Q & A – Ethical Challenges with COVID-19

In this Q & A, Andrea Sturm and Ian Edwards talk about ethical dilemmas and challenges we are all facing due to the coronavirus pandemic. Ian Edwards is an ethics expert, and has featured in many Physiotherapy resources before, some of which you may be familiar with including a recent International ethics study. It is an interesting conversation with some take home lessons for us all.

AS: Hello Ian! As always it is a pleasure talking to you. We met first a few years ago when doing an interview for our Physiopedia Online Course ‘Applied Ethical Reasoning’. You highlighted your concept ‘The Ethical Reasoning Bridge‘ and it’s components for us.

What I really like about it is the flexibility that allows to adapt the ER Bridge to any specific context, no matter, if might be cultural or situational, without losing sight of it’s key elements. It is one of the few ethics concepts I know that embraces our professional obligations and duties plus the individual circumstances of the patient and their system. Simultaneously it’s paying respect to the ambiguity and multifacetedness of any kind of human interaction. That is key in such unprecedented times like ours.

To me it is easy to recognize that this has not been developed by someone sitting behind a table who is theoretically philosophising about ethical questions. What were the professional or personal circumstances, that led you so deeply and lively into professional ethics?

IE: Thanks Andrea. It’s good to talk with you once again. I became interested in professional ethics, or more particularly teaching ethics, after I went back – as a mature age student – to do further physiotherapy study. Having worked as a physiotherapist in other cultures I had become interested in the question ‘Why do people do what they do?’ But such a question is really like the hub on a wheel, with spokes that link to culture, poverty, health, injustice, war and conflict and the myriad of influences which arise from each of these. And, of course, one can’t ask a question like that with respect to others without asking it of oneself – as a person and a health professional. So, professional ethics for me was therefore never just about teaching others what makes up the ‘nuts and bolts‘ of a professional code of conduct or warning students about the potential consequences of not adhering to such codes. It was much more about exploring the moral terrain between ‘what we ought to do‘ and ‘what we actually do‘ and seeking to understand what happens to us and within us in that space. And that is what ‘The Ethical Reasoning Bridge‘, as a model, seeks to help explain.

AS: Currently our profession is facing immense challenges due to the new form of the Coronavirus, that keeps the world in suspense. PT Clinics are locked down, if by governments or due to the personal responsibility an individual therapist feels towards his or her vulnerable clients or themselves. Deciding for the right thing to do causes in many cases financial shortages to these colleagues, which are not always compensated by national emergency security plans.

A lack of PPE’s (personal protective equipment) not only in low resource countries but nearly all over the world puts health care professionals sometimes at undue risks when working at the frontlines of health care to save infected persons. Medical ethical values and also the understanding of the profession until now are at stake. Our current PT generations – except colleagues working for the military or in conflict zones – were usually not confronted with procedures such as triage or questions how to handle questions regarding our own safety when helping others. We also have loved ones we care for and who are concerned about our well being.

You have worked in conflict zones and war torn countries, where a lack of personal safety and resources were the order of the day. What are your thoughts on ethical challenges of this crisis and how did you respond to your own dilemmas regarding such issues?

IE: Yes, I think that there are parallels to working in war zones and working during this pandemic in places like hospitals which mimic war zones. Risk management is certainly a common thread. But unfortunately risk management is not a perfect calculation or science that provides a 100% guarantee that all will end well. When I was last working in Afghanistan we used to get daily updates delivered to our mobile phones which advised us of current ‘incidents‘ and whether it was safe or not to go to work and which route(s) we should take or not take to get there. Interestingly, we also used the term ‘lock down‘ at that time to describe times when we were confined to our houses during periods of unrest. And so, staying safe as a health worker is a reality which can take various forms at different times according to context. Technology is vital, whether it be in the form of aid workers in Afghanistan receiving SMS updates or frontline healthcare workers being equiped with the right PPE when treating patients with Covid19. In addition to technology and expertise, however, working in uncertain situations also requires strategies for monitoring one’s own level of stress and well-being. And then further to technological and psychological support strategies, I think that there is also an ethical perspective that underpins one’s ability to work in such situations. And that has to do with the nurturing of conviction and belief in the value of what one is doing in placing oneself at risk.

Reflecting on the value of what you are doing, in turn, inevitably brings to notice the increased vulnerability which others are experiencing around you. It has been sobering to witness the other effects of Covid19. Health inequity has brought in to sharper focus as the poor suffer most from being locked down and unable to work. And those with existing poor health and limited access to health care are made even more vulnerable to the more serious or even fatal effects of Covid19. And then, on a different note, even in Australia, we have seen racism rear its ugly head during this time as non Anglo Australians are abused in the street or on public transport. It therefore becomes a different form of ethics to widen our focus as health professionals from that which is purely on the physiological effects of the virus on patients to one which also recognizes the harms inflicted on people in other ways.

AS: Thank you for highlighting these important aspects, Ian. After a fruitful and productive life as a PT clinician and academic at the University of South Australia you retired but still are busy with some research projects and writing a single author book about ethics. I would be interested in what force drives you to still advocate for our profession whilst you could easily Stand-up-Paddle at Seacliff Beach or hike in the Flinders all day long?

IE: I became a physiotherapy teacher only in the latter part of my career and remain grateful for that opportunity and the satisfaction it has brought me. But I have to say that I never enjoyed teaching more than when I was in Afghanistan. Even though I was alluding above to some of the dangers of being there, I came to also appreciate its rewards. I was continually inspired by my Afghan colleagues‘ thirst for information and their persistence to go on learning in very challenging situations, both at work and in the general situation around them. My recent writing reflects on how I was challenged both personally and ethically at various times during my introduction to Afghanistan and subsequent teaching visits there. The way through all of that was, in part at least, to recognize what my Afghan colleagues (and other Afghans) were able to teach me.

I have the freedom now to write about these things drawing more on my personal experiences rather than from ethics textbooks. I also get to use plain language rather than academic language. And I have enjoyed doing that.

AS: I am convinced all of your contributions to the profession are highly appreciated. To be honest – it would be a pity if you keep all your knowledge and experience to yourself. Thank you so much for talking with us, Ian. Stay safe in these challenging times!

Andrea Sturm is a PT clinician, educator and researcher with interest in Ethics and Mental Health from Austria. She is a Physioplus tutor and developed their Online Ethics and Mental Health Programmes. Recently she created a new short course addressing mental health of patients and health-care professionals during the Covid19 pandemic.

Ian Edwards has contributed to several books and chapters:

  • Edwards I & Delany C 2019. Ethical reasoning. In: Clinical Reasoning in the Health Professions. Higgs J, Jensen GM, Loftus S and Christensen N eds. 4th Ed. Elsevier: London pp 169-180.
  • Delany C & Edwards I 2020. From Ethical Reasoning to Ethical Action. In: Clinical Reasoning and Decision Making in Physical Therapy: Facilitation, Assessment and Implementation. Musolino GM and Jensen GM eds. Slack Inc: Thorofare, NJ pp 47-56
  • The Second-Time Teacher: Lessons from Afghanistan. Ian Edwards 2020.