The COVID-19 pandemic has been a time of moral reckoning, says independent scholar and nurse ethicist Dr Megan-Jane Johnstone AO.
“Primarily because it has called into question the taken-for-granted values, norms and role expectations of society and the adequacy of accepted professional ethical frameworks for guiding just (fair) decision-making and behaviours during a pandemic.”
In her book Bioethics: A Nursing Perspective and in a recent presentation to the Coalition of National Nursing and Midwifery Organisations (CoNNMO), Dr Johnstone highlights key contemporary nursing ethical issues, including moral limits to the ‘duty to care’ and the ethics of ‘refusals to care’, tragic choices, and standards of care.
During the pandemic, nurses have had to grapple with the tensions that exist between a system of healthcare ethics that is centred on the rights of individuals’ vs what is best for the community, says Dr Johnstone.
“This is what has really torn them apart: when they don’t have the resources to give the patient-centred care or the quality of patient-centred care that they’ve been schooled in.
“Across the board, doctors, nurses and other healthcare workers have not been really prepared for public-centred care and for having to deal with public-centred emergencies and pandemic care, and care that has to be guided by public health considerations and the difficulties associated with that.”
“Although I wonder if any education could prepare healthcare providers for the kinds of realities that they had to end up facing.”
Tragic choices
Tragic choices is one of those realities, says Professor Johnstone.
Tragic choices refers to the shocking, intensely sad, or mournful event that typically ends in disaster and which occurs through no fault or failing of those involved. Some examples during COVID include aged based triage in Italy with older people not put on ventilators; and parents triaged over single people.
It underscores human vulnerability and encompasses the idea that people ‘cannot control life’ and that ‘things will always happen that we are powerless to change’.
“We’ve seen people’s intolerance for ambiguity – this idea that they have control of their life, it being upended. I think for many people they have found that incredibly confronting and terribly threatening,” says Dr Johnstone.
The take home message is that there is no magic formula for calculating the lesser of two evils when trying to decide what really is the ‘best thing to do’ in the extreme situation at hand.
“Inevitably someone is going to get hurt and I think those on the front line really experienced that first-hand,” says Dr Johnstone.
Historical (militaristic) expectations have been that nurses will ‘stand at their post’ and not ‘abandon patients’ and have no right to ask “Is this case contagious?” “Am I running any personal risk?”
The COVID pandemic, and previously the spread of SARS in 2003 in some countries, has questioned the limits of what can be expected in the course of professional duty. Globally nurses and midwives have been subjected to verbal abuse and physical assaults when asking patients to wear a mask. In Australia, there’s been cases of nurses in scrubs being refused service in supermarkets.
“There’s got to be some accounting for what the public can reasonably expect of nurses in the case of a pandemic or extreme weather event/s and everything they’re working under,” says Dr Johnstone.
‘Refusals to care’/’non-abandonment’ narratives
This language of abandoning patients has crept in, says Dr Johnstone.
“I think it’s unfortunate that this has become woven into the ‘duty to care’ debate and my reason being if you look at words like ‘refusal’ it has pejorative overtones.”
“It implies a degree of recalcitrance, of resisting authority or resisting ordinary measures, which really falls way from the mark of what nurses are going through.
Nurses feel guilty enough without having this sort of language thrown at them.
Likewise, the notion of ‘non-abandonment’, which implies that the agonising decisions of those who choose not to step forward have abandoned patient care, says Dr Johnstone.
“Which again I would say is not a true reflection of what, for many nurses, has been an agonising decision of whether they will stay with the profession or whether they will move on.”
Dr Johnstone suggests an alternative narrative, a decision not to ‘step forward’ or ‘opt-in’, needs to be considered in the context in which it is being made – contexts which tend to be rife with extreme risk and uncertainty, not only to the decision-maker but to others for whose health and safety they may also be responsible for.
“We really need to be looking at a language that is more reflective of the agonising decisions that many nurses have had to make about whether to continue in practice.”
The American Nurses Association and the Canadian Nurses Association (CNA) have formulated guidelines and criteria specific to recognising that nurses may want to opt out.
For example, the nurse:
- Is in a vulnerable group (eg. medical condition or comorbidities that may make them more vulnerable to infection).
- Feels physically unsafe due to a lack of PPE/inadequate testing
- Inadequate support for meeting their personal and family needs
- Is concerned about professional, ethical and legal protection for providing nursing care in the COVID-19 pandemic.
Dr Johnstone cites the CNA which notes: “…the essential moral question in cases of nurses withdrawing is not ‘must nurses show up?’ but rather, ‘when nurses show up, how should they be supported?’”.
Three articles by Dr Johnstone are freely available on the ANMJ website:
The bogus ‘right’ NOT to wear a mask – ANMJ
COVID-19: The ethics of solidarity and encouraging responsibility – ANMJ
COVID-19: The moral costs of making tragic choices – ANMJ
Bioethics: A Nursing Perspective provides practical guidance on the moral and ethical issues you might come across in nursing practice (Elsevier, Sydney) and includes a new chapter on Pandemic ethics (Chapter 14).
Dr Megan-Jane Johnstone AO is a retired professor of nursing who writes as an independent scholar.
