Duty versus distributive justice during the COVID-19 pandemic

Introduction

The COVID-19 pandemic demanded implementation of rapid measures to collectively protect populations in the face of uncertainty. In many low- and middle-income countries (LMICs), the pandemic occurred against a backdrop of inadequately prioritized health systems and a strained health workforce. In addition, the COVID-19 crisis posed several ethical challenges for healthcare professionals. ¹ Nurses are the backbone of healthcare systems and work at the frontline of the COVID-19 pandemic response in most countries, including Kenya. In this context, they face multiple ethical problems, including moral distress, as they provide care and risk exposure to the virus. ² Globally, the International Council of Nursing Code of Ethics for Nurses (ICN) ³ and International Confederation of Midwives Code of Ethics for Midwives (ICM) ⁴ guide nurses’ and midwives’ practice, respectively. These codes have been adopted in many countries, including Kenya, where nurses’ and midwives’ practice is guided by the Code of Ethics and Conduct for Nurses in Kenya. ⁵ However, these ethics codes tend to be ambiguous during public health emergencies ⁶ and do not necessarily guide nurses/midwives in what to do when faced with patients with COVID-19. Globally, ethical issues identified as affecting nurses and midwives include nurses’/midwives’ safety and the allocation of scarce resources. ² This article discusses nurses’ duty of care and the tension with resource allocation in LMICs in the context of the COVID-19 pandemic. We consider nurses’/midwives’ obligations during the COVID-19 outbreak and ethical challenges related to resource allocation during this pandemic. We contend that there is a pressing need to clarify nurses’/midwives’ rights and responsibilities, especially in the current context of limited resources, political influence, and nurse image in Kenya. Moreover, we present an account of the duty of care in professional healthcare codes of ethics to open social dialogue and advance public debate on this increasingly relevant issue. Finally, we argue that these rights and responsibilities would best be codified in the nursing/midwifery codes of ethics.

In previous highly infectious diseases outbreaks in which healthcare workers (HCWs) were exposed to risk for infection, they experienced ethical tensions between professionalism and the risk for contagion. HCWs reported conflicts between their responsibility to care for sick patients and the fear of infection, anxiety, lack of appropriate personal protective equipment (PPE), and excessive workload. ^7,8 During the severe acute respiratory syndrome (SARS) epidemic in Taiwan, infection control measures and quarantining health workers were statistically significant predictors of nurses fulfilling their professional care obligations. ⁹ Furthermore, a study conducted during the Middle East Respiratory Syndrome outbreak in Korea found that nurses were reported to have a mind-set of patient avoidance and were cognizant of self and family social stigmatization. ¹⁰

There is a dearth of literature on ethical issues in Africa during epidemics and pandemics, despite issues such as the recent Ebola outbreak in West Africa that caused many HCWs to experience moral distress. ¹¹ Most ethical issues faced by nurses in Africa are focused on HIV care, ¹² informed consent, ¹³ reproductive health, and workplace issues. ^14,15 In their discussion, Havenga and colleagues contended that nursing ethics in South Africa reflected a Western viewpoint, and therefore advocated for Indigenous knowledge systems and personhood or “Ubuntu” (togetherness) to guide nursing values. ¹⁶ Although nurses in Africa (including Kenya) face ethical challenges embedded in Africa’s socio-cultural, political, and economic realities, they use Western countries’ guidelines that may not necessarily resonate with the African ethos. ¹⁷ The COVID-19 pandemic presents an opportunity for African nurses to identify ethical challenges and address them appropriately.

Code of ethics and ethical issues in Kenya

The nursing code of ethics is the formal articulation of professional values and beliefs which guide nurses on ethical decision making. ¹⁸ The code of ethics provides a framework for standard of practice in all nursing settings and encapsulates social, ethical concern, and nursing ethical tradition. The code of ethics involves nurses in matters of social justice, altruism, advocacy, and rights of care. In Kenya, nursing and midwifery practice is governed by the Nurses Act Cap 257 of Kenya’s laws, which defines the nursing code of ethics as the professional code of conduct specified by the Nursing Council of Kenya. This code primarily covers components of nursing practice and education; in other words, ethical principles of practice. ⁵

Nursing is driven by the concept of caring, which often works on the premise of ethics as an absolute and objective notion. However, tension exists between nursing and the political and structural context in which caring is expected to take place. The reality on the ground is that the prevailing work environment, political and social contexts, shape ethical practice in Kenya. Nurses find themselves expected to work in a context where there are limited resources required to provide care and also protect themselves in the course of providing care. The matter is further complicated by the political structure, which has two government levels—national and county. The devolution of healthcare has meant that while the resource allocation is done from the national level of government, the decision on where to put the money rests on the county level of government. The result is a variation in available resources between counties, a focus on buying equipment and putting up buildings without foresight on the available human resources for health, and some hospitals in these counties receiving inadequate funds due to poor planning. ¹⁹ This exposed glaring economic disparities that have affected access to healthcare during national emergencies, particularly between rural and urban areas. For example, recently, nurses have been on strike in Kenya to demand better working conditions, increased risk allowance, and PPE access. Therefore, nurses are caught in a space where they not only have to provide care under challenging circumstances but also go out in the streets to advocate for better pay.

Nursing is often excluded from leadership and policymaking at multiple levels, thus reducing advocacy and engagement opportunities in shaping healthcare systems conducive to caring and ethical practice. Several reasons have been blamed for this situation. First, nursing, being a female-dominated field, finds itself suffering the fate of engendered roles in which females are less likely to be accorded leadership and will often obtain less pay than their male counterparts. Second, the nursing profession’s social responsibility and the nurse’s image give the expectation that nurses need to focus on providing care instead of demanding better pay and working environment, even when this is at the expense of their well-being. This expectation may stem from the nursing profession’s association with selflessness and the assertion that nursing is a “noble profession.” Finally, by virtue of the nursing role, nurses spend most of their time by the bedside. This creates a dilemma where nurses have to make an impossible decision between providing care while risking infection and staying away from work until the employers provide a safe work environment alongside the accompanying resources and equipment.

The Kenyan nursing code is ambiguous about the ethical conduct of nurses during pandemics. This does not necessarily mean that there is a gap in the nursing code of ethics. This article articulates the need for nurses to appreciate that the function of codes of conduct in daily care, especially during this pandemic, may not be enough to give a clear-cut direction to how nurses handle ethical dilemmas. However, the code of ethics can be updated to include a framework for resolving ethical dilemmas. Anecdotally, we have observed that nurses often face various ethical and moral issues, which may be compounded by the country’s resource-limited healthcare landscape. Overall, there is a dearth of research on nurses’ and midwives’ ethical dilemmas in Kenya and the East African region more broadly. The COVID-19 pandemic has added to the layer of complexity.

Duty of care

Nurses and midwives are health professionals who work with patients and have a duty to provide care and relieve suffering. This duty of care is consistent with the principle of beneficence. ²⁰ Their training gives them special skills and abilities to work in their chosen profession, which may expose them to diseases. Therefore, nurses and midwives have to balance the demands of their profession and their personal values against competing obligations to their health and that of their family. A review of nurses’ experiences of ethical dilemmas illustrated that balancing harm with care was one of the most prevalent challenges confronting nurses in their nursing practice. ²¹

In LMICs, nurses and midwives face significant challenges because of limited resources. Inadequate PPE provision also raises ethical questions about the extent and limit of nurses’ and midwives’ duty to provide care for patients. Nurses have an innate duty to promote their health and safety. However, when faced with professional obligations without safeguards, they are vulnerable to contagious diseases such as COVID-19. Therefore, nurses must balance their obligations of beneficence and duty of care for patients with their rights and responsibilities while addressing the inadequacies of resources in the health systems in which they practice.

Nurses and midwives confront dilemmas on balancing COVID-19 response with other important healthcare needs. ^22,23 Reports from other countries indicate that nurses and midwives are also at greater risk for COVID-19 than other HCWs and the general public. ^24,25 Therefore, nurses and midwives are understandably concerned about their risks for contagion and infecting their families, as well as the ability of the health system to assure their safety as they care for patients. Some private hospitals in Kenya have offered free medical benefits for nurses who test positive for COVID-19. However, if they become patients in their hospitals, they may experience an intensification of ethical complexities relating to the priority of care. ²²

Resource allocation/distributive justice

The pandemic cast a spotlight on the state of health systems in LMICs and led to broader public conversations on health financing as a moral imperative. In the current health crisis, those with COVID-19 infection are prioritized over other existing ill-health causes because health services are overwhelmed. COVID-19 emergency response planning has also diverted resources from other urgently needed health services, leading to poor health outcomes and disparities.

The pandemic has tested the ability of already strained health systems in LMICs to navigate the ethical issues emerging from the pandemic. These include decisions related to resource allocation, to fulfill and respect human dignity, ²⁶ and to support nurses and midwives to protect their health and that of their clients while upholding key ethical ideals. ²⁷ In several African countries, there is a lack of clarity on defining “fairness” in the allocation of finite resources to respond to the pandemic, including distribution of limited PPE. ^28,29 Workforce shortages also mean that Kenyan nurses and midwives are deployed to settings where they may not necessarily have adequate preparation and resources to manage the pandemic, inconsistent with the utilitarian principle. ¹⁷

Nurses and midwives are the backbone of the healthcare delivery system in the African region and Kenya. ³⁰ Therefore, their contribution to the community’s health and well-being alongside other healthcare professionals and high risk of contagion means governments, policymakers, and hospitals have a duty to provide appropriate safety gear and infection prevention and control training. ^31,32 By taking care of patients without appropriate PPE, nurses and midwives are vulnerable to COVID-19 infection; therefore, lack of these safety provisions shifts the ethical dynamic that subjects nurses to a greater professional obligation to care at the expense of their own health and that of their families. Although nurses often show sensitivity to ethical norms and professional conduct, the lack of resources like PPEs has impacted their decision making. For instance, if a nurse is not wearing appropriate PPEs, they put the community/patients at risk, which is unethical. If they give care without appropriate PPEs, they put patients at risk of infection and, in turn, deny the community/patients the right to safe care. ²⁸ On the contrary, if nurses refuse to give care because they have not been supplied with appropriate PPEs, they deny patients access to care, which becomes a social justice issue. This poses an ethical dilemma as nurses are expected to have ethical sensitivity to the norms and codes which model nurses’ conduct and professional behavior.

The lack of PPE has also been reported in several other countries ¹ and attributed to shortages along the supply chain. In March and April 2020, Kenyan nurses threatened to go on strike over the shortage of PPE and lack of training to handle COVID-19 cases. ^{33 –35} Similarly, nurses working in public hospitals in Zimbabwe went on strike over the lack of PPE, ³⁶ and nurses in Botswana sued the government over the lack of provision of PPE. ³⁷ Without adequate resources, nurses’ and midwives’ capacity to protect their bodily integrity in the COVID-19 crisis is hindered, which poses serious public health. ^38,39 Given the lack of clear guidelines, and policy, and limited resources, the argument for nurses’ strike during health emergencies raises serious moral questions about nurses’ duty to care, risk of infection and improvement of working conditions, and quality of healthcare through collective action.

Well-established ethical principles should guide resource allocation decisions in the COVID-19 pandemic. In particular, the rapidly evolving pandemic means there is a need for clarity and consistency in guidance for ethical decision making, ²⁶ especially for nurses and midwives in Kenya. Questions abound on which account of distributive justice guides nurses’ involvement in decision making and who receives priority for limited resources. An ethical framework that respects contextual values and is cognizant of the local healthcare system’s realities should be used to inform ethical decision making.^13,16,17,40 Nurses and midwives play an important role in shaping sustainable and resilient healthcare systems, and an inclusive approach will enable them to participate in key resource allocation decisions during the pandemic effectively.

Competition across the various levels of health systems for scarce resources is fierce, ⁴¹ which has widened health disparities and may exclude nurses and midwives at the primary care level. ⁴² Reports show that only 16% of health facilities in Kenyan counties have essential equipment, and only 22 of the 47 counties have ventilator-capable intensive care units. ^43,44 Similarly, there is a shortage and maldistribution of critical care nurses, with most of them working in urban areas. ⁴⁵ In 2015, only 130 nurses specialized in critical care nursing were deployed in 21 hospitals in Kenya. ⁴⁶ According to the NCK database, there are currently 922 registered critical care nurses in Kenya; however, there is no deployment data. ⁴⁷ Although the number of critical care beds and nursing workforce has increased over the years, this remains insufficient to meet the populace’s needs. ⁴⁵ Nevertheless, those in morally similar situations need to have an equal chance to access health resources regardless of the level at which they interact with healthcare systems.

The prolonged COVID-19 pandemic has placed increasing strain on health systems’ ability to maintain an adequate health workforce and maximize the capacity of each nurse and midwife to care for a large workload of sick patients. Nurses and midwives have to deal with a greater risk for infection, increased workload, evolving practice guidelines, and scarcity of health resources, all of which result in challenging moral dilemmas. Ethical care requires a reorientation of social values of care, which must be matched by a political will to make investments in healthcare systems. According to Tronto, ⁴⁸ care is seen as political as it is associated with economic costs. In addition, the World Health Organization also advocates for the mobilization of political will in the investment of developing an effective nursing and midwifery workforce. ⁴⁹

Conclusion

The COVID-19 pandemic has highlighted ethical challenges in nurses’ duty of care, caring obligations, and resource differentials globally and Kenya. The ethical codes that guide nursing and midwifery practice should be revisited to address ambiguities and assist nurses and midwives in making decisions about duty of care, resource allocation, and other ethical challenges. The Nursing Code of Ethics in Kenya does not offer guidance of professional conduct and obligation during health emergencies. Moral distress arises when nurses feel physically unsafe due to scarce resources and the lack of protective and supportive organizational environments to provide services that meet the standards of care during the pandemic. Clarity should be provided on the course of action to follow and the moral justification of a breach of safety and operational protocols.

Furthermore, ethical frameworks that guide decision making need to be structured to reflect universal ethical principles as well as local socio-political values and the realities in which nurses and midwives practice. The framework should include basic steps that nurses can follow to help them make decisions more proactively than reactionary. ⁴ A series of transparent stakeholder consultations involving the nursing regulatory and professional bodies may be necessary to review and develop a tailored code of ethics that reflects and protects nurses’ and midwives’ ethical obligations in the context of Kenya’s political, healthcare system, and cultural values during a pandemic. The inclusion of ethics education in nursing curricula at all levels is essential to prepare nurses to deal with future ethical challenges in practice. ⁵ Beyond this pandemic, we will have to review the ethical challenges that nurses and midwives face, factors that underpin them, and the ethical codes that guide practice during emergencies.