The Moral Dilemma, if Left Unaddressed, Drowns Us

By Karla Mijangos

The COVID-19 phenomenon, at a global level, has not only left in its wake deaths, family breakdown, deepening of social inequalities and transformations in the education system. COVID-19 has also allowed us to see and touch that which has always been in the soul of society, but which we had not learned to talk about and live with.

One of the veils that are being lifted today has to do with the psychological and emotional aspects of the people who inhabit societies. In this regard, today COVID-19 also revealed that those who care for us in hospitals are the ones who suffered first-hand the impact of this pandemic and whom we need to care for today.

In this sense, to bring the issue of the moral dilemma out of the confinement of the past is to start from the uncertainties and conflicts that nursing professionals went through during this pandemic and that, for many of them, has them under this incommensurability. It is with this in mind that researchers from Spain, Brazil, Mexico, Argentina and Peru decided to understand this phenomenon in depth, with the aim of offering better alternatives for those who care for us. With this in mind, today we are talking to Dr Verónica Tíscar González (head of nursing research at the Bioaraba Health Research Institute and collaborating lecturer at the Vitoria-Gazteiz School of Nursing at the University of the Basque Country).

REHUNO: Hello Verónica. As a nurse and principal investigator of this project, we would like you to tell us how this study came about?

Verónica: This project arose logically out of necessity and as a result of the situation experienced during the COVID-19 pandemic worldwide, which had an impact on all health professionals, especially in the first wave in which resources were more limited, the mechanisms of transmission were not yet well understood, prevention measures and circuits and protocols were changing. Given this situation, many of the studies that have been carried out during 2020 and part of 2021 have focused on assessing the emotional impact on health professionals who have acted on the front line during the pandemic. In this regard, such research has yielded worrying data on the impact on their mental health.

On the other hand, it must be considered that any management decision taken at the micro, meso or macro level, in situations of such magnitude as the one experienced, entails a series of ethical connotations, because there are situations in which this initial lack of resources may have led professionals to have to prioritise the care of patients who, in normal situations, would have benefited from health care. In general, this is something that happens in disaster situations (accidents with multiple victims, for example), but we are not used to it in the health care continuum, especially in a public health system such as ours.

There are also a number of other principles and patients’ rights that may have been transgressed and values that have come into conflict. For example, restrictions on family visits and the vulnerability of the principle of autonomy in some cases. In general terms, it can be said that we have acted in the best possible way, and adopted the best measures from an epidemiological point of view, I have no doubt and I do not question it, but the situation has meant that health professionals have also had to face these other more subjective and moral approaches.

REHUNO: Was the issue of the moral dilemma already part of your particular interests or has it arisen now with the pandemic?

Veronica: My sensitivity to the phenomenon of moral distress predated the pandemic. I have been participating in the Health Care Ethics Committee for many years, first in OSI Bilbao Basurto, and now in OSI Araba (Osakidetza). So much so that part of my doctoral thesis dealt with this subject, although in the much more specific context of cardiopulmonary resuscitation.

REHUNO: And why think about this project at an international level? And how were the participating countries selected?

Verónica: During a research stay at the University of Toronto in Canada, I met Dr Carol Caram, a professor at the University of Minas Gerais in Brazil. She was also addressing this topic in her doctoral thesis. So, knowing this concern and this common sensitivity that we both had, the opportunity for international collaboration arose. In general, the situation we are experiencing in our country is similar to that experienced by colleagues in other countries, so if we want to know or somehow establish a strategic framework for future pandemic situations, which hopefully will not be repeated, we must look at what has happened from a more global and macro perspective, in order to propose various areas for improvement, making this comparison and seeking the impact at the level of health policies.

So, yes, the interest arises from a team of researchers and very specific concerns about bioethics, but the opportunity to carry out this research at an international level was fundamental. Therefore, Karla Ivonne Mijangos Fuentes (from Mexico) is another key player, because of the special sensitivity you have for everything related to care and its humanisation; and this is how the union of these three countries came about, but more with the team in mind than the country. In Spain, the team is completed with Dr Mayte Moreno from Investen-Isciii and Dr Joan Blanco from the University of Lleida, national leaders in care research and key pieces in the composition of this puzzle.

Subsequently, the union of other countries such as Argentina and Peru was almost accidental, because when it came to disseminating the study through social networks, the interest of these countries arose, due to situations very similar to ours; because of the idiosyncrasies, the context and many things in common that we must show and put on the table, above all, in the fact of being able to design health policies so that in the future this does not happen again and we can act differently. Joining the team here are Sergio Oscar Alunni leading in Argentina and Janet Mercedes Arévalo Ipanaqué in Peru.

REHUNO: What are the expected benefits of this research?

Verónica: Many of the ethical dilemmas that have arisen among the professionals were related to the humanisation of care with which we were used to working and for which we nurses advocate. above all, at the beginning of the pandemic, in which, due to ignorance, fear, the virulence, the severity of the first wave, in some cases, there have been patients who have been alone in the final moments and who in some way, have seen their principles such as autonomy diminished.

Likewise, in some of the in-depth interviews that we have already conducted, one of the professionals commented that the time that was normally spent with patients at the beginning was reduced to a minimum due to fear, so that comprehensive care was also affected. That is to say, the patients who are the centre of care, in such acute moments, became objects of care in some way, especially, I insist, in the first wave or tsunami, but it is a reality that has been experienced.

In general, I believe that the impact that this study can have is to collect the testimonies of nurses and, above all, in the future, to advocate for the re-humanisation of care, such as the fact of recovering the presence of family members in the care process, as well as investing in infrastructures that humanise this action.

REHUNO: Would you like to add a final message about this collaborative project?

Verónica: I would like to highlight the effort and dedication of the nurses, as well as the other members of the multidisciplinary teams, in trying to bring care closer and humanise it, because even in such delicate and restricted situations as those I have described above, initiatives have arisen, such as the issue of video calls between patients and their families, which meant that relatives could be in contact or even say goodbye to their loved ones. In addition, it is worth mentioning the collaborative work with other disciplines, which, like the nurses, have readapted to the situation and have developed competencies and functions that were not theirs to begin with, but which they did only in order to help out.

I believe that this is the positive part of the pandemic that we must keep and that, of course, we must give it a voice. Despite all the bad things and the chaos, I insist on that initial phase or first wave (tsunami), which was followed by more waves that, although they were big, we were already more prepared in every sense of the word. But in that first wave we must highlight the professionalism of the nursing staff and all the health professionals (doctors, assistants, orderlies, technicians, cleaning staff, etc.) who lent a hand.

REHUNO: Finally, Verónica, in closing her interview, invites all nursing professionals from Spain, Brazil, Mexico, Argentina and Peru, and those who have been caring for people with COVID-19, to participate in this wonderful project that seeks to give visibility and voice to these other subjectivities that are enclosed in the exercise of the care profession, and that are very necessary to show and treat through health policies, which should point towards the humanisation of care for the person and the professional

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This post was previously published on Pressenza.

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