By Aamir Khan, Andria Bianchi and Angela Gonzales

Bioethicists support clinicians, patients, families, and staff who encounter ethical dilemmas (i.e., situations in which it is difficult to determine how one ought to/should respond when multiple options can be pursued). When a person asks, “How should I respond to this situation? Should I pursue option A, B, or C?” then they may be experiencing an ethical dilemma.

Upon being consulted, ethicists typically try to facilitate fair decision-making processes so that an ethically defensible decision is agreed upon. Sometimes, however, even the most defensible option is not ideal. Depending on the circumstances, decision-makers must sometimes make decisions by determining which option is the least bad amongst a list of unfavourable options.

An example of where this kind of decision-making has potentially had to occur is in the dissemination and use of personal protective equipment (PPE). As a result of COVID-19, PPE is in short supply. This is problematic insofar as healthcare workers need PPE to prevent exposure to and transmission of COVID-19.

The scarcity of PPE has forced organizations, leaders, and healthcare providers to make difficult decisions about how PPE ought to be used. While a best-case scenario would be to provide all providers with enough PPE so that they can work in accordance with best practices, the resource shortage has made this option nearly impossible. Consequently, some providers have been advised to extend their use of PPE beyond a single patient interaction (i.e., under circumstances that would typically warrant changing equipment) and to return some of their used masks to be sterilized and reprocessed.

One reason that the above decisions may, from some perspectives, be ethically defensible is if the potential benefits to society outweigh the possible harms and if there are no better alternatives available (i.e., if it is the least bad option given the current context). For instance, if it is known that using PPE in accordance with best practices will result in a rapid elimination of useable PPE from which healthcare workers will not be protected at all, then altering standards may be deemed justifiable.

In addition to the use of PPE, its dissemination is also worth exploring. In order to ensure that frontline staff are provided with a fair and equal opportunity to protect the health and safety of themselves (as essential care providers), as well as the people they care for, we ought to ensure that those who are situated both in and outside of hospital walls are recognized. Several campaigns are presently occurring to solicit PPE for healthcare professionals; these campaigns are primarily focused on hospital settings.

One group outside of hospitals that has made news headlines is staff working in long-term care. According to the Ontario Nurses’ Association, long-term care staff are working in unfathomable conditions and require access to appropriate PPE immediately. Because of the number of COVID-19 cases occurring in long-term care amongst residents and staff, as well as a lack of available PPE, facilities are substantially understaffed and require human resources as well as equipment.

In addition to long-term care (and plausibly many other settings and professions), one group’s need for PPE that has failed to be sufficiently acknowledged is staff and residents who live in group homes. Group homes offer housing arrangements and shared personal care resources for specific individuals who require a certain level of support (e.g. people with developmental disabilities and other complex needs). It has been noted by those working in the field that staff at some group homes do not have access to appropriate PPE, making it such that the risk to both them and residents is present. Consequently, some staff may decide that the risk of working is too high to take.

In addition to group homes, there are many other environments in which care staff are working with vulnerable people. These environments include homeless shelters and family homes.  Without appropriate PPE being available in these settings, workers, supported persons, and people in close physical proximity are also exposed to risks that could be mitigated with PPE. Consider also that at least some of these individuals may need to go into the community after being exposed to unsafe conditions.

Additionally, if vulnerable people are exposed to COVID-19 due to a lack of equitable access to PPE for their care staff, then they may need to go to the hospital. If caregivers are unable to enter emergency departments due to precautionary restrictions, this could place vulnerable patients and healthcare staff under further strain as at least some of these patients may not be able to communicate their unique needs to staff, resulting in confusion, extra effort, and possibly harm.

Similar to those in long-term care, if staff working in these environments are unable to protect themselves, then some of society’s most vulnerable citizens who require support will either be insufficiently cared for (because staff may choose not to work in such risky conditions) and/or be at an increased risk of harm from COVID-19 from not having PPE. Both consequences could result in preventable hospital admissions that our healthcare system may not have the capacity to sufficiently manage.

Here are some possible recommendations to consider in response to the described challenges above:

1. The Ministries of Children, Community and Social Services (MCCSS) and Health and Long-Term Care (MOHLTC) could partner to coordinate & consolidate supplies of PPE and allocate distribution to mitigate the impact of COVID-19.
2. The MOHLTC could review processes for supporting vulnerable patients when they arrive at emergency departments. It may be more prudent from a resource allocation and risk mitigation perspective to allow one caregiver to enter emergency departments with some vulnerable patients.
3. Workers that support vulnerable clients (i.e., personal support workers, developmental service workers, and other paraprofessional staff working in environments such as group homes and homeless shelters) should be considered as vital and as deserving of protection (i.e., by being provided appropriate PPE) as staff working in hospitals and long-term care. This consideration could be formalized at a policy level in order to ensure that staff and residents/clients are protected.

Ultimately, it is important to ensure that healthcare providers in both hospital and non-hospital settings are offered a fair and equal opportunity to protect themselves and those to whom they provide care. Given that the developmental services and healthcare sectors are interconnected and in order to be responsible stewards of a scarce resource, it is necessary for our system to provide PPE to at-risk staff in both contexts.

Aamir Khan, M.ADS, BCBA, is a Behaviour Facilitator at Surrey Place; Andria Bianchi, PhD, is a Bioethicist at the University Health Network; and Angela Gonzales is a Health Care Facilitator RN at Surrey Place.