Ethical obligations for supporting healthcare workers during the COVID-19 pandemic

During the coronavirus disease 2019 (COVID-19) pandemic, some healthcare facilities have, at times, reached the limits of their capacity to handle the surge in patient volume. Hospital beds and other medical resources became scarce as a consequence. Healthcare workers (HCWs), both clinical and non-clinical, were required to increase their workload, under extremely stressful circumstances.

Short abstract

Based on considerations of justice, healthcare workers must be able to rely on support and protection from the societies in which they work. Prioritisation of healthcare workers for vaccines may be a way to maintain a functioning healthcare system. https://bit.ly/3pouzQu

To the Editor:

During the coronavirus disease 2019 (COVID-19) pandemic, some healthcare facilities have, at times, reached the limits of their capacity to handle the surge in patient volume. Hospital beds and other medical resources became scarce as a consequence. Healthcare workers (HCWs), both clinical and non-clinical, were required to increase their workload, under extremely stressful circumstances.

HCWs are routinely exposed to numerous stressors, which results in high rates of burnout, post-traumatic stress disorder and suicide, especially among those working in high intensity environments [1]. This has been especially true during the COVID-19 pandemic [2]. Physically stressful working conditions and witnessing the suffering and death of large numbers of patients take a toll. Further, when resources cannot fully meet demand, HCWs may experience moral distress due to rationing decisions [3]. In addition, being confronted with a highly contagious pathogen such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there is also the fear of becoming infected oneself or spreading the infection to one's family (table 1) [4]. This stress may contribute to physical exhaustion and feelings of fear and anxiety, sleep disorders and insomnia, or even burnout and depression [2]. All of this is compounded in a situation like a pandemic where the effects are felt beyond the work environment, giving HCWs the sense that there is no way to escape the pressures outside the hospital. Anxiety is further heightened by the uncertainty about when the pandemic will end or how bad it will get. With all of this psychological trauma, some HCWs will need extra time away from the hospital; some may never return to their jobs. As a consequence, healthcare facilities and systems could lose HCWs precisely at a time when they are needed most, further aggravating the situation of scarcity created by the increased demand. Therefore, it is crucial to keep working conditions as safe as possible in times of crisis. As patient surge reaches critical limits, tasks not absolutely necessary for patient care should be reduced as much as possible, while preserving safety.

TABLE 1.

Stressors for healthcare workers (HCWs) during the coronavirus disease 2019 (COVID-19) pandemic

Stressor	Description
Physical stress	Care for COVID-19 patients is particularly strenuous, since wearing of protective gear is required and specific interventions, e.g. prone positioning, are physically demanding for HCWs
Extra hours	When hospitals become overburdened by the number of patients and at the same time suffer from absenteeism of diseased HCWs, the remaining staff may require to work serious amounts of extra hours
Fear of becoming infected or transmitting infections to non-COVID-19 patients, family or friends	Close contact to infectious patients poses a risk for HCWs of getting infected and also a risk for transmission of SARS-CoV-2 to non-COVID-19 patients
Restricted visitor policy	Visiting restrictions for relatives and friends of patients causing regrets and sorrow for HCWs
No conceivable spatial or temporal boundaries of the pandemic	No outlet to escape the situation because the pandemic as well as the stressors are not confined to the hospital, and not knowing when the pandemic is going to end
Social isolation	Family members of older age are at risk and cannot be seen, family celebrations cannot take place
Fear of losing family members, friends or colleagues	HCWs may care for many severely ill patients, constantly aware of the danger of a COVID-19 infection
Frustration with political leaders	Perceived or real inconsistencies and management failures of political leaders increase the feelings of helplessness and being at the mercy of others
Frustration with administration for not having enough equipment/PPE or failure to protect/testing equipment	Perceived or real management failures of administrative staff when equipment for self-protection is not sufficiently available increase the feelings of being sacrificed, thus causing anger
Uncertainty because of frequently changing information about COVID-19	HCWs are frequently asked about their opinion and for advice; they have to deal with a lot of uncertainty themselves and can be overwhelmed when facing individuals who do not understand social distancing and deny the danger of a pandemic spreading rapidly
Moral distress	Feelings of being left alone for rationing decisions on own moral standards when there are limited supporting structures and guidelines can lead to considerable moral distress

Ongoing support for HCWs is critical at all levels, for instance, from family, friends and colleagues, as well as healthcare institutions, professional organisations, governments and society at large. The support must be aimed at protecting and maintaining the mental and physical wellbeing of HCWs and early identification of when they are at risk. For the individual, this support may come in many forms, such as meditation, exercise, creative arts therapy, and religious or spiritual activities. Furthermore, interprofessional teams caring for patients, especially in intensive care units, need to be assisted in fostering community [5]. Psychological support for those in need may include a trauma psychologist in those regions deeply affected by the pandemic. This support could also help counteract “social contagion”, an aggravation of symptoms among peers [6].

The issue of supporting HCWs, however, is not only a question of physical and mental health; there are moral questions of responsibility, solidarity and justice at stake. HCWs not only have a professional and legal obligation to provide care for patients, but also a moral obligation [7]. This moral obligation is reflected by the acceptance of professional codes like the Hippocratic oath and the codes of various medical and allied health associations. However, the extent to which this obligation is appropriate in a situation where the acceptance of it would entail a significant threat to the HCWs own health and well-being is debatable. Neither heroism nor self-sacrifice can be demanded based on a perceived moral obligation [7].

Moral imperatives, and, similarly, the legal and professional obligations derived from them, cannot be a unilateral commitment by HCWs; they should instead be considered as part of a societal contract consisting of mutual interests, rights and duties. HCWs should be able to rely on reciprocal obligations from others [8]. The scope of these reciprocal obligations is similarly context- and situation-dependent. In the setting of the COVID-19 pandemic, HCWs must be able to rely on a wide array of support, as well as the responsible behaviour of other members of society (table 2). For instance, situations in which HCWs put themselves at risk due to the lack of personal protective equipment must be strenuously avoided [9]. Similarly, reciprocal responsibility and solidarity also includes responsible behaviour of all members of society. Contact restrictions, social distancing and the wearing of facemasks in public can help save HCWs, health facilities and health systems from being overburdened. Finally, compensation for surviving dependents of HCWs who became infected during their work and died should be part of these reciprocal obligations as a matter of solidarity.

TABLE 2.

Reciprocal obligations for members of society with the goal of limiting the number of infected patients and reducing strain on the healthcare system

Societal level	Responsibilities
All members of society	Social distancing Contact restrictions and avoidance of large group gatherings Wearing of facemasks in public Frequent handwashing Protection of healthcare workers from unjustified legal action due to providing crisis standard of care
Friends, family, colleagues and neighbours	Active listening Provide emotional support Encourage healthcare workers to seek help from mental health specialists Provide help for everyday duties (e.g. shopping, childcare)
Healthcare administrators and institutions	Ensure adequate personal protective equipment Limiting healthcare workers’ workload by shifting tasks that are not absolutely necessary for patient care to non-clinical personnel Provide for counselling services Develop “work–life balance” programmes Promote self-care messaging Provide for education and teaching about recent scientific evidence related to the spread of SARS-CoV-2 and protective measures
Unions and professional organisations	Develop “work–life balance” programmes Promote self-care messaging Develop educational programmes about recent scientific evidence related to the spread of SARS-CoV-2 and protective measures Advocate for healthcare workers’ needs to employers, hospital administrations and governments Protection of healthcare workers from unjustified legal action due to providing crisis standard of care
Local, regional and national government	Ensure adequate access to personal protective equipment for institutions Support development of institutional and regional policies for rationing and triage Provide for financial protection of dependents of healthcare workers who become infected during their work Thorough explanation and public education regarding (scientific) rationale of restrictions and burdens Protection of healthcare workers from unjustified legal action due to providing crisis standard of care

When demand for resources overwhelms supply, the inability to provide standard of care due to lack of staffing or equipment raises not only moral but also legal questions [10]. HCWs, and in particular physicians, may be at risk for being sued for not providing a normal standard of care despite being in a crisis for which they themselves could not reasonably be held responsible [11]. Working under a crisis standard of care that may, of necessity, be well below the ordinary standard of care, can be a source of extreme stress for all HCWs. This stress should not be compounded by the fear of legal prosecution, whether civil or criminal. The reciprocal responsibility of society at large should therefore entail the protection of HCWs in general from legal action based on a failure to provide an impossible-to-achieve standard of care in times when clinicians are forced to practice under crisis standards of care.

One additional remedy that has been proposed is to prioritise such individuals for vaccines and treatments that are limited in availability, with the rationale resting on the instrumental value of HCWs as well as on reciprocity or even reward for their commitment to society [12]. This argument has merit, particularly in the context of preserving the HCW workforce, when it comes to the distribution of a vaccine that will not be equally available for all from the outset. However, it will be challenging to balance this argument against prioritisation according to medical need. Preserving the lives of HCWs may help preserve one of the scarcest resources in this pandemic and thereby potentially save more lives through their work at the bedside. However, prioritisation of HCWs will disproportionately benefit the educated and thereby aggravate existing social and racial disparities, which may be in conflict with egalitarian principles and equity. Several prioritisation guidelines for the distribution of COVID-19 vaccines have acknowledged prioritisation of frontline HCWs. However, other guidelines avoid taking a position with regard to favouring HCWs over elderly patients by awarding both groups the vaccine with equal priority [13, 14]. Both approaches have merit, but considering all arguments we advocate for prioritisation of frontline HCWs for SARS-CoV-2 vaccines.

Considering a broader range of treatments beyond vaccines, we believe prioritisation of HCWs for receipt of scarce resources should be subordinate to other more convincing principles. It is impossible to fairly judge instrumental value from the socially useful behaviour of a person, and to weigh it against other values. In addition, the judgement of instrumental value brings with it considerable danger of discrimination through overrating of an alleged instrumental value compared to morally competing principles, such as non-discrimination based on race, gender, age, disability or socioeconomic status.

The COVID-19 pandemic has put many health facilities and systems, and even entire societies, under unprecedented levels of stress. For reasons of justice and in order not to jeopardise the functioning of the health sector, HCWs must be able to rely on broad support to fulfil their duties for the benefit of society. Protecting and preserving the healthcare workforce has a direct bearing on the functioning of the entire healthcare system, which is paramount for the well-being of all societies.

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