1), 1-12.