Ethical dilemmas faced by health care workers during COVID-19 pandemic: Issues, implications and suggestions.

Sir,

The unexpected and unprecedented challenges brought on by the COVID-19 pandemic has inflicted tremendous strain on health care resources, even in developed countries. The sheer magnitude of numbers coupled with high virulence of the infection has triggered country wide lockdowns across vast swathes of the globe. One group expected to work as usual in these trying times are health care workers and, therefore, the impact of COVID-19 pandemic on the mental health of frontline health care workers is gaining legitimate attention (Ayanian, 2020; Lai et al., 2020). In this regard, we point out a few moral and ethical dilemmas that can be faced by health care workers (HCW) while attending the call of duty:

Dilemma 1 – How to balance my ethical duty to care for my patient against genuine concerns of contracting COVID-19 and spreading it to my family? These concerns are likely to be more pronounced among health care workers with aged parents or young children. To some extent, these concerns are also fuelled by limited availability of personal protective equipment (PPE), inequitable distribution of available equipment and limited and constantly changing recommendations on usage of masks and other PPE.

Dilemma 2 – Should I retain ventilatory support for a critical patient who is unlikely to survive or use the ventilator for a less critical patient with better prognosis? As much as doctors are bound by the Hippocratic oath that entrusts every doctor to treat all sick patients to the best of their abilities, in times such as these, triaging of finite resources is a pragmatic consideration. Consequently, frontline HCW’s may find themselves in an unpleasant situation where they have to make a choice of allocating scant resources for those who need them the most.

Adding a further layer of complexity to this issue are laws governing passive euthanasia in India, which state that a medical board constituted for the purpose by the hospital should first discuss the issue with family members and only after obtaining their written consent, proceed with withdrawal of ventilatory support. Clearly, for an acute illness like COVID 19, it is going to be an onerous task to convince emotionally charged family members about the limited chances of their loved one’s survival and ask them to be ‘altruistic’ enough to spare the ventilator for another sick patient with better chances of survival.

Dilemma 3 – If I have some respiratory symptoms and I think I may have been exposed, should I open up about my symptoms and stay at home, risking social and workplace discrimination, or continue to go about my work as usual, risking my colleague’s health, till my test comes positive? How do I balance my physical and mental health care needs against the call of duty in these testing times? Every health care worker counts during these times and there have been instances where entire hospitals have been forced to shut down because of presumed exposure or suspected status of one health care worker. In such an all hands-on deck scenario, to try and push oneself to the limits of endurance, neglecting physical symptoms and needs, is par for the course.

The above dilemmas, apart from being very personal, may also have larger ramifications for health care delivery. As these thoughts pre-occupy the mind, juxtaposed with other considerations such as looking after the needs of their families, their own physical and mental health care needs, as well as day to day demands of work and caregiving, judgment of HCW’s may become clouded. This, in turn, may affect clinical decision, increase chances of medical errors and eventually increase the risk of burnout.

We offer some suggestions to tackle the above scenarios:

Institutions need to be upfront about their plans, policies and standard operating procedures to its staff and health care workers. Availability of patient care, safety equipment and risk stratification protocols must be communicated clearly and updated on institutional websites. All health care workers should be briefed periodically about the rational use of PPE so that their safety concerns are addressed and at the same time, resources are utilized rationally. There must not be any attempt to paper over cracks; instead an open admission of possible shortcomings and steps taken to overcome them will allay anxieties and allow HCW’s to mentally prepare themselves for challenges. As COVID-19 duty is admittedly stressful, institutions may consider giving reduced shift hours (for instance, 4−6 h) per work day to prevent burnout.

Institutions must consider giving accommodation and quarantine facilities for its staff. If there are resource constraints, this facility must be made available at least to the HCW’s during the period of COVID duty as many of them may not feel comfortable going back to their families every day during this period.

Pre-counselling of HCW before going to the frontline may help to allay concerns and provide opportunities for clarifying safety queries. The above mentioned ethical and moral dilemmas can be discussed beforehand so that HCW’s are mentally prepared to handle such scenarios. Involvement of mental health professionals at this stage would add value to the process by enabling utilization of their specific expertise in crisis counselling and problem-solving skills.

Setting up of a COVID support cell in every institution would serve as a one stop resource for mental and physical health care needs of HCW’s. It also provides a forum for HCW, who may feel overwhelmed from time to time by the demands of caring, to discuss ongoing concerns and help to prevent burnout. As mentioned earlier, every HCW matters and their mental health often correlates with workplace productivity (Duffield et al., 2014; Kim et al., 2018). Health care team leaders should be trained to recognise signs of burnout among junior doctors as early identification and intervention is key (Greenberg et al., 2020).

Ultimately, personal health is an individual responsibility. If an HCW has respiratory symptoms and does not wish to endanger others, the onus is on them to stay back and give a proper explanation for their decision. When in doubt, it is desirable to apply the ethical self-test as follows; “If my colleague at work had these symptoms, would I prefer him to come for duty?” Setting out standard operating procedures for HCW’s in this regard would remove ambiguity, facilitate individual decisions and lessen discrimination.

Extraordinary times call for extraordinary measures. We hope that the measures outlined above would assist institutions and team leaders in providing the best possible working conditions for their staff and health care workers. This will enable and motivate frontline health care workers to give their best while simultaneously preserving themselves for another day.

Financial disclosures

There are no financial disclosures or sources of support for the present work.

Declaration of Competing Interest

The authors declare no conflicts of interest relevant to the contents of the manuscript.