Resistance involves a range of actions such as disobedience, insubordination, misbehaviour, agitation, advocacy, subversion, and opposition. Action that occurs both publicly, privately, and day-to-day in the delivery of care, in discourse and knowledge. In this article I will demonstrate how resistance plays an important role in shaping health and well-being, for better and worse. To show how it can be largely productive and protective, I will argue that resistance intersects with health in at least two ways. First, it acts as (...) an important counterbalance to power; undermining harmful policies, disobeying unfair instructions, challenging rights abuses, confronting those who would otherwise turn a blind eye and even holding ourselves to account when simply accepting the status quo. Second, and beyond being oppositional, resistance is a constructive, productive force, that is fundamental to imagining alternatives; new and better futures and perhaps most fundamentally resistance is cause for hope that we are not resigned to the status quo. While there are numerous examples of how resistance has been employed in service of health and well-being, resistance is not always rational or productive, it can also harm health. I will briefly explore this point. Finally, I will offer some reflections on the intersections of power and health and why this makes resistance both distinct and important when it comes to how it shapes health and well-being. (shrink)

Moral injury results from the violation of deeply held moral commitments leading to emotional and existential distress. The phenomenon was initially described by psychologists and psychiatrists associated with the US Departments of Defense and Veterans Affairs but has since been applied more broadly. Although its application to healthcare preceded COVID-19, healthcare professionals have taken greater interest in moral injury since the pandemic’s advent. They have much to learn from combat veterans, who have substantial experience in identifying and addressing moral injury—particularly (...) its social dimensions. Veterans recognise that complex social factors lead to moral injury, and therefore a community approach is necessary for healing. We argue that similar attention must be given in healthcare, where a team-oriented and multidimensional approach is essential both for ameliorating the suffering faced by health professionals and for addressing the underlying causes that give rise to moral injury. (shrink)

Background The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario’s protocols were presented to the public in a democratic deliberation during the summer of 2022. Objectives (1) To explore the perspectives of Quebec and Ontario (...) citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. Methods This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. Results A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value – a less acceptable tiebreaker. Conclusion Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria. (shrink)

The context of Covid-19 has offered an unusual cultural landscape for examining how workers view their own position relative to others, and how individuals respond to prolonged exposure to workplace stress across different sectors and cultures. Through our recent work tracking the well-being of frontline workers in the UK and Ireland, we have uncovered additional psychological factors that have not been accounted for in previous models of occupational stress or burnout. In recent months, frontline workers have worked to protect the (...) community from the threat of SARS-CoV-2 and, simultaneously, have evaluated their perceptions of collective efforts of others as either congruent or incongruent with collective goals : we call this novel aspect solidarity appraisal. These frontline workers have been hailed as heroes, which we argue has led to the creation of an implicit psychological contract between frontline workers and the public. Here, the heroes are willing to “go above and beyond” for the greater good, with the expectation that we do our part by adhering to public health guidelines. Where frontline workers perceive incongruence between the words and actions of others in working toward collective goals this drives negative affect and subsequent burnout. In this perspective article, we evaluate the cultural context of the pandemic in the UK and Ireland and suggest important socio-cultural factors that contribute to perceptions of solidarity, and how this may relate to burnout and worker welfare during and beyond the pandemic context. (shrink)

Abstract2020 saw the rapid onset of a global pandemic caused by the SARS‐CoV‐2 virus. For healthcare systems worldwide, the pandemic called upon quick organization ensuring treatment and containment measures for the new virus disease. Nurses were seen as constituting a vital instrumental professional component in this study. Due to the pandemic's unpredictable and potentially dangerous nature, nurses have faced unprecedented risks and challenges. Based on interviews and free text comment from a survey, this study explores how ethical challenges related to (...) “being a nurse” during the COVID‐19 pandemic was experienced and understood by Danish hospital‐based nurses. Departing from anthropologist Jarett Zigon's notion of moral breakdown, the study demonstrates how the rapid onset of the pandemic constitutes a moral breakdown raising ethical demands for nurses. Analytically we identify three different ethical demands experienced by the nurses. These ethical demands are Nursing and societal ethical demands, Nursing and personal ethical demands, and Nursing and conflicting ethical demands. These demands represent not only very different understandings of ethical demands but also different understandings of ethical acts that are seen as necessary to respond to these demands. (shrink)

The 2003 SARS pandemic heralded the return of quarantine as a vital part of twenty-first century public health practice. Over the last two decades, MERS, Ebola, and other emerging infectious diseases each posed unique challenges for applying quarantine ethics lessons learned from the 2003 SARS-CoV-1 outbreak. In an increasingly interdependent and connected global world, the use of quarantine to contain the spread of SARS-CoV-2, or COVID-19, similarly poses new and unexpected ethical challenges. In this essay, we look beyond standard debates (...) about the ethics of quarantine and state power to explore a key quarantine principle, Reciprocity, and how it is being negotiated by healthcare workers, volunteers, and citizens in the context of the Wuhan, China, quarantine. We analyze Reciprocity through the lens of two Wuhan case studies: healthcare workers, particularly nurses, who are simultaneously essential workers and quarantined citizens, asked by their hospital administration to shave their heads because adequate PPE was not available, and citizen-to-citizen mutual aid societies attempting to fill gaps in essential supplies left unfilled by the state. We analyze social media and video-blogs from Wuhan, on the platforms of Douyin and Sina Weibo, to understand how people define and respond to ethical and legal obligations in the wake of COVID-19. It is no surprise that quarantine principles from the 2003 SARS outbreak are inadequate for COVID-19 and that both infectious disease outbreak responses and ethics must adapt to the virtual age. We offer ideas to strengthen and clarify Reciprocal obligations for the state, hospital administrators, and citizens as the globe prepares for the next wave of COVID-19 circulating now. (shrink)

While COVID-19 has generated a massive burden of illness worldwide, healthcare workers (HCWs) have been disproportionately exposed to SARS-CoV-2 coronavirus infection. During the so-called ‘first wave’, infection rates among this population group have ranged between 10% and 20%, raising as high as one in every four COVID-19 patients in Spain at the peak of the crisis. Now that many countries are already dealing with new waves of COVID-19 cases, a potential competition between HCW and non-HCW patients for scarce resources can (...) still be a likely clinical scenario. In this paper, we address the question of whether HCW who become ill with COVID-19 should be prioritised in diagnostic, treatment or resource allocation protocols. We will evaluate some of the proposed arguments both in favour and against the prioritisation of HCW and also consider which clinical circumstances might warrant prioritising HCW and why could it be ethically appropriate to do so. We conclude that prioritising HCW’s access to protective equipment, diagnostic tests or even prophylactic or therapeutic drug regimes and vaccines might be ethically defensible. However, prioritising HCWs to receive intensive care unit (ICU) beds or ventilators is a much more nuanced decision, in which arguments such as instrumental value or reciprocity might not be enough, and economic and systemic values will need to be considered. (shrink)

The coronavirus disease imposes an unusual risk to the physical and mental health of healthcare workers and thereby to the functioning of healthcare systems during the crisis. This study investigates the clinical knowledge of healthcare workers about COVID-19, their ways of acquiring information, their emotional distress and risk perception, their adherence to preventive guidelines, their changed work situation due to the pandemic, and their perception of how the healthcare system has coped with the pandemic. It is based on a quantitative (...) cross-sectional survey of 185 Swiss healthcare workers directly attending to patients during the pandemic, with 22% of them being assigned to COVID-19-infected patients. The participants answered between 16th June and 15th July 2020, shortly after the first wave of COVID-19 had been overcome and the national government had relaxed its preventive regulations to a great extent. The questionnaire incorporated parts of the “Standard questionnaire on risk perception of an infectious disease outbreak”, which were adapted to the case of COVID-19. Clinical knowledge was lowest regarding the effectiveness of standard hygiene. Knowledge of infectiousness, incubation time, and life-threatening disease progression was higher, however still significantly lower than regarding asymptomatic cases and transmission without physical contact. 70% of the healthcare workers reported considerable emotional distress on at least one of the measured dimensions. They worried significantly more strongly about patients, elderly people, and family members, than about their own health. Adherence to preventive guidelines by the government displayed patterns such that not all guidelines were followed equally. Most of the participants were faced with a lack of protective materials, personnel, structures, processes, and contingency plans. An increase in stress level was the most prevalent among the diverse effects the pandemic had on their work situation. Better medical equipment, better protection for their own mental and physical health, more personnel, more comprehensive information about the symptoms of the disease, and a system of earlier warning were the primary lessons to be learned in view of upcoming waves of the pandemic. (shrink)

Epidemics, the medical historian Charles Rosenberg argued, typically have four Acts, as in a play. In Act I, which he termed ‘Progressive revelation’, ‘merchants’, ‘municipal authorities’ and ‘the complacency of ordinary men and women’, alike are reluctant to acknowledge an epidemic because of its threat to their ‘economic and institutional interests’ and to ‘their accustomed way of doing things’: gradually however, ‘inexorably accumulating deaths and sicknesses’ bring ‘ultimate, if unwilling, recognition’. In Act II, ‘Managing randomness’, ‘collective agreement’ is sought on (...) an ‘explanatory framework’ to manage the epidemic’s ‘dismaying arbitrariness’. Such frameworks, in previous centuries mainly religious, are now more ‘secular and mechanistic’, but again also moral and social: explanation for example of the ‘differential susceptibility of particular individuals’ is sought in terms of ‘risk-enhancing behaviour’ and ‘style of life’, but also of environmental and social factors, such as ‘residence and occupation’, providing ‘a vehicle for social criticism as well as a rationale for social control’. In Act III, ‘Negotiating public response’, pressure is generated for ‘decisive and visible community response’, often taking the form of ‘collective rites integrating cognitive and emotional elements’. Such rites, including not only ‘the imposition of a quarantine’ and ‘procedures to cleanse and disinfect’, but also religious, or now more often moral or social rituals, afford ‘the reassurance of familiar frames of explanation and logically consequent policies that provide both meaning and the promise of efficacy’. Finally, In Act IV, ‘Subsidence and retrospection’, ‘incidence of the disease gradually declines’, and questions are raised ‘for retrospective moral judgement’ about ‘what “lasting impact” particular incidents have had and what “lessons” have been learnt. Have the dead died in vain? Has a heedless society reverted to its accustomed ways of doing things as soon as denial became once more a …. (shrink)

Dr Caitríona L Cox’s recent article expounds the far-reaching implications of the ‘Healthcare Hero’ metaphor. She presents a detailed overview of heroism in the context of clinical care, revealing that healthcare workers, when portrayed as heroes, face challenges in reconciling unreasonable expectations of personal sacrifice without reciprocity or ample structural support from institutions and the general public. We use narrative medicine, a field primarily concerned with honouring the intersubjective narratives shared between patients and providers, in our attempt to deepen the (...) discussion about the ways Healthcare Heroes engenders military metaphor, antiscience discourse, and xenophobia in the USA. We argue that the militarised metaphor of Healthcare Heroes not only robs doctors and nurses of the ability to voice concerns for themselves and their patients, but effectively sacrifices them in a utilitarian bargain whereby human life is considered the expendable sacrifice necessary to ‘open the U.S. economy’. Militaristic metaphors in medicine can be dangerous to both doctors and patients, thus, teaching and advocating for the critical skills to analyse and alter this language prevents undue harm to providers and patients, as well as our national and global communities. (shrink)

Dr Caitríona L Cox’s recent article expounds the far-reaching implications of the ‘Healthcare Hero’ metaphor. She presents a detailed overview of heroism in the context of clinical care, revealing that healthcare workers, when portrayed as heroes, face challenges in reconciling unreasonable expectations of personal sacrifice without reciprocity or ample structural support from institutions and the general public. We use narrative medicine, a field primarily concerned with honouring the intersubjective narratives shared between patients and providers, in our attempt to deepen the (...) discussion about the ways Healthcare Heroes engenders military metaphor, antiscience discourse, and xenophobia in the USA. We argue that the militarised metaphor of Healthcare Heroes not only robs doctors and nurses of the ability to voice concerns for themselves and their patients, but effectively sacrifices them in a utilitarian bargain whereby human life is considered the expendable sacrifice necessary to ‘open the U.S. economy’. Militaristic metaphors in medicine can be dangerous to both doctors and patients, thus, teaching and advocating for the critical skills to analyse and alter this language prevents undue harm to providers and patients, as well as our national and global communities. (shrink)

The purpose of this article is to offer an alternative, more nuanced analysis of the labelling of frontline workers as heroes than originally proposed. Here, we argue that the hero narrative in itself need not be problematic, but highlight a number of wider factors that have led to the initial rise in support for labelling frontline workers as heroes. Through our related work, we have gathered similar stories from frontline workers where they feel betrayed, let down or otherwise short-changed by (...) the hero label, and we have sought to make sense of this through understanding more about how the hero label is used rather than what it means. In this article, we propose a way forward where there is greater discussion around the hero label in this context where individuals can be heroes but still struggle, still fail and still feel vulnerable, and where heroism is viewed as a state of interdependence between heroic actor and the wider group. It is true that heroes can inspire, lead, guide and build morale and camaraderie, but collective responsibility is held with us all. We can draw hope and energy from our heroes, but we must dig deep and be proactive, particularly in the face of adversity. In doing so, we support the heroes to lead from the front and ensure that even though we cannot physically help; we are not making their situation worse. (shrink)

Background: Critical care nurses have risked their lives and in some cases their families through hazardous duty during the COVID-19 pandemic and have faced multiple ethical challenges. Research/aim: The purpose of our study was to examine how critical care nurses coped with the sustained multi-faceted pressures of the critical care environment during the unchartered waters of the COVID-19 pandemic. It was anticipated that our study might reveal numerous ethical challenges and decision points. Research design: A qualitative descriptive study, utilizing an (...) interpretivist paradigm. Participants and research setting: Critical care nurses, working in either intensive care units or emergency departments (N = 11) who were primarily from Northern California hospitals. Individual in-depth ZOOM® session interviews, guided by semi-structured questions, were used to collect data. Interviews lasted between 18 and 59 min, with an average length of 33 min. Session interviews were transcribed and analyzed. Ethical considerations: This study was approved by the researchers’ university Institutional Review Board. Findings: Five main themes emerged: Fear of the Unknown, Adapting to Practice Changes and Challenges, Patient Advocacy and Moral Distress, Isolation and the Depersonalization of Care, and Professionalism and a Call to Duty. Discussion and conclusion: Fear of becoming ill or bringing COVID-19 home to their families was a constant source of anxiety for nurses. There were numerous changes in policy and challenges to standard practice protocols, including most notably shortages in personal protective equipment, which nurses navigated resourcefully. Most nurses interviewed were motivated by a sense of professional duty. The nurses experienced some moral distress in their inability to advocate as they might like for their patients, especially at end of life. Infection control requirements for isolation. (shrink)

BackgroundGeneral practitioners often act as gatekeeper, authorizing patients’ access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners’ experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic.MethodsSemi-structured interviews with Dutch general practitioners working in the Netherlands were (...) conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding.ResultsFifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients’ self-determination vs. the general practitioners’ paternalism, (3) the general practitioners’ duty of care vs. the general practitioners’ autonomy rights, (4) the general practitioners’ duty of care vs. adequate care provision.ConclusionsLack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account. (shrink)