Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Doctors are often faced with ethical decisions in the course of patient care. These decisions may be emotionally wrenching, and can have an impact on a patient's life, and affect a doctor’s career and wellbeing. Medscape UK surveyed 1355 doctors to find out how they feel about key ethical issues they may be faced with in their daily practice. Here we look at issues around life, death, and pain. Your responses were gathered before the COVID-19 pandemic changed lives and medical practice. We wanted to take account of how coronavirus has changed the way UK doctors work, and the dilemmas they faced. We carried out an additional reader poll and we also have data from a wider Medscape/WebMD online poll.
Some totals in this presentation may not equal 100% due to rounding.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Our Medscape UK poll showed 64% of participants had been involved in frontline COVID-19 care. Excluding those who said 'not applicable', 31% experienced COVID-19 patient contact without adequate PPE.
Data were collected between 14th and 26th April 2020, and 340 UK doctors' responses were received.
When it came to PPE supplied to doctors polled in the separate Medscape/WebMD survey, 3 in 4 (74%) described their equipment as inadequate to some degree. Kit was not at all adequate for 14%. Those who responded ‘did not apply’ were excluded.
PPE was adequate for 20% or very adequate for 5%.
The Medscape/WebMD online reader poll had responses from 110 UK doctors between 9th-20th April.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Doctors who cared for COVID-19 patients without adequate PPE used these words to describe their feelings: horrible, upset, sad, apprehensive, scared, vulnerable, nervous, frightened, worried, angry, unsafe, worried for myself and my family, appalled, stressed, anxious, fearful, frustrated, ignored, controlled, unvalued, sleepless nights, deeply uncomfortable, terrible, disgusted and frustrated, disgusting, powerless, worthless, terrifying, morally and ethically confused, and dreadful.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
When it came to burnout, results from the Medscape/WebMD poll found no significant overall change in burnout before (81%) and during the pandemic (82)%. However, responses for very burned out doubled from 8% to 16%.
Of the 44 respondents who had returned to medical practice for the pandemic, 48% would consider staying on afterwards, 52% would not, according to our Medscape UK poll.
We also asked if returning doctors and nurses, medical students, and others involved in the care of COVID-19 patients had adequate supervision and training.
Only 16% of all respondents agreed with this statement. Of the rest, 36% said no, and 48% weren't sure.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
We also asked if respondents had ever prescribed drugs with no specific market authorisation for COVID-19 patients.
Excluding respondents who said 'not applicable', more than 1 in 20 (6%) had prescribed drugs with no specific market authorisation for COVID-19 patients. Of the rest, 94% had not.
The drugs prescribed included those under the clinical trials RECOVERY, RECAP, RESPECT. They were:
Antioxidants
Azithromycin
Beta glucans
Ceftriaxone
Clarithromycin
Dex, HIV Combination
Dexamethasone
Doxycycline
Hydrocortisone
Hydroxychloroquine
Methylprednisolone
Probiotics
Remdesivir
Tazocin and gentamicin
Tocilizumab
Vitamin C
Vitamin D
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
We asked if doctors had taken sick leave when they weren't sick, or when they didn’t need to self-isolate, to avoid coming into contact with COVID-19?
Excluding those who said not applicable, only six respondents (2%) had taken sick leave when they weren't sick, or when they didn't need to self-isolate, to avoid coming into contact with COVID-19.
The reasons given were:
"Asthmatic son and parent living with me who recently underwent open heart surgery."
"Stress related to inappropriate and flimsy PPE, blame when raising issues and being asked to 'man up' and take more leadership when given below minimum standard PPE. Being asked not to spread fear when raising concern."
"My wife is immune suppressed."
"I had recurrent minor infections since the start of the year which "felt viral". I felt vulnerable."
"To protect everyone."
"Shielding due to severe asthma."
We also asked if doctors had ever exaggerated underlying clinical risk factors, so that they or their patient could get tested for COVID-19.
Only one doctor said they'd exaggerated underlying clinical risk factors to get themselves tested, and 11 more did so to get tests for patients. Overall 96% said they had not done this.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Of the 44% of respondents who experienced specific ethical problems, these included:
Treating COVID-19 patients without appropriate PPE
Who/when to intubate
DNR discussions/policies
Bullying/pressure from management
Lack of ability to practise properly, eg, not able to examine patients
Treatment/management of patients who don't have COVID-19 but who do have serious/other health problems
Fear - for patients/colleagues/family/self
Implications of 'mismanagement' by UK Governments
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
More doctors were happy (41%) than unhappy (17%) to be working in the NHS during the pandemic. However, 33% were neither happy or unhappy, and the question did not apply to 8%.
Of those who were very happy, reasons included:
"I'm not just happy but very proud to be working in the NHS."
"I have never felt more appropriately relevant in my role."
"It is in the finest traditions of medical practice to care for patients as a GP at this time."
"It is an integral part of my medical DNA."Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Despite the rise of robotic surgery, on the whole we're all human, and humans make mistakes. Sometimes these result in warnings and more training, in more serious cases doctors get struck off. We asked: Is it ever acceptable to cover-up or avoid revealing a mistake if that mistake would cause harm to the patient? Most (87%) said covering up a mistake was unacceptable, but it was OK for 4%. It was a grey area for 9%. Over 45s (4%) were more likely than under 45s (1%) to say hiding a mistake was acceptable.
What were some of the reasons for 'yes' answers?
"If there were no consequences then I think this is reasonable as long as the medical professionals involved learn from the mistake."
"Litigation."
"We're all human."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
So those were the replies about the acceptability of covering up a mistake. But had respondents actually done so? Or would they? More than 1 in 10 (12%) said yes. But the vast majority (88%) said no. Covering up was more likely in over 45s (13%) than under 45s (7%).
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
If you made a mistake, would you apologise to the patient? The vast majority (98%) would. For the other 2%, half wouldn't, and half said it depends. The results reflect NHS policies to be more transparent and accountable when it comes to medical errors. GMC guidance also enforces a 'professional duty of candour' and to tell the patient when something goes wrong.
We asked for your additional comments:
"It would be bad practice not to accept responsibility and apologise for a mistake. Also, failure to apologise is counter-productive, and places the physician in a worse position than he might otherwise have been in."
"Transparency and remorse are key factors in a doctor-patient relationship."
"Most patients are very understanding and will accept if explained."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Nearly three quarters (74%) of respondents said they'd report a doctor friend, or colleague, who occasionally seemed impaired by drugs, alcohol, or illness. The ethical grey area accounted for nearly a quarter (23%), who said 'it depends', while 3% would keep quiet.
Many said they'd talk to the colleague first. Comments from those who said 'it depends' included:
"I would get them some help! Medics need support not reporting!"
"Just about every single doctor or nurse has been impaired as a result of a night out..."
"I would fear being victimised by the authority as foreign medical graduate if I were reporting a white British colleague."
"All humans are occasionally impaired by illness and if none of us worked if we were only at 99% capacity, due to a minor illness and the drugs you had been given to treat it, the health service would collapse."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
It happens in some walks of life, but should doctors be subjected to random testing for drug and alcohol use? Half of respondents said no, while just under a third agreed with testing, and it was a grey area for just under a fifth. Under 45s (58%) were more likely to be against testing than over 45s (48%).
Comments among those against random testing included:
"It makes everyone seem like crooks, is scattergun and erodes trust."
"The general population doesn't require that so why should doctors. They have fundamental rights which is not alienated because they are doctors."
"Only if they want to be in the Tour de France."
"Come on, where would this end?"
"The presumption of innocence is not a nuisance to the terminally vexed and halfwits who work in HR."
"Test society as a whole, or it is discrimination."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Sometimes with NHS rules and guidance it can be hard to get the care doctors believe a patient needs. We asked: Would you consider it warranted to 'bend the rules' to allow a patient to receive NHS funding for a treatment that wouldn't otherwise be funded? Only a fifth would bend the rules while just under half definitely wouldn't. However, just under a third were in the ethical grey area of 'it depends'.
Comments from rule benders included:
"Many rules are arbitrary and not in the patient's best interests."
"Rules set by the NHS in respect of accessibility to treatment are often set by anonymous fools."
"NHS rules are political not clinical."
"If the rules were ridiculous as they so often are eg, outdated NICE recommendations."
"Postcode prescribing exists. If standardisation, accessibility and availability was ensured then this would not occur."
"It happens all the time when overseas patients do not have the means to pay their bill."
"The NHS purports to provide a comprehensive service, it is therefore immoral to deny patients funding. Denial of funding or exclusion of services should be done nationally, openly and in advance of the liability occurring. Not retrospectively and arbitrarily."
"Some rules are crap."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
When NHS budgets are stretched, should some things, like IVF, be considered lifestyle choices and not funded? What about people whose conditions are caused by smoking, alcohol abuse, or obesity? Or the Sunday league footballers heading to A&E with broken legs? These examples, and others, should always be funded, more than 6 out of 10 said. A firm no came from 12%, while it was a grey area for just over a quarter (27%).
One respondent pointed out: "IVF is not a lifestyle issue and infertility cannot be compared to smoking or obesity."
Comments among those against paying for these treatments included:
"Finite resources. Patients need to take ownership of their own health."
"Patients have responsibilities as well as rights."
"Patients should be charged for any acquired illnesses brought about by poor lifestyle choices and which are preventable in the first place."
"NHS was set up to give treatment for those that could not afford or get access. It was not for every whim."
"Not part of original NHS concept. Can NHS pay for my dinner too - let me live irresponsibly and someone else can pay?"
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Should patients who engage in unhealthy behaviour or don't follow treatment recommendations be denied a place or given lower priority on NHS waiting lists? More than 1 in 10 doctors (12%) said this should be the case. More than half disagreed, while it was a grey area for 37%. There was a gender difference with men (15%) taking a harder ‘yes’ line than women (8%).
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
We asked if you had more to say on deprioritising those with unhealthy habits. Here are some of your comments:
"NHS is in crisis facing effects of 10 years austerity. Can't afford to treat time or resources wasting patients."
"If obese patients do not lose weight there is increased risk and reduced benefits to orthopaedic surgery, similarly transplants should not be available to those still drinking."
"It is unethical to withhold treatment on the basis of your opinion of someone's behaviour."
"Patients' behaviour needs to be investigated to discover motivation or cognitive set. Lower priority should be strictly on clinical grounds only."
"It is the doctor's duty to continue to support patients even if they do not follow the advice given."
"It is hypocritical to treat patients, who persistently deliberately ignore medical advice and use resources funded by public sources."
"Slippery slope - then you can start not treating cancer caused by smoking, sports injuries etc. We need to look at why people don't engage rather than punishing them for it."
"The minute we become judges and jury, then we have lost sight of our role. Where would you draw the line?"
"Why don't [we] ask them to share the cost of their treatment?"
"If we start judging everyone for their behaviour it becomes a complete quagmire of who or who should not be treated."
"We all lead imperfect lives."
"Wasting time and money on non-compliant patients makes no sense and is an unjustifiable waste of effort."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
GMC rules say doctors can tell patients they have a conscientious objection to a particular procedure, but a patient being difficult to treat is not usually a valid reason to turn someone away. But does it happen? Yes for nearly 1 in 5 (18%) of respondents. Of those around 1 in 50 do it often, the rest did it occasionally. Turning people away was more common among specialists (21%) than GPs (4%). No GPs said they turned people away often.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
In the new world of genetic medicine, new ethical dilemmas may emerge. A High Court judge recently spoke of doctors' "duty of care" to balance the interests of a woman's genetic risk of inheriting Huntington's disease against her father's patient confidentiality. We asked: If your patient had genetic testing and was found to have a genetic marker for a disease for which there is no preventive treatment, is it right to withhold that information? More than 8 out of 10 (81%) said it was wrong to keep information back. Only 2% said it was OK. It was a grey area for nearly 1 in 5 (18%).
Comments from those who would withhold information or said 'it depends' included:
"May not even get the disease. There's a lot to learn about prognosis with genetic test results."
"If the patient was appropriately briefed in advance and consented in this direction. If not and the patient wants to know s/he should be told. If there is a risk to other family members then the patient should be told."
"The genetic marker by itself does not equal disease. It depends on the patient. If he is overanxious, this information will only make him more anxious and cause harm to him, without any benefit."
"Yes, unless family planning is not finished yet and there is a risk of the disease being passed on to future children."
"Never do a test unless you know what you'll do with the result!"
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Patient confidentiality is key to doctors' social media use, according to General Medical Council (GMC) guidelines. But do our survey participants ever share patient information – anonymised or not - over social media, chat, or messaging apps? Most don't (83%) but 17% do. This possible oversharing was more prevalent in under 45s (36%) than over 45s (11%).
Comments from sharers included:
"Without patient's details, yes, to get opinions or answers."
"Only anonymous. Never, never identifiable. For example 'remember to check the CXR on the medical boarder tomorrow - the drain was put in late'."
"Only on encrypted apps and without patient identifying information."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
One issue with religious and cultural sensitivities is abortion. Do women have a universal right to have an abortion? More than 7 in 10 said they do, over a quarter said not. Women (77%) were more likely to agree than men (69%). More under 45s (80%) agreed than over 45s (70%).
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
The NHS in England now offers 'social prescribing', with activities like gardening and exercise, as a key part of Universal Personalised Care. However, in August 2019 the Drug and Therapeutics Bulletin questioned the lack of evidence to support it.
Overall, doctors in our survey were almost evenly split three ways between 'yes' (30%), 'no' (31%), and 'it depends' (39%). However, more than half of GPs (51%) believe it is worthwhile compared to 26% of specialists. Females (37%) were more likely to support it than men (26%).
Many said they didn't recognise the term. Comments from those against social prescribing included:
"People should sort their own lives out. Exercising and better diet does not need to be medicalised."
"The literature suggest we, the medical profession, love the idea but the effect doesn't persist and could be waste of money. Need solid evidence base before we do this."
"Such programmes tend to be poorly governed, and tend to constitute low-budget alternatives to more rigorously monitored interventions."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
This year, England follows Wales in moving to presumed consent for organ donation. However, so far Wales hasn't seen a significant rise in organ donation. So could letting people sell organs help? We asked: Should competent people be able to sell or buy organs to be used for transplantation? It was a resounding 'no' for 84%. Only 7% said yes, while it was grey area for 8%.
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Another way to ration available organs for donations might be some kind of age cut-off. We asked: Should people over the age of 70 years old continue to be allowed to have organ transplants? Yes they should, said nearly 6 out of 10 (58%). Only 5% said a firm 'no', but it was a grey area for 37%. Among your comments:
"People over 70 can have a life expectancy of another 20 years. They contribute to society, pay taxes, may work, contribute to the economy. There is no ethical reason why it should be denied the same treatment as a 60-year-old."
"Biological age is important as are the organs in question."
"Limited resources, priority to those for whom the outcome would have the most impact re work, dependents in family etc."
"Yes but point based system should favour younger unless high urgent status is in place."
"Medically today's 70 is yesterday's 55 so depends on priorities and fitness."
"Generally until such time as there are more organs available than demand there will be some degree of rationing."
"I think younger people who have a good chance of good quality life should have priority."
"Poor use of scant resources given life expectancy."
"I am undecided on this and can see the merits of both arguments."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
No operation or procedure is without risk, but if you believe that a procedure or treatment will help a patient, would you be less aggressive about describing the risks in order to encourage the patient to give informed consent? No was the answer from more than three-quarters (76%). Yes, said 12% and it was a grey area for another 12%. Men (14%) were more likely to be less aggressive about disclosing risks than women (9%).
We asked for your additional comments:
"Informed consent is informed consent. No relevant information should be withheld, irrespective of my views on the benefits of the intervention. Nevertheless, patients do often ask me: What would *you* do, Doctor? Would you have it done? In which case I tend to answer in their best interests."
"Not intentionally but probably."
"It may be a subconscious act to help patients decide."
"I describe the risk but stress the probability."
"Probably I am, though I should not be."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Some of the biggest ethical dilemmas have been around the withdrawal of life support. Sometimes these cases end up with judges to decide, like that of 5-year-old Tafida Raqeeb. In 2019, her parents disagreed with her doctors that there was no chance of her recovering. We asked: Do you think decisions are being made to withdraw life support from patients too soon? Only 1 in 10 thought so while 67% said not. However, for nearly a quarter (23%) it was an ethically grey area.
We asked for your additional thoughts. Here are some:
"In my experience the reverse is true, life support is continued beyond what is reasonable in many situations. As a society we have developed a false hope culture and doctors are part of it and find the challenge of withdrawing treatment too difficult. We should ‘give death a chance' where it is clear therapy is prolonging suffering."
"I believe that doctors are uniformly reluctant to withdraw patients from life support, partly because they feel obliged to comply with the relatives' wishes."
"Usually this is something teams struggle with and this delays the withdrawal or avoids it."
"To vacate the beds and free-up resources, the decisions are sometimes pushed through."
"The cost-benefit ratio of life support is poor."
"Not soon enough in many cases. Futile attempts at preserving life are frequent and distressing for both patient and family."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
The issue of whether doctors should help terminally ill patients end their lives is a source of major ethical debate. In February 2020, the Royal College of GPs (RCGP) maintained its opposition to assisted dying after a ballot with a low turnout. The Royal College of Physicians is neutral on the topic, and the British Medical Association (BMA) also consulted members. We asked: Should physician-assisted suicide or ‘physician-assisted dying' be made legal for the terminally ill - or for those who say they have irredeemable suffering, even if the disease may not be terminal for many years? No said 42%, while 37% said yes. It was a grey area for 22%. GPs were more likely to be against assisted dying (55%) than specialists (39%).
We asked for your additional comments:
"Slippery slope as per Swiss, Dutch, and Belgian experiences."
"There is no reason why physicians should be compelled to kill patients."
"This process must have robust safeguards in place for the professionals and patient involved."
"Living an impaired life is a terrible sentence and death would be preferable but different people have different thresholds."
"The fact that we have people who request this is largely due to modern health care – ie, people can now survive devastating illnesses and injuries in the way in which they could not have done in the past. Therefore this is a problem caused by doctors and doctors need to play a role in addressing it."
"I will do this to myself."
"I have seen family members die slowly and painfully, their lives racked by discomfort or pain. If I was diagnosed with one of these conditions I would prefer to die without people's last memories of me being very unpleasant."
"Bloody obvious, it already happens. We call it palliative care medicine."
"My worry is older folk who 'didn't want to be a burden' might apply, so strict rules needed."
"A routine standard of care in veterinary medicine is denied to human patients."
"There are enough people on the planet. We do not need to enforce people staying alive just for the sake of living."
"In years to come, it will appear barbaric that we did not offer people this choice as long as it is undertaken with the due diligence that it deserves."
"This is an ethical minefield but I think in many circumstances physician assisted suicide is appropriate and merciful."Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Another end of life ethical dilemma may be keeping back bad news to keep a patient's spirits up. We asked: Would you ever withhold information from a patient about a terminal or pre-terminal diagnosis in order to bolster the patient's attitude or morale? Among our respondents, most wouldn't hold the news back (68%) but 8% would. However, it was a grey area for nearly a quarter (24%). Over 45s (9%) were more likely to hold back than under 45s (3%).
We asked for your additional comments:
"Losing hope is unreasonable most of the time."
"Bad news or poor prognosis can be deferred to suit the circumstances if it is felt that favourable time may come."
"If the patient asks I tell them the truth. But if they don't want to know and I see no purpose in distressing them I don't insist on telling them."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
When there are no standard treatments left for a patient with a terminal diagnosis, why not give something else a try? This raises many ethical and consent issues. Before the pandemic we asked: Do you think terminally ill patients should be permitted to try any remedy or possible treatment they wish? Yes said 43%, no said 26%. It was a grey area for 31%. Specialists (46%) were more likely to be in favour of trying something new than GPs (28%). Men (46%) were more likely to agree with a new non-standard approach than women (37%).
We asked for your additional comments:
"Their bodies, their lives, their choice."
"Many unscrupulous people would take advantage. False hopes are ultimately crushing."
"They need protection from being peddled snake oil."
"Clutching at straws may appear futile to the outsider, but for the person concerned, it gives them hope, and helps them come to terms with their situation."
"Terminally ill patients have nothing to lose by trying alternative remedy or possible treatment."
"If the person has capacity who am I to forbid anything."Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
This year the Society of Homeopaths professional registration was renewed with conditions attached. But the evidence-based NHS has stopped funding it. But does homeopathy still have a role in medicine? Over half (54%) said not, but nearly 1 in 5 (19%) said it did. Homeopathy was a grey area for 27%. Men (57%) were more likely to be against homeopathy than women (49%). GPs (24%) were more likely than specialists (18%) to support homeopathy.
We asked for your comments:
"It is placebo, oft expensive thus has a role. Not on NHS."
"Some people swear by it. And in most cases, it's harmless at worst."
"The placebo response is very powerful."
"There is no evidence for this farcical stuff."
"It is based on pseudoscience."
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Medscape UK Ethics Report 2020: COVID-19, Life, Death, and Pain
Hospitals were the most common workplace for our respondents (67%). GP settings accounted for 12% of work settings, with 1% in single-handed practice, and 11% in a group practice. Of survey respondents 76% were employees and 14% were independent contractors.
Comments