Keywords
Coronavirus disease 2019 - ethical challenges - medical ethics - scarce resources
INTRODUCTION
The coronavirus disease 2019 (COVID-19) has grasped the world in a firm grip, and
individuals everywhere face unprecedented challenges in providing the best health
care. Healthcare organizations, across the world, have been rapidly reacting to different
medical, ethical, and social challenges imposed by the pandemic. Lockdowns have an
impact on the health and disease of hundreds of millions of people confined to homes.
Hospitals have shown great flexibility, with many elective operations and outpatient
clinics widely canceled. The COVID-19 has already created ethical questions about
the need for prioritization of treatment, availability of personal protective equipment,
testing, and resuscitation decisions. Ethical challenges continue to emerge as the
pandemic continues to progress,[1] including how best to deal with research on additional vaccine when an effective
product is already in hands, and how to prioritize patients for medical care as medical
services reopen.
SCARCE RESOURCES ALLOCATION
SCARCE RESOURCES ALLOCATION
The ethical implications of scarce resources are very drastic in this COVID-19 pandemic.
The great demand for critical care services in several areas of the world, such as
the northern region of Italy and New York, was exceeding the supply. Intensive care
doctors were facing challenging decisions about who should receive a ventilator or
not, knowing the fact that those who are not admitted to the intensive care units
will very likely die. Physicians have to consider the prioritization of patients who
are most likely to survive over those with remote chances. This practice has stimulated
an immense debate about the right of everyone to get access to the health care.[2] Priority decisions, if required, will be delegated to the skillful physicians who
will wisely utilize the resources available to them.
The University of Pittsburgh, the Washington University, and the State of New York,
have all created models with assigning scores to the patients, based on their age
and comorbidities, which guide the clinicians in the allocation of scarce resources.[3]
The criteria to allocate scarce lifesaving resources may make older adults, people
from minority communities, or people with disabilities, vulnerable. Triage teams should
be set up to implement criteria for prioritization, to minimize bias, and to avoid
unintended negative consequences. Health systems should also prepare for the long-term
psychological effects on the clinicians and families.[4] Withdrawing ventilators from patients who arrived earlier, to save those with better
prognosis, can be psychologically traumatic for the physicians, and some doctors may
even refuse to do it. In patients with similar prognoses, providing the intensive
care services should be equally invoked, and organized through random allocation,
such as a “lottery,” rather than adopting the first-come, first-served allocation
process.[5] There is “no ethically significant difference between decisions to withhold or withdraw
treatments (if other factors are equal).”[6] A national policy is urgently needed to provide the clinicians with clear guidance
about how patients should be practically prioritized, when the available resources
are limited.[7]
PERSONAL PROTECTION EQUIPMENT
PERSONAL PROTECTION EQUIPMENT
A major challenging ethical issue in this pandemic is the lack of adequate personal
protection equipment (PPE) in most countries, with the consequent risk of catching
the virus. This created a great pressure on the healthcare providers, in taking proper
action, without violating the ethical principles.[8] What would the clinician do if he is faced with a situation, where there is a lack
of adequate PPE? Can he withhold treatment without any medicolegal consequences? And
what are the legal sequels of such action? There is an obvious need for clear guidelines
outlining the proper way of action, the clinician should take, in such scenarios.[9]
In the present pandemic, the physicians are the most valuable asset for the society,
and sacrificing clinician’s life without a proper PPE is probably considered an irresponsible
act.[8] Sadly, many physicians and other healthcare providers in Italy, United Kingdom,
Egypt, and elsewhere, lost their lives during this pandemic.
ETHICAL ISSUES OF THE VACCINE
ETHICAL ISSUES OF THE VACCINE
The world is extremely anxious to see the availability of an effective vaccine for
the COVID-19. Once it is available, a number of ethical questions will emerge. Many
researchers will continue to test the efficacy of other vaccines, for the same virus,
in clinical trials involving human subjects. Is it ethical to conduct a trial on another
vaccine and to deprive subjects in the trial from the benefit of an effective vaccine
already in hand?
A robust principle in medical ethics is that no effective treatment or vaccine would
be withheld from the patients, if their survival may rely on it. It is feared that
such studies may be carried out in areas with less-resourced health systems, and hence
there is a major concern that any trial withholding an efficient safe vaccine would
probably affect the vulnerable populations who have been badly utilized with biomedical
research in the past.[10]
On the contrary, one can argue that it is justifiable to conduct a trial with another
vaccine, if it is expected to have clear advantage over the existing product. Thus,
the burden is on the vaccine developers to convince the scientists that their potential
vaccine is more appealing than the existing product, in terms of advantages and side
effects. Both pharmaceutical companies and researchers conducting the vaccine trials
should take all measures to protect the vulnerable research subjects. Such measures
include providing appropriate compensation to the trial participants, and sharing
the financial rewards of the successful vaccine with the involved communities. Besides,
the informed consent should be obtained in culturally and linguistically appropriate
way.[10]
CLINICAL TRIALS
In view of the urgency to obtain a vaccine or treatment of the COVID-19, many authorities
fear that the design of randomized controlled trials (RCTs) may not be ideal, taking
no account of the patients’ essential interests. The investigators may loosen the
inclusion and exclusion criteria, and fail to obtain a proper informed consent, particularly
from the vulnerable subjects. Before the subject makes his/her decision, the investigator
should discuss with him/her the study aims and procedures, risks and benefits, and
the rights and commitments of the participant. Even after the participant decides
to share in the study, the research team should continue to provide the participant
with any new information that might affect his situation, and provide him with reasonable
compensation. Ethical committees should reemphasize these sensitive issues, and the
researchers must maintain all efforts to not expose participants to any possible risks
or harm.[11] Investigators should realize that pandemics are not an excuse for relaxing the universal
scientific standards, and researchers should always act according to the ethical principles.[12]
PSYCHOLOGICAL EFFECTS
The major burden of this pandemic is that healthcare providers are faced with huge
number of patients to care for, and quite often, with limited resources. Worldwide,
large number of patients with COVID-19 are seen dying in emergency rooms or intensive
care units. At the same time, the majority of population throughout the world has
been requested to reduce their activities, in the hope of minimizing the spread of
the corona virus. All of these have created significant distress across the globe.[8] In this era of rapid change, anxiety, social distancing, and financial burden, it
is not unexpected to see that mental health, worldwide, might be at risk, and researchers
have already initiated such research.[13]
LABORING ALONE
In order to protect both the healthcare providers and the patients during the pandemic,
hospitals have taken the rules of prohibiting patient’s visitors. In most hospitals,
labor units have been considered as an exception to this rule. A “support person”
during delivery is felt to have an “essential” role in the maternity care, and not
having a partner around in labor or at the birth of a child is considered to be unkind,
inconceivable, and for some, it may be traumatic.
Several hospitals in New York City were hit hard by the huge number of COVID-19 patients,
and consequently, they imposed a ban on labor visitors, aiming at reducing staff exposures.
The resulting reaction was a combination of ambiguity and resentment. Many obstetricians
were worried that such policy may force women to arrange for home deliveries, or may
force them to search for delivery at hospitals permitting the presence of supporting
person. The “New York City Department of Public Health” published new guidance stating
that a “support person” in labor is “essential,” and the Governor of New York issued
an order commanding hospitals to permit (healthy) visitors to be present during delivery.[14]
The notion of not having a “support person” during labor is unkind, and it may even
be detrimental. However, one can argue that the same may apply to many patients left
to die alone during this pandemic, without the presence or comfort of their loved
ones.[14] We are really facing an extraordinary situation in the history of medicine!
VIOLENCE AGAINST WOMEN DURING PANDEMIC RESTRICTIONS
VIOLENCE AGAINST WOMEN DURING PANDEMIC RESTRICTIONS
Intimate partner violence (IPV) is considered as a major public health problem across
the world, and it is more commonly referred to as “domestic violence.” The World Health
Organization (WHO) defines IPV as “any behavior within an intimate relationship that
causes physical, psychological, or sexual harm to those in the relationship.” It is
estimated that 30% of women, worldwide, experience some form of physical or sexual
violence by their intimate partners in their lifetime. It is typically experienced
by women but can also be experienced by men.[15]
Though robust data are scarce, media news and reports from the organizations, responding
to domestic violence incidents, indicate that there is an alarming increase in the
IPV cases during this pandemic.[16]
Although the healthcare system, worldwide, is under tremendous pressure as the pandemic
overstretched the capacity of health institutions, the health sector should still
take effective measures to alleviate the risk of violence against women during the
pandemic. Healthcare providers should be aware of the risks and sequel of IPV, and
provide the affected subjects with psychological and social support, in addition to
the necessary medical treatment. The use of telemedicine and mobile health system,
to safely support those affected with IPV, must be urgently explored.[16]
CONCLUSION
The COVID-19 pandemic raised unique ethical dilemmas, but the key issue has been the
need to ration scarce critical care resources. There is a desperate need to substantially
increase the resources dedicated to the health system, so that clinicians do not have
to face the difficult decision of which life to save.
The intimate relationship between medicine and ethics is unequivocal, and the contribution
of ethical perspective, particularly during the pandemic, is invaluable. Identifying
the ethical challenges emerging from the pandemic will assist physicians in making
proper decisions and in maintaining the best standards of care for their patients.
