This guidance aims to remind psychiatrists of the ethics principles which will help them and their teams and colleagues to articulate and resolve these dilemmas.
Services and the NHS are likely to be under unprecedented pressure as the COVID-19 pandemic grows. The UK government is considering introducing emergency legislation for this period, including temporary changes to the Mental Health Act 1983 England and Wales, The emergency Coronavirus Bill also amends the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Mental Health (Northern Ireland) Order 1986.
For doctors working in mental health, learning disability and autism services, usual ethics principles apply – see General Medical Council and Royal College of Psychiatrists. In addition, see the report published by the World Health Organisation on ethical considerations in developing a public health response to pandemic influenza. The Faculty of Public Health has also provided briefings on the legal and ethical dimensions and providing professional & public guidance.
the Legal and Ethical Dimensions and Providing Professional & Public Guidance
However, this pandemic is likely to throw up some dilemmas for which more specific advice is needed.
It is strongly recommended that all psychiatrists check that their local clinical ethics committees are in place as they can provide advice and guidance in real-time.
The BMA have produced guidance on the ethical issues arising from COVID-19
The College has also endorsed the following guidance developed by the Royal College of Physicians –
Particular dilemmas for psychiatrists
Most issues will arise in the first instance from reduced staffing (itself due to suspected or confirmed CoViD or other illness, indirectly due to childcare should schools close, or if families are infected, etc) with the following possible consequences:
- Reduced inpatient beds
- Reduced clinical offer (fewer therapeutic and recreational activities on offer)
- Blanket restrictions on all patients
- Greater reliance on physical and procedural security measures to compensate for reduced relational security
- Less communication with families, relatives, carers
- In secure services, less ability to support escorted community leave
- Mental health, learning disability and autism services may need to prioritise the most unwell individuals and those presenting the most severe behavioural challenges.
Principles to be borne in mind in resolving particular ethical dilemmas include fairness and distributive justice, equity, respect for autonomy, necessity, proportionality and reciprocity, and beneficence and non-maleficence, whilst continuing to promote empowerment, autonomy and recovery. All approaches need to remain consistent with human rights – the Universal Declaration of Human Rights and the Convention on Rights of Persons with Disabilities.
- We must ensure equity of access for individuals with mental disorders, learning disability and autism to CoViD assessments, testing and treatment (i.e. ensuring that these individuals are not considered lower priority purely on this basis alone).
- We must make “reasonable adjustments” to ensure equity of access – this is the driver for people with learning disabilities and autistic people in particular but obviously applies to all disabilities.
- We must ensure that public information and health advice is not discriminatory or disadvantaging e.g. insistence on using on-line support for COVID information.
- It is important to ensure that in such crises situations, individual needs and preferences are not automatically considered secondary to collective or community needs.
- However, public health approaches clearly involve a degree of restriction of ordinary freedom in the context of social distancing. This may need to be enforced, especially for individuals in our care who are vulnerable – this will require careful consideration in each instance.
- In addition, we must stay aware that these social distancing measures may need to be enforced upon individuals whose liberty is already restricted by virtue of being detained under the Mental Health Act, but who retain capacity to make decisions for themselves. Therefore, decisions may have to be made in the best interests of all, not just the individual.
- Ultimately, each case turns on its own merits.
- Whilst it is the case that all health professionals are at increased risk by virtue of their work, we must remember the professional obligations of doctors and psychiatrists, as laid out in GMC Good Medical Practice and RCPsych Good Psychiatric Practice.
- Doctors have a duty in such circumstances to consider all requests for redeployment to areas of greater need, andmust also ensure that we have a suitable degree of competence in any duties undertaken.
- Doctors must be aware that crises such as global pandemics will cause such complex ethical dilemmas as to cause moral conflict for individuals, especially when there appear to be differing directives. As ever, doctors have a duty to raise these with their supervisors, and attempt to resolve where possible. Equally, doctors must not only satisfy themselves that they are acting in good conscience, but also in accordance with the GMC Good Medical Practice and RCPsych Good Psychiatric Practice.
- It is important to ensure that patients and families have clear advice regarding what is done with information pertaining to CoViD in individual patients – there will be an obligation to report some data for pandemic management and future learning. However – as ever, the duty of confidentiality to individual patients remains.
- Psychiatrists must ensure they use legislation, both the Mental Health Act 1983, and any emergency legislation introduced, appropriately and fairly.
- The Mental Health Act must be utilised for the assessment and treatment of mental disorder only, not for the treatment of physical illness, except where the physical disorder is ancillary to mental disorder, as per current practice. Psychiatrists must adhere to the principles of the Mental Capacity Act.
- Psychiatrists and mental health services will need to adapt quickly to working differently during this pandemic. Much routine clinical work including consultations will need to be done virtually.
- This will require changing a number of areas of practice, including, for instance, assessing and managing risk on the basis of remote consultations, whilst remaining aware of the usual rules of confidentiality and record-keeping.
- Any alterations of service, especially withdrawal of routine treatment or diversion of resource to CoViD management, may impact on the health and emotional wellbeing of patients. We will therefore need to carefully consider of the impact of changing clinical practice rapidly upon patients and their families.
- Please see the College’s digital policy for the CoViD pandemic.
- We must remain transparent with patients and families as well as colleagues and other stakeholders about dilemmas and difficulties that services face in a crisis, when difficult decisions may have to be made about prioritising clinical need and resource allocation.
- The GMC Good Medical Practice and RCPsych Good Psychiatric Practice are clear that part of the duty of care of doctors towards their patients includes protecting our own health and the health of our colleagues.
- The social contract between doctors and society is bidirectional – so whilst doctors must use their training and skills, their employers have an equal duty to ensure that minimum protection such as adequate PPE is available.
- Does the organisation have an existing clinical ethics committee? It may be possible to repurpose that to focus on ethical dilemmas from the pandemic
- If not and you are setting up a forum from scratch, consider the organisation - is it mental health only? Does it offer acute physical health services? This will help determine issues such as terms of reference, membership and scope
- Terms of reference - could limit to issues arising from COVID-19 only, or could consider all ethical dilemmas. It may be best to be prepared to consider all ethical dilemmas, especially if there is no pre-existing ethics committee, in that clinicians are keen to raise issues and it promotes the importance of clinical ethics generally. This decision will need to depend on capacity. There is much useful information available from the UK Clinical Ethics Network website, which is not specific to pandemics ethics groups but remains a useful starting point. It is important to note that clinical ethics groups do not provide research ethics advice
- Membership - it is important to have some technical expertise (a background in the theory and practice of clinical ethics, ideally an ethicist) in addition to multi-disciplinary clinical and non-clinical representation. Legal members, plus members with expertise in safeguarding and the Mental Capacity Act should be considered.It is important to have a link with the organisational executive leadership so emerging risks and themes can be flagged - especially if the pandemic requires a departure from usual clinical practice. The background of the clinical members will need to depend on the organisation's service provision. Membership should be limited to around six or seven people to make the forum manageable, while also identifying others with specific skill sets that can be called upon when required
- Chair - it is important as far as possible to have a consistent chair, with a deputy for when the chair is not available
- Frequency and timing - ethical dilemmas during the COVID-19 pandemic are likely to arise at short notice and more frequently than normal. It is suggested that daily meetings should be scheduled with an hour allocated as standard, which are only stood down when no cases are provided for discussion
- Mode - meetings can be conducted virtually on platforms such as Skype. It needs to be a secure platform because sensitive, individual patient information will be discussed
- Administrative support is essential for setting up meetings, compiling minutes or meeting notes and preparing reports for the board.
- Minutes - a decision is needed at the start about whether verbatim minutes are required or if meeting notes are sufficient.
- Identification of cases - it is suggested that a daily deadline is established for cases to be brought to the committee, ideally with a brief written summary provided beforehand. This will allow committee members to read the summary and if there is no case to hear, members can be advised in good time. Referral routes need to be simple, straightforward and not bureaucratic
- Case discussion - some committees prefer to use a very structured approach, mandating the use of a set of criteria, while others prefer a more eclectic approach. There is a balance to be achieved between applying an ethics 'formula' and allowing a more global discussion without losing the core ethical dilemma. Refer to the other resources on this page to help determine the most appropriate approach.
- Be aware that not all clinicians will have the language of clinical ethics through which to articulate their dilemma and will need help to reach that point.
- Advice - ethics committees are usually advisory rather than executive, so the final decision on how to proceed should remain with the clinician/team. The ethics committee provides a view and advice, but does not take over the function of the clinician or the team.
- Sharing information - consider beforehand how the minutes/summary notes will be shared and with whom. If minutes are detailed with patient identifiable information, consider carefully the value of sharing widely - usual rules of confidentiality still apply. One way forward may be to summarise every week any key general themes to share more widely, with actual minutes/summary notes only made available to members and the clinical staff/team which presented the dilemma.
- Review effectiveness and utility of the committee every so often.