Pragmatic Approaches to COVID-19 Related Ethics Dilemmas for Psychiatrists.

Psychiatrists face complex ethics dilemmas in the COVID-19 pandemic era when assessing dangerousness in patients or forensic evaluees who threaten to purposely infect others or spread the virus. Understanding local public health and medical quarantine laws for their jurisdictions can help guide treating psychiatrists in how to handle some of these situations; however, challenges occur when what is ethically best conflicts with the action that will confer the greatest protection against legal liability. Additionally, the calculus of weighing competing ethics considerations changes based on how relevant it is to the duties of a particular role (e.g., treatment, forensic, research, managed care, etc.) as well as the contextual factors of the situation. We present dialectical principlism as a framework to help psychiatrists resolve such ethics dilemmas related to the COVID-19 and future pandemics, illustrating how it can be applied in different roles (i.e., treatment versus forensic) and situations (i.e., when it is clear the danger of viral transmission is secondary to a delusion versus a delusion-like belief) to come to the best outcome that balances patient welfare, legal considerations, and societal safety. Occasionally, the most ethical action may entail small liability risks.

KANT IN THE TIME OF COVID

During the coronavirus pandemic, communities have faced shortages of important healthcare resources such as COVID-19 vaccines, medical staff, ICU beds and ventilators. Public health officials in the U.S. have had to make decisions about two major issues: which infected patients should be treated first (triage), and which people who are at risk of infection should be inoculated first (vaccine distribution). Following Beauchamp and Childress’s principlism, adopted guidelines have tended to value both whole lives (survival to discharge) and life-years (survival for years past discharge). This process of collective moral reasoning has revealed our common commitment to both Kantian and utilitarian principles. For Kant, respecting people’s rights entails that we ought to value whole lives equally. Therefore we ought to allocate resources so as to maximise the number of patients who survive to discharge. By contrast, the principle of utility has us maximise life-years so that people can satisfy more of their considered preferences. Although people are treated impartially in the utilitarian calculus, it does not recognise their equal worth. Subjecting Kantian ethics and utilitarianism to the process of reflective equilibrium lends support to the idea that we need a pluralistic approach that would accommodate our moral intuitions regarding both the equal value of whole lives and the additive value of life-years. © Altman M. C., 2022.

Moral distress in medicine: An ethical analysis.

Moral distress is a negative emotional response that occurs when physicians know the morally correct action but are prevented from taking it because of internal or external constraints. Moral distress undermines a physician's ethical integrity, leading to anger, poor job satisfaction, reduced quality of care and burnout. Scarce literature exists on the ethical aspects of moral distress in medicine. We conducted an ethical analysis of moral distress as experienced by physicians and analysed it from the literature using two predominant ethical theories: principlism and care ethics. Finally, we consider the emergence of moral distress in medicine during the COVID-19 pandemic.

Utilitarian Principlism as a Framework for Crisis Healthcare Ethics.

This paper introduces the model of Utilitarian Principlism as a framework for crisis healthcare ethics. In modern Western medicine, during non-crisis times, principlism provides the four guiding principles in biomedical ethics-autonomy, nonmaleficence, beneficence, and justice; autonomy typically emerges as the decisive principle. The physician-patient relationship is a deontological construct in which the physician's primary duty is to the individual patient and the individual patient is paramount. For this reason, we term the non-crisis ethical framework that guides modern medicine Deontological Principlism. During times of crisis, resources become scarce, standards of care become dynamic, and public health ethics move to the forefront. Healthcare providers are forced to work in non-ideal conditions, and interactions with individual patients must be considered in the context of the crisis. The COVID-19 pandemic has forced healthcare to shift to a more utilitarian framework with a greater focus on promoting the health of communities and populations. This paper puts forth the notion of Utilitarian Principlism as a framework for crisis healthcare ethics. We discuss each of the four principles from a utilitarian perspective and use clinical vignettes, based on real cases from the COVID-19 pandemic, for illustrative purposes. We explore how Deontological Principlism and Utilitarian Principlism are two ends of a spectrum, and the implications to healthcare as we emerge from the pandemic.