In March and April last year as the COVID-19 pandemic made its presence felt in the UK, there were a number of concerns that the NHS might find itself overwhelmed, and that demand for intensive care unit beds, mechanical ventilation, and other critical care interventions would outstrip supply. In those circumstances, agonising decisions about which patients should be prioritised for certain care and treatment would have to be made.
There were calls for national guidance on how such decisions should be approached. Whilst a number of professional organisations have provided advice to their members, this does not meet the need for authoritative and comprehensive national guidelines.
As the very worst fears of scarcity did not come to fruition, neither did any national guidance or ethical framework. Nearly one year on, however, record increases in daily COVID-19 cases combined with routine winter pressures in the NHS threaten to overwhelm and engulf. These decisions are no longer a worst-case scenario, but an immediate reality.
The prolonged nature of the crisis has exacerbated the problem. The pandemic has had swingeing impacts on other parts of the NHS, causing major disruption to planned hospital treatment and other routine appointments for millions of patients - most notably in the diagnosis and treatment of cancers. The longer the crisis continues, the less justifiable it becomes to ignore health needs unrelated to COVID-19 - whether emergency needs or those that have been overlooked or exacerbated by long delays in diagnosis or treatment. Questions about resource allocation must now contend with trade-offs between COVID and non-COVID care.
In the event that demand outstrips supply, how should clinical teams proceed? Should they prioritise the worst-off patients most in need of treatment? Or should they choose those with the greatest chance of survival? Is it simply chance of survival that is relevant or is a matter of considering quality of life in that survival? Can it be justified to prioritise younger patients over older patients? Is that discriminatory?
These are not just matters of intellectual curiosity, but are the questions needing answered on the frontline. There is an overwhelming need for clear, robust and authoritative guidance about how these decisions should be made. That is why we are today calling on the government, urgently, to:
- issue nationally developed and co-ordinated guidance on how decisions about the allocation of constrained resources should be made;
- ensure that this is developed at pace, whilst endeavouring to hear a broad range of perspectives and voices; and
- communicate clearly the advice being given to healthcare professionals and members of the public, setting out the ethical considerations that have informed decisions and why. Doing so is essential to ensuring public trust and confidence.
Guidelines must be authoritative, in enabling clinicians to act with confidence in caring for patients. They must be clear and definitive, so there is little or no room for ambiguity or uncertainty in their application. They should be robust so that they can be used continuously, even in the face of fast-moving developments, and transparent so decisions being taken can be seen and understood by all. They should be seen to have been developed fairly and credibly. Crucially, and underlining the importance of nationally agreed guidelines, they must be consistent across the health service so that treatment is not dependent on where you happen to be.
To leave these decisions to a local or individual level is manifestly unjust. It is unfair to the clinicians working under extreme pressure, under fear of litigation or professional sanction, and at risk of severe moral distress. It is unfair to patients and their families to not understand why or how these tragic decisions are to be made. It is unfair and disingenuous to the public at large to refuse to acknowledge that these decisions will have to be made, or to communicate openly about how healthcare professionals will make those decisions.
These are heart-breaking decisions and there are no ready-made answers. We do not have all the answers, nor can we claim to speak on behalf of everyone. We are ready, however, to engage in and support discussion to develop ethical guidance which will endure long past the COVID-19 pandemic.
Dave Archard, Chair of the Nuffield Council on Bioethics
Hugh Whittall, Director of the Nuffield Council on Bioethics
On behalf of the members of the Nuffield Council on Bioethics
Contact: Sophia Griffiths, Acting Communications Manager, firstname.lastname@example.org, 07718136512.