Ethics and law

Postgrad Med J: first published as 10.1136/postgradmedj-2020-138344 on 10 October 2020. Downloaded from http://pmj.bmj.com/ on October 21, 2020 by guest. Protected by copyright.
COVID-19 and medical professionalism in a pandemic
Denis Harkin

Regional Vascular Surgery Unit, the primacy of patient welfare, patient autonomy
Royal Victoria Hospital, Belfast EDITORIAL
Health and Social Care Trust, The global pandemic caused by transmission of the and social justice.4 In the UK, the Royal Society
Belfast, Northern Ireland, UK novel severe acute respiratory syndrome coronavirus of Physicians defined medical professionalism as
2 (SARS-CoV-2) and resultantCOVID-191 has created ‘a set of values, behaviours and relationships that
Correspondence to a crisis worldwide for health, healthcare and society. underpins the trust the public has in doctors’.9
Denis Harkin, Regional Doctors and healthcare workers will confront fears, Upon these professional foundations are built
Vascular Surgery Unit, Royal the professional codes of both the UK’s General
Victoria Hospital, Belfast and endure risks, making many difficult life-or-death
Health and Social Care Trust, decisions to treat patients and support colleagues as Medical Council8 and Irish Medical Council.9
Belfast BT12 6BA, UK; denis. we confront this pandemic. United, in common pur- Here we discuss how the key principles of medical
harkin@belfasttrust.hscni.net pose, we shall prevail against this generational chal- professionalism, as set out by the American Board of
lenge reliant upon our medical professionalism. Internal Medicine Foundation,47–9 may guide us as
Received 28 May 2020 On 31 December 2019, the WHO China country we strive to act in patients’ best interests and for the
Accepted 29 June 2020 greater good of society during this greatest public
Revised 25 June 2020
office was notified of a severe contagious novel
pneumonia outbreak in Wuhan, China, and con- health emergency for many generations.
cerned by the severity of illness and rapidity of
spread, it was declared a Public Health Emergency THE PRIMACY OF PATIENT WELFARE
of International Concern on 31 December 2019.1 Doctors have a primary responsibility to act in the
The infection due to SARS-CoV-2 and the resultant best interests of their patients, without being influ-
coronavirus sisease first identified in 2019 was enced by any personal consideration.7 8 10 We provide
named COVID-19 by the WHO and declared care with compassion to vulnerable patients in extra-
a global pandemic on 11 March 2020.1 2 COVID- ordinary moments of fear, anxiety and doubt. Patients
19 is asymptomatic or causes mild illness in most, with COVID-19 can progress rapidly to severe type-1
but in a significant minority causes severe interstitial respiratory failure, necessitating intubation, ventila-
pneumonia and type-1 respiratory failure with tion and critical care management.1 2 5 6 In the earliest
florid systemic inflammatory response leading to epicentre of the outbreak in Wuhan, China, the death
multisystem organ failure and death. Worldwide, rate was as high as 5.25%.2 5 Worldwide deaths have
millions of people have been infected and hundreds mostly occurred in elderly patients and those with co-
of thousands have died, and among them are many morbid disease. Epicentres, overwhelmed by
front-line healthcare workers and surgeons.1–4 demand, have had insufficient ventilators for all in
Epicentres have been overwhelmed by the demand clinical need and have directed finite and scarce
for critical care support even in countries with well- resources to those who are most likely to survive.
resourced healthcare networks and have had to Altruism is defined as the selfless concern for the
divert any available resource to cope with the pan- well-being of others.8 COVID-19 has been trans-
demic surge.1 2 5 6 Our doctors will be asked to make mitted within the hospital setting to infect healthcare
many challenging decisions as this global pandemic workers, inpatients and visitors.6 Indeed, during the
now rages across Europe, the UK and Ireland. global pandemic, thousands of healthcare workers
Doctors will face unique challenges while have died with COVID-19 succumbed to the disease.
managing the pandemic, including the personal Our doctors, nurses and healthcare professionals,
risks of infection and the professional challenges despite those risks, have continued to selflessly
of healthcare rationing, clinical priorities and place themselves at risk to help patients and support
working within a severely restricted health each other. However, to sustainably care for others
service.7 Doctors are also aware that significant we must care for ourselves, and that demands we don
collateral damage will arise from delays to diag- effective personal protective equipment (PPE) and
nosis and treatment of other acute and chronic adhere to infection-control protocols even if that
conditions. In practice, medical professionalism delays or reduces patient contact in an emergency.
will involve the interaction between doctors and In a pandemic, some individual patients’ best
patients, and this should be a partnership based interests may come secondary to the primacy of
© Author(s) (or their on respect, integrity and accountability.8 societies greater good.8
employer(s)) 2020. No Prerequisite to a healthy patient–doctor relation-
commercial re-use. See
rights and permissions. ship is trust; the patient must be able to place PATIENT AUTONOMY
Published by BMJ. trust in their doctor to act in their best interests. In law, autonomy is often considered a negative right,
Physicians in ancient times pledged upon the rather a right to refuse treatment, sometimes termed
To cite: Harkin D. Postgrad Oath of Hippocrates3 to act: ‘for the benefit of non-interference.8 In contrast, to interpret autonomy
Med J Epub ahead of print:
[please include Day Month my patients, and abstain from whatever is deleter- positively would arguably entitle everyone to any
Year]. doi:10.1136/ ious or mischievous’. More recently, the American requested treatment, regardless of medical advisabil-
postgradmedj-2020- Board of Internal Medicine Foundation defined ity or competing claims for finite resources.8 11 12
138344 three fundamental principles of professionalism: However, to interpret autonomy in that positive
Harkin D. Postgrad Med J 2020;0:1–2. doi:10.1136/postgradmedj-2020-138344 1
 Ethics and law

Postgrad Med J: first published as 10.1136/postgradmedj-2020-138344 on 10 October 2020. Downloaded from http://pmj.bmj.com/ on October 21, 2020 by guest. Protected by copyright.
respect would be considered incompatible with other ethical prin- Justice dictates that as doctors will endure these changes,
ciples of non-maleficence (first do no harm), social justice (fair society (including employers and our professional bodies) should
distribution of finite or scarce resources) and indeed with the ensure staff are appropriately supported through and beyond the
practical reality of the provision of healthcare provision in pandemic in respect to health, well-being, career, indemnity,
a pandemic.12 licencing and revalidation.
In partnership with patients, the doctor has a duty to be honest,
and educate and empower patients so they may make the appro- CONCLUSIONS
priate informed choices about their medical care. During this Doctors have a duty and responsibility to act according to the best
pandemic, elderly patients and those with co-morbid disease values of medical professionalism, and society has
may be considered most vulnerable, and yet are also the least a corresponding duty to ensure the infrastructure and support
likely to survive. We as doctors are not obligated to offer treat- available allow doctors to deliver those responsibilities as safely as
ments that are considered to be futile. However, to withhold or possible. Our professionalism will help guide doctors to do the
withdraw precious life support from one individual considered right thing and strive to get the best available outcomes for their
less worthy for use in another more worthy patient creates a real patients during this COVID-19 pandemic. There will of course be
dilemma for the doctor as patient advocate and public servant.8 pain, but we shall persevere and together hope to build a better
The practice of medicine can be distinguished by the need for future to honour those who are lost along the way.
good judgement in the face of uncertainty. We must rely on our
professionalism to do the right thing and be open and honest in
Acknowledgements The responsibility for the content lies with the author and the
communication with patients and families. If we are to maintain views stated herein should not be taken to represent those of any organisations or
the public trust, we must also be candid when treatment choices groups with and for which he works.
are restricted by the availability of resources rather than the Twitter denisharkin.
clinical needs.
Contributors DWH conceived, researched and wrote this article.
In a pandemic, when finite resources become scarce, some
patient’s choices will be restricted and in some situations withheld. Funding The author has not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests The author has read and understood the policy on declaration
of interests and has no relevant interests to declare.
SOCIAL JUSTICE
The principle of social justice in healthcare obliges us to take into Patient consent for publication Not required.
consideration the needs of all patients and availability of Provenance and peer review Not commissioned; externally peer reviewed.
resources as we appraise our individual patients’ needs.4 We This article is made freely available for use in accordance with BMJ's website terms
have seen that in pandemic epicentres, highest death rates have and conditions for the duration of the COVID-19 pandemic or until otherwise
coincided with a breakdown of overburdened local healthcare determined by BMJ. You may use, download and print the article for any lawful, non-
commercial purpose (including text and data mining) provided that all copyright
systems. The critical care demand has overwhelmed even well- notices and trade marks are retained.
resourced healthcare systems such that subjective evaluations of
the benefits and burdens of life support have had to direct finite ORCID iD
resources to those patients most likely to survive.5 6 12 Grave Denis Harkin http://orcid.org/0000-0002-4701-8350
decisions such as these should not be taken alone but by working
in partnership with patients, colleagues and teams. Barriers to
multidisciplinary team (MDT) decision-making created by the REFERENCES
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2 Harkin D. Postgrad Med J 2020;0:1–2. doi:10.1136/postgradmedj-2020-138344