COVID-19 and ethics: lessons from the Netherlands

IN the late 1970s, Beauchamp and Childress described the principles of biomedical ethics that have been the cornerstone of ethical practice ever since: respect for autonomy, beneficence, non-maleficence and justice.

The coronavirus disease 2019 (COVID-19) pandemic has caused and still is causing immense pressure on health care systems in many countries, due to the vast number of patients. The care required has threatened to overwhelm both community care and hospitals. In order to manage the number of patients requiring care concurrently, serious public health measures (eg, social distancing) were taken to “flatten the curve”.

We can consider the first wave with some hindsight, notwithstanding the current situation in Victoria and New South Wales. Here we analyse the extent to which the principles of medical ethics have been compromised in times of the COVID-19 pandemic, and what could have been different for countries still in the first wave or when we face further waves.

Autonomy

Respect for autonomy, according Beauchamp and Childress, means that patients autonomously decide about medical care after consideration of adequate information. In practice, this means that patients may refuse treatment if they are competent. In publicly funded health care systems, such as the one in the Netherlands, access is only granted to medically useful and affordable treatment. If a system is fully marketised, there is more on offer for patients who can pay. In both systems, care is reduced in times of scarcity. Although autonomy needs not be compromised, reduction of options can lead to the feeling that choices are imposed.

In the Netherlands, it is common to discuss a patient’s wishes in case of severe disease. Very frail patients often autonomously choose not to go to the intensive care unit (ICU). As a result, the number of people dying of COVID-19 outside the ICU in the Netherlands is relatively large compared with other countries.

In this pandemic, physicians face an important challenge to inform patients adequately to enable autonomous decisions on hospital and ICU admittance. Patients should be informed in all their encounters with health care personnel about the possibilities (supportive care and medication with some effectivity, such as dexamethasone) and impossibilities (curative treatment). Patients need to be aware of the alternatives to admission to hospital, such as access to supportive or palliative care outside the hospital. They also need to know the characteristics of hospital COVID-19 care: isolation, with or without intubation for weeks, often followed by months of recovery, and a substantial risk of dying.

The enormous pressure on health care may threaten these conversations. With the continuous media coverage of the scarcity of beds, care personnel and ventilators, these conversations may be experienced as attempts to persuade people to choose not to be admitted or ventilated.

Beneficence

Beneficence, according to Beauchamp and Childress, means that health care should contribute to wellbeing of patients. Health care professionals are driven to do everything they can for their patients, but the restrictions imposed by the pandemic are limiting their options.

The benefits to patients with COVID-19 who get access to care may or may not justify the lack or delay of treatment to other patients whose treatment is less urgent. However, the question about the harm done by the postponement of that treatment needs to be answered to see whether it was justified. Also, it can be argued that it is in the collective interest to manage the pandemic in order to minimise infections and deaths and allow the health care system to cope.

While much of the debate focuses on scarcity of resources in ICU, it is important to realise that the outcome of ICU treatment for patients with COVID-19 may not be favourable. The outcomes after a long period of ventilation in the ICU are not fully known yet, but may involve compromised physical and mental health. In the cases of patients with poor prognosis, beneficence may therefore be achieved by the avoidance of ICU admission.

Non-maleficence

Non-maleficence means, according to Beauchamp and Childress, that patients should not be harmed by medical care. How can this be achieved in the current context of the COVID-19 pandemic? Harm will occur in this pandemic, but can it be minimised?

There is scarcity of personnel, space and equipment — physicians, nurses, beds in hospital or ICU, personal protective equipment, medication etc. Guidelines cannot be followed as usual, and, for instance, oncological patients have had to wait for therapy.

Social distancing and consequent isolation may harm vulnerable groups (psychiatric patients, intellectually disabled individuals) who are unable to understand the measures. Despite the measures to prevent infection of these vulnerable patients, the infection rate in residents of nursing homes in the Netherlands, for example, has been very high.

Patients with COVID-19 run the risk of harm in various ways, including long isolation and missed diagnoses due to protocolised treatment of large numbers of patients with COVID-19. Patients may be harmed both by admission and non-admission to the ICU, in spite of careful weighing of the benefits of both options.

Justice

Justice, according to Beauchamp and Childress, means that patients should have equal access to treatment. When analysing justice during this pandemic, we need to consider patients with and without COVID-19, patients needing care now, and those who may need care in the future.

In times of scarcity, it can be justified to redistribute personnel, space and equipment to guarantee access to adequate care for all, whether patients have COVID-19 or not. However, the standard of adequate care has shifted. Still, patients with similar complaints should be able to access equivalent care. It is crucial here to define “similar”. Is it the same disease? Similar life expectancy? Similar chances of recovery?

In most countries, the COVID-19 pandemic started with discrete areas of high infection rate and local high pressure on the health care system. In the Netherlands, the outbreak started in the south of the country. As a result of justice considerations, patients were spread across hospitals in the country to allow all patients with COVID-19 access to care. The aim was to guarantee an ICU bed for all those who would benefit from it. This has been described in countrywide agreements. If the national ICU capacity fails to keep pace with the number of patients with COVID-19, the Dutch Minister of Health will proclaim the so-called code black nationally. In case of code black, ICU admission will not be solely on medical grounds anymore, but following national triage guidelines, which have now been published.

The consequences of the Dutch policy of restricting non-urgent but important care for the patients without COVID-19 are, as yet, unclear. Justice demands that national guidelines are developed to ensure equal access to care for patients without COVID-19 who have treatments delayed or restricted.

Conclusions

The principles of medical ethics — autonomy, beneficence, non-maleficence and justice — remain central to medical practice even in times of a pandemic. However, as a result of scarcity and uncertainty, acting according to the principles is under pressure.

Autonomy can be safeguarded even if treatment options are reduced. It does require a concerted effort by the whole health care system to engage in careful conversations with patients about their preferences once they need care. The uncertainty about prospects for individual patients with COVID-19 should be acknowledged.

To abide by the principle of justice, it is important to develop national guidelines on access to treatment for patients with and without COVID-19 and to be prepared to prioritise on need during a possible next wave.

The pressure on the system means that quality of care for many patients may be suboptimal. The harms done managing the COVID-19 pandemic are concerning to patients with and without COVID-19, to those in care in the community, and to society at large. It has become clear that these harms will be substantial.

Acknowledgments: This article is based on a Dutch publication by Marleen Bakker and Suzanne van de Vathorst, we thank her for allowing us to rework the ideas for an international audience.

Dr Marleen Bakker is a respiratory physician and medical coordinator of the COVID-19 department at Erasmus Medical Centre in Rotterdam.

Dr Eva Asscher is Assistant Professor in Medical Ethics at Amsterdam University Medical Centre.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.