Morals at the Margins: A Qualitative Case Study Exploring Ethical Tensions Experienced as a Result of Policy Constraints in Two Canadian Primary Care Practices

Introduction: Healthcare delivery is shaped by policy, which responds to contemporary circumstances. As an example of this, the COVID-19 pandemic significantly disrupted healthcare delivery in Canada, including the work of primary care professionals, whose experiences have received less attention. Accordingly, this study investigates the experiences of primary teams during the COVID-19 pandemic, with particular attention paid to experiences of moral distress as precipitated by policy changes. Methods: Qualitative case study methodology was employed to collect data across two distinct cases: primary care practices, located in Ontario (1) and Alberta (1), Canada. Semi-structured interviews were conducted with 25 healthcare and administrative professionals, and review of public policy and clinic-associated documents aided in understanding policy context. Data analysis was concurrent with data collection and generated within- and across-case themes. Results: Participants in both cases recognized the importance of infection control policies but described constraints relating to forgoing preventative care and disruption of care continuity. Participants described the cumulative effect of ethical tensions arising from constraints in providing care related to the core values of primary care. While most participants did not mention moral distress explicitly, many described ethically challenging situations that align with core features of the phenomenon. Conclusions: Primary care professionals felt that pandemic policy changes affected them leaving them unable to provide the type of care they felt morally obligated to provide. They experienced a cumulative sense of unresolved ethical tension that grew over time, as the pandemic-induced policies disrupted their core practice of continuous, preventative, and relationship-centered care.