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The Perfect Protocol? Ethics Guidelines in a Pandemic

Written by Joshua Parker and Ben Davies

One question occupying politicians and healthcare workers in the middle of this global pandemic is whether there will be enough ventilators when COVID-19 reaches its peak. As cases in the UK continue to increase, so too will demand for ventilators; Italy has reported overwhelming demand for the equipment and the need to ration access, and the UK will likely face similar dilemmas. Indeed, one UK consultant has predicted a scenario of having 8 patients for every one ventilator. Aside from anything else, this would be truly awful for the healthcare professionals having to make such decisions and live with the consequences.

Ethics is an inescapable part of medical practice, and healthcare professionals face numerous ethical decisions throughout their careers. But ethics is challenging, often involving great uncertainty and ambiguity. Medics often lack the time to sort through the morass that is ethics.  Many therefore prefer heuristics, toolboxes and a handful of principles to simplify, speed up and streamline their ethics.

There has been something of a race to create the protocol to determine how to ration scarce ICU resources fairly. Indeed, we even have a protocol for creating a protocol! There are significant potential advantages to this kind of approach. In theory, if there is an agreed guideline used across hospitals, this creates procedural fairness since all patients are evaluated using the same criteria, removing the potential for individual bias. Guidelines also increase transparency in how difficult decisions are made. For doctors making these decisions, such guidelines will likely appeal given their role in streamlining otherwise difficult ethical decisions. Moreover, a protocol can increase their confidence in the decisions as well as reducing their decision-making burden.

Yet protocols are not a panacea. For one thing, the sheer number of guidelines being generated means that medical professionals who want to do the right thing face a tidal wave of information, paradoxically increasing their decision-making burden. Moreover, the fact that these are such hugely consequential decisions is precisely why we must be careful handing over ethical decision-making to guidelines. We have said that one apparent advantage of protocols is that they free doctors from the weight of ethical responsibility – after all, how could you have done the wrong thing if you followed the ethics guideline? But if ethical guidelines encourage uncritical decision-making, this risks the kind of moral errors that could be catastrophic in these difficult and uncertain times.

This problem is exacerbated by some of the apparent advantages we listed above. For instance, a national protocol might give the appearance of avoiding bias. Yet guidelines may have biases built right in; for instance, NICE recently revised their guidelines after disability groups raised serious concerns about the use of frailty scores in potentially determining ICU access. Such serious ethical problems show us that guidelines cannot entirely replace individual ethical decision-making.

This leaves healthcare professionals and philosophers in somewhat of a bind where the very solution is also the problem. Those seeking the perfect protocol are right to want to help doctors make hard decisions unhindered, particularly if they will face numerous such decisions every day. But guidelines risk biased or unreflective ethical decisions; the ethics guideline could produce unethical decisions. Perhaps the ideal is to have guidelines act as heuristics, where doctors use them to guide, but not replace, ethical decision-making. But whether this approach is feasible in the pressure cooker of pandemic care is unclear.

Dr Parker is a GP registrar, and Education Fellow in Ethics and Law at Wythenshawe Hospital, Manchester.

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