Covid-19 has amplified moral distress in medicine

Dear Editor

Covid-19 is one of the most challenging crises for our current generation of health care affiliated staff. Robust attention to self-care and well-being needs to be a priority consideration sustained for all.
Sheather and Fidler (1) outline the risks of moral distress (2) in health care professionals as one of the many challenges faced during the covid pandemic. We agree all health care organisations need to be actively supporting staff, promoting insight and advice through established real-time peer support networks and reflection forums.

In their GMC appointed research, West and Coia underpin an ABC structure of core needs for investment in well-being of doctors – Autonomy/control, Belonging (within teams) and Competence (3 ). Inevitably, as a result of redeployment, altered training paths and continued clinical pressures during each wave of the pandemic, these parameters have been significantly impacted, particularly for junior medical staff.
We are proud of the resilience, professionalism and dedication all those delivering health care have demonstrated over the past year. We must work hard to negate the risks of burnout and post-traumatic stress disorder, subsequently reconciling meaningful career paths, for this most precious commodity within our National Health Service (NHS).

In addition to the enhanced well-being resources currently within organisations, there should be planning to establish and galvanise mentoring, support and coaching teams for health care staff in training for many years to come. This strategy may benefit from being operationally managed, appropriately resourced and devolved from a national template such as Health Education England.

In establishing such an advisory network, we should continue to include health care workers who leave the NHS either through end of fixed term contract or for other reasons, as they will have reduced access to support networks and systems traditionally provided by employers.

An example of such a group will be UK foundation year 2 doctors. A GMC report indicated that only 37% of doctors finishing foundation training in 2018 directly entered speciality training, a progressive decline each year from 66% in 2012 (4). The current foundation year 2 trainees have had both their foundation year 1 and 2 placements significantly affected by challenges of the pandemic. Many may choose not to progress to a recognised training post from August 2021, with the risk of becoming a ‘lost tribe’ with little or no access to on-going support.

In recognising that morale and attainment of all trainees may be compromised, there must now be focus to avoid disenchantment and attrition of our highly trained workforce, facilitating them to achieve their career aspirations and dreams. As Sheather and Fidler concluded– we must not let this pandemic ‘eat our children’ (1).

Cecilia M Jukka and Christopher J Webb, Foundation Training Programme Directors, Royal Liverpool University Hospital, Liverpool University Hospitals Foundation Trust.

References
1. Sheather J, Fidler H. Covid-19 has amplified moral distress in medicine. BMJ 2021;372:n28.
2. Greenberg N, Docherty M, Gnanapragasam S, Wessley S. Managing mental health challenges faced by health care workers during covid-19 pandemic. BMJ 2020;368:m1211.
3. GMC 2019. West M and Coia D. Caring for doctors; Caring for Patients. https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-p... [Accessed 4th February 2021]
4. GMC 2019. The state of medical education and practice in the UK. https://www.gmc-uk.org/-/media/documents/somep-2019---full-report_pdf-81... [Accessed 4th February 2021]

Dear Editor,

Every day, the COVID-19 pandemic dramatically reminds us that we are social beings, for better or for worse. We can readily acknowledge that celebrations with our friends and family are essential for our well-being or that, even when they annoy us, we are happy to meet up with our colleagues around the coffee machine. Yet it is more difficult to admit that, when faced with illness, and especially when this is contagious, we are still social beings.

Indeed, contagious illness metamorphizes each of us into a hybrid being, both victim and vector of a health threat . As victims, we have the right to demand to be protected, looked after, with help tailored to our particular needs as much as possible. However, as vectors, we must accept that we constitute a threat to our peers and that it is legitimate that society impose reasonable rules and constraints to contain this threat. This is the sanitary Janus engendered by the contagious malady: one overwhelmed face needing care, and one threatening face against which we need protection.

While this description might strike you as an accurate depiction of daily reality, it remains difficult to accept if we adhere to bioethics guidelines. For years, there have been attempts to convince us that, as patients, users of healthcare services, we are autonomous individuals who must be respected by health professionals. We have the right to be informed with respect to our illnesses, to consent to the treatments proposed, to refuse them if we are not happy with them. In short, each of us, as an individual patient, is free to follow his or her own health path. Obviously, all this can only be possible in an individualistic society dominated by a vision of liberty reducible to self-determination and freedom of movement.

Yet suddenly, with COVID-19 every one of us is forced to consider his or her freedom to make decisions in relation to others. The sacrosanct individual autonomy shifts towards relational autonomy . Human beings are no longer islands, isolated from the continent; they are kept afloat thanks to their community roots and in respect for them.

When the epidemic arrives, a new health ecosystem must replace the old one. This is not a matter of simply eliminating individual liberties. Of course, these remain essential, but they have to be balanced with the promotion of the common good. The individual human is one among many and must find his or her place within the community in which he or she is evolving and for which he or she is morally responsible.
Thus, a Copernican revolution is occurring in the small world of bioethics. Knowing that, through contamination, we can harm others, we have the moral duty to put everything to work to avoid transmitting our condition to others, even at the risk of our own autonomy.

Must we cry wolf, weeping about our restricted, threatened, flouted individual liberties? Clearly not, since, essentially, health precautions and measures to avoid contaminating others in case of infectious diseases are generally not very demanding on an individual level and offer, in return, enormous social benefits. Indeed, while the simple seasonal flu or COVID-19 are merely a bad time for most of us, nevertheless they can have fatal consequences for the most fragile among us (seniors, the immunosuppressed, the disabled, etc.). In these circumstances, preventative measures such as vaccination, handwashing, social distancing in case of infection, etc., assume all their moral significance. The balance between, on one hand, individual efforts, even sacrifices and, on the other, social benefits falls clearly on the side of the benefits.

However, avoiding hysteria about reduced individual autonomy does not signify sinking into a blessed naivety. There is a real risk of sliding into health totalitarianism, with new champions of 21st century healthcare ethics pretending that community health must be preserved at any price, even at the cost of basic individual liberties.

Faced with this risk, we must defend the idea that the moral obligation to avoid wilfully infecting others can be neither limited nor unconditional. In that regard, it would be useful to recollect the sad history of Mary Mallon . “Typhoid Mary,” as the press of the day called her, was a young American cook with typhoid fever, without ever presenting any symptoms. Today, we would call her a “super-spreader” who infected hundreds of people. In 1907, she was confined to isolation at Riverside Hospital in New York, which she left in 1910, just as contagious as before. Although the health authorities forbid her to practice her profession, she still accepted a position as a cook in a maternity hospital in Manhattan where again she spread the disease. Subsequently, she was put into quarantine until her death in 1938.

Thus, the COVID-19 epidemic serves to draw us out of our ethical torpor in reminding us of our duty with regard to the communities which welcome us. But this brutal awakening should not disturb us to the degree that we lose all sense of judgment. Our contagious existence must certainly incorporate the need to protect the community, but not at the price of refusing to exist, because without individuals, society disappears.

Prof. L. J.-C. Ravez (University of Namur)