Clinical Ethical Challenges in the Covid-19 Crisis in South Africa

In a recent paper, the USA-based Hastings Center, which addresses social and ethical issues in health care, science and technology, observes that in public health emergencies a shift needs to take place away from the ethical norms of standard clinical practice, which is patient-centred and responsive to individual patient preferences, towards public health ethics, which is concerned with safeguarding the health of the population by means of the best use of resources. This can entail limiting individual rights and choices.(1) They assert that “public health emergencies may feature tragically limited resources that are insufficient to save lives that under normal conditions could be saved”.(1) This necessitates decisions about how to allocate limited resources: “In a public health emergency featuring severe respiratory illness, triage decisions may have to be made about level of care ...; initiation of life-sustaining treatment ...; withdrawal of life-sustaining treatment; and referral to palliative ... care if life-sustaining treatment will not be initiated or is withdrawn”.(1) This is equally true in the South African context. However, clinicians here may be more accustomed to working with limited resources and rationing decisions, and the tension between the patient-centred and public health orientations might not be as unfamiliar or stark for them. However, this does not change the fact that triage decisions take their toll on health-care workers, emotionally. The Hastings Center asserts that one important way in which this emotional distress can be alleviated is by ensuring that there are clear rules in place for public health emergencies, for instance, “triage protocols ... help first responders to swiftly prioritize patients for different levels of care based on their needs and their ability to respond to treatment given resource constraints”.(1) Unclear rules or rules that cause patient distress can lead to moral distress in caregivers, especially in situations in which protocols require the withholding or withdrawing of treatment against the wishes of patients or their families. Thus, there is a critical need and an ethical obligation for ethics guidelines for decision-making about treatment allocation to be in place before the pandemic reaches the level where tragic choices need to be made. The question now is, what would an ethically sound policy for rationing in a health emergency look like? In a recently published paper entitled “Fair allocation of scarce medical resources in the time of Covid-19”, Emanuel et al. write that the literature on resource allocation in pandemics emphasizes four main values that should inform policies: “Maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value and giving priority to the worst off ”.(2) They go on to make six recommendations derived from these four principles. It is not possible to discuss these in any detail here, and only the four most pertinent recommendations will be briefly discussed in the following.(2) Their first recommendation is that the most important value when faced with a pandemic is the maximizing of the benefits of scarce resources. They assert, “priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life”.(2) Given the lack of time and information in this pandemic, they go on to claim that it is “justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim”.(2) Several recent publications broadly agree with this position.(3–6) Emanuel et al. acknowledge that there are many possible ways of seeking a balance between saving more lives and saving more life years, but whatever means of balancing is chosen ought to be applied consistently.(2) This recommendation applies as much in South Africa as anywhere else. The biggest challenge it presents in our context relates to the existing inequalities in our healthcare system, where the private sector is far better resourced