The COVID-19 pandemic has generated an imbalance between the clinical needs of the population and the effective availability of advanced life support (ALS) resources. Triage protocols have thus become necessary. Triage decisions in situations of scarce resources were not extraordinary in the pre-COVID-19 era; these protocols abounded in the context of organ transplantation. However, this prior experience was not considered during the COVID-19 outbreak in Spain. Lacking national guidance or public coordination, each hospital has been forced to (...) put forth independent and autonomous triage protocols, most of which were, nonetheless, based on common ethical principles and clinical criteria. However, controversial, non-clinical criteria have also been defended by Spanish scientific societies and public institutions, including setting an age cut-off value for unilaterally withholding ALS, using ‘social utility’ criteria, prioritising healthcare professionals or using ‘first come, first served’ policies. This paper describes the most common triage criteria used in the Spanish context during the COVID-19 epidemic. We will highlight our missed opportunities by comparing these criteria to those used in organ transplantation protocols. The problems posed by subjective, non-clinical criteria will also be discussed. We hope that this critical review might be of use to countries at earlier stages of the epidemic while we learn from our mistakes. (shrink)

COVID-19 is a very complex pandemic. It has affected individuals, different countries and regions of the world equally in some senses and differently in other senses. While sub-Saharan Africa has weathered a range of outbreaks of emerging and re-emerging infectious diseases, the manner in which the COVID-19 pandemic has evolved necessitates some observations, remarks and conclusions from our own situated observation point. Compared to previous epidemics/pandemics, many African countries have displayed a sense of solidarity in the face (...) of COVID-19 that convincingly demonstrates that an Ubuntu ethic is viable and globalizable. The African continent seems, at last, to have realized that ethics dumping must be avoided and has made strides in defining its COVID-19 research agenda and strengthening its epidemic response for both public health and health research. More needs to be done in terms of public engagement, funding and technical support for research on potential therapies/candidate vaccines that are a product of scientific studies on the continent. (shrink)

This open access casebook addresses complex and important ethical challenges arising when health-related research in conducted in the context of epidemics and pandemics. This book provides contextually-rich real-world case studies illustrating research ethics issues encountered by researchers, ethics reviewers and regulators around the globe during the COVID-19 pandemic. The accompanying commentaries outline relevant conceptual approaches and ethical considerations. These promote understanding and reflection on relevant ethical issues, ethical approaches and competing considerations in a manner supporting thoughtful (...) evaluation of their implications for practice. As such the casebook is relevant to academic and professional audiences with an interest in global health, research ethics, and outbreaks and epidemics. (shrink)

Few novel or emerging infectious diseases have posed such vital ethical challenges so quickly and dramatically as the novel coronavirus SARS‐CoV‐2. The World Health Organization declared a public health emergency of international concern and recently classified Covid‐19 as a worldwide pandemic. As of this writing, the epidemic has not yet peaked in the United States, but community transmission is widespread. President Trump declared a national emergency as fifty governors declared state emergencies. In the coming weeks, hospitals will become overrun, (...) stretched to their capacities. When the health system becomes stretched beyond capacity, how can we ethically allocate scarce health goods and services? How can we ensure that marginalized populations can access the care they need? What ethical duties do we owe to vulnerable people separated from their families and communities? And how do we ethically and legally balance public health with civil liberties? (shrink)

Commentators believe that the COVID-19 pandemic reveals the inconveniences of capitalism and that the end of “neoliberalism” could be near. In this article we show that a capitalist ethics is capable to deal with the challenges of pandemics and comes with important advantages such as the prevention of overreactions. We apply both utilitarian and rights-based ethics to the case of epidemics in general and COVID-19 in particular. First a libertarian natural law ethics is used (...) to assess the government interventions in the Corona pandemic. We maintain that these interventions cannot be justified from a libertarian point of view despite of the possible objections that are discussed such as the “potential threat argument”. Moreover, the utilitarian argument in favor of government lockdowns is evaluated. The negative effects of lockdown on mental health, addictions, domestic violence, etc. have to be taken into account. The utilitarian argument in favor of lockdown is far from convincing, as economic calculation is not possible. (shrink)

Background Healthcare professionals (HCPs) face a myriad of ethical challenges during the coronavirus disease 2019 (COVID-19) pandemic. However, there is limited literature examining the ethical challenges faced by HCPs in low- and medium-income countries. The research was designed to explore the ethical challenges experienced by HCPs in a Malaysian hospital setting during the pandemic. Methods Semistructured interviews were conducted via video calls with 10 Malaysian HCPs across different clinical disciplines involved in managing patients diagnosed with COVID-19 infections. The (...) calls were audio-recorded, transcribed verbatim and checked. Thematic analysis with constant comparison across transcripts was carried out to identify categories and themes. Results Three main themes emerged. Firstly, there was deprioritisation of care for non-COVID-19 patients resulting from resource limitations. HCPs raised concerns that there was curtailed access to various healthcare services by non-COVID-19 patients. There was also a trade-off between protecting individual patient safety and public health interests. Secondly, patients were disempowered from decision-making; the decision to segregate suspected COVID-19 patients to high-risk areas without seeking patients’ approval may result in an increased risk of infection. Lastly, HCPs expressed internal conflicts when balancing the professional duty of care against concerns about contracting COVID-19 and spreading it to their family members. Conclusion The study highlighted ethical issues faced by HCPs in Malaysia during the pandemic. It underscores the need for clinical ethics consultation services in hospitals to navigate the various ethical dilemmas. (shrink)

As COVID-19 spread, clinicians warned of mental illness epidemics within the coronavirus pandemic. Funding for digital mental health is surging and researchers are calling for widespread adoption to address the mental health sequalae of COVID-19. -/- We consider whether these technologies improve mental health outcomes and whether they exacerbate existing health inequalities laid bare by the pandemic. We argue the evidence for efficacy is weak and the likelihood of increasing inequalities is high. -/- First, we review recent (...) trends in digital mental health. Next, we turn to the clinical literature to show that many technologies proposed as a response to COVID-19 are unlikely to improve outcomes. Then, we argue that even evidence-based technologies run the risk of increasing health disparities. We conclude by suggesting that policymakers should not allocate limited resources to the development of many digital mental health tools and should focus instead on evidence-based solutions to address mental health inequalities. (shrink)

The current COVID-19 pandemic has raised many questions and dilemmas for modern day ethicists and healthcare providers. Are physicians, nurses and other healthcare workers morally obligated to put themselves in harm’s way and treat patients during a pandemic, occurring a great risk to themselves, their families and potentially to other patients? The issue was relevant during the 1918 influenza epidemic and more recently severe acute respiratory syndrome epidemic in 2003. Since the risk to the healthcare workers was great, there (...) was tension between the ethical duty and responsibility to treat and the risk to one’s own life. This tension was further noted during the 2014 Ebola outbreak in West Africa that left hundreds of healthcare workers dead. The AMA Code of Ethics states that physicians are to ‘provide urgent medical care during disasters…even in the face of greater than usual risk to physicians’ own safety, health or life.’1 Classic Jewish sources have dealt with this question as well. There is an obligation ‘to not stand by idly when your friends life is in danger’; however, the question arises as to whether there are limits to this obligation? Is one required to risk one’s own life to save another’s? There is a consensus that one is not required but the question open to debate is whether it is praiseworthy to do so. However, regarding healthcare workers, there is agreement for ethical, professional and societal reasons that they are required to put themselves in harm’s way to care for their patients. (shrink)

In this review study, I reflect on Richard Horton’s book and his thesis that Western countries failed in their response to the current epidemic in the first half of 2020, with a few exceptions. In the five sections of the paper, after an initial modification of Horton’s thesis (A), I discuss briefly: the suppression approach in China (B), the mitigation approach in the West (C), the SARS epidemic as the key global public health event (D), the causes of Western failure (...) (epistemic, political, ethical, cultural, etc.) (E), and final envoi (F). (shrink)

At the height of the COVID-19 crisis in the Netherlands a shortness of intensive care beds was looming. Dutch professional medical organizations asked a group of ethicists for assistance in drafting guidelines and criteria for selection of patients for intensive care treatment in case of absolute scarcity, when medical selection criteria would no longer suffice. This article describes the Dutch context, the process of drafting the advice and reflects on the role of ethicists and lessons learned. We argue that (...) timely interaction between clinical and ethical expertise is necessary since the distinction between medical and non-medical considerations is not as clearcut as sometimes assumed. Furthermore, pragmatic considerations related to the specifics of an epidemic are of importance, for example, in relation to prioritizing health care workers. As a consequence, any protocol already present before the pandemic would need alterations to fit the current situation. The ‘fair innings’ criterion we proposed, rephrased as an argument of intergenerational solidarity, was considered reasonable by professionals as well as patient organizations. While it is desirable to draft ethical guidelines in ‘peacetime’ as a matter of pandemic preparedness, the pressure of an actual crisis facilitates decision-making, although it will also complicate a more democratic approach. (shrink)

Informed by evidence from past studies and experiences with epidemics, an intervention combining quarantine, lockdowns, curfews, social distancing, and washing of hands has been adopted as “international best practice” in COVID-19 response. With massive total lockdowns complemented by electronic surveillance, China successfully controlled the pandemic in country within a few months. But would this work for Africa and other communalistic resource-poor settings where social togetherness translates to effective sharing of basic needs? What ethical and practical challenges would this (...) pose? How would communalism be translated in special contexts to be useful in contributing to the ultimate common good? This paper uses examples from the current situation of COVID-19 in Kenya to address these questions. (shrink)

In 2020, COVID-19 patients overwhelmed hospital beds in several Spanish cities, producing an increase in mortality derived from a lack of resources. The provision of new spaces to be reconfigured as healthcare centers for COVID patients was one of the measures implemented. In Madrid, two of these COVID centers drew enormous media and political repercussions due to their high cost and the controversy surrounding the quality of the care they offered. In this scenario of misinformation, several doctors (...) and patients rejected to be transferred to such medical centers, but they were nonetheless compelled to make the move. This manuscript underscores how this lack of transparency affects health workers, patients, and the relationship between them, and brings out the question of how many essential bioethical principles can be individually violated by a matter of public health. New guidelines for the transfer of patients should be designed from an ethical perspective and updated, as the epidemic continues, to improve the modern understanding of human factors in times of uncertainty. The lesson that these centers provide us is that we must rethink crisis resource management from a new perspective that prioritizes access to quality information. In its absence, the principle of autonomy must prevail. (shrink)

The COVID-19 Law Lab platform enables quantitative representation of epidemic law and policies in a given country for multiple years, enabling governments and researchers to compare countries, and learn about the impacts and drivers of policy choices. The Law Lab initiative is designed to address the urgent need for quality legal information to support the study of how law and policy can be used to effectively manage this, and future, pandemic(s).

Vaccines are a powerful measure to protect the health of individuals and to combat outbreaks such as the COVID-19 pandemic. An ethical dilemma arises when one effective vaccine has been successfully developed against an epidemic disease and researchers seek to test the efficacy of another vaccine for the same pathogen in clinical trials involving human subjects. On the one hand, there are compelling reasons why it would be unethical to trial a novel vaccine when an effective product exists already. (...) First, it is a firm principle of medical ethics that an effective treatment or vaccine should not be withheld from patients if their life may depend on it. Second, since epidemic outbreaks often emerge in settings with less-resourced health systems, there is a pronounced risk that any trial withholding an effective vaccine would disproportionately affect the vulnerable populations that historically have been exploited for biomedical research. Third, clinical trials for novel vaccines may be at odds with efforts to control active outbreaks. On the other hand, it may be justified to conduct a trial for a candidate vaccine if it is expected to have certain advantages compared with the existing product. This essay discusses key factors for comparing vaccines against epidemic pathogens, including immunological, logistical and economic considerations. Alongside a case study of the development of vaccines for Ebola, the essay seeks to establish a general framework that should be expanded and populated by immunologists, epidemiologists, economists and bioethicists, and ultimately could be applied to the case of COVID-19 vaccines. (shrink)

Volume 20, Issue 7, July 2020, Page W7-W11.

The Covid‐19 pandemic has highlighted many of the difficult ethical issues that health care professionals confront in caring for patients and families. The decisions such workers face on the front lines are fraught with uncertainty for all stakeholders. Our focus is on the implications for nurses, who are the largest global health care workforce but whose perspectives are not always fully considered. This essay discusses three overarching ethical issues that create a myriad of concerns and will likely affect nurses (...) globally in unique ways: the safety of nurses, patients, colleagues, and families; the allocation of scarce resources; and the changing nature of nurses’ relationships with patients and families. We urge policy‐makers to ensure that nurses’ voices and perspectives are integrated into both local and global decision‐making so as to minimize the structural injustices many nurses have faced to date. Finally, we urge nurses to seek sources of support throughout this pandemic. (shrink)

COVID-19 is a new type of coronavirus that has spread all over the world and has caused a global epidemic that affected all parts of society. Healthcare professionals that are involved in the diagnosis, treatment, and care of patients diagnosed with coronavirus have been under a heavy burden both physically and psychologically during the fight against this disease. Articles published on protecting the mental health of healthcare professionals during the epidemic have stated that healthcare professionals should be supported to (...) prevent the negative effects of the epidemic on them. This new situation requires developing appropriate strategies for coping with the COVID-19 pandemic, due to the given heavy burden by healthcare professionals. Therefore, the determination of effective approaches for the protection of mental health of healthcare professionals and increasing their protective factors, such as psychological resilience, has got great importance. Positive religious coping contents can be seen among the protective factors that affect the psychological resilience of healthcare professionals. Positive religious coping behaviors, such as refuge in Allah, praying, and reading Qur'an, not only provides a spiritual strength against the troubles of life but also provides a sense of control, peace, and security. This research aims to examine the relationship between religious coping and psychological resilience in healthcare professionals during the COVID-19 pandemic. Ethical approval for this research was obtained from Atatürk University Social and Human Science Ethics Committee (12.04.2021 dated and 88656144-000.E.2100103436 numbered). Descriptive research and correlational methods were used in the study. The population of the research consists of personnel working in health facilities operating throughout the country. The sample consists of doctors, nurses, pharmacists, midwives, and other health workers working in these health institutions. The Snowball sampling method was used in this study. For this aim, a Google Forms was established and 293 health workers in more than 40 provinces have filled this form. Personal Information Form, Religious Coping Scale, and Brief Psychological Resilience Scale were used as data collection tools. These data collection tools were used to determine whether positive and negative religious coping and psychological resilience differs according to gender and age. In addition to the above-mentioned aim, the relationship between positive and negative religious coping and resilience was examined in this study. T-test and ANOVA were applied in the analysis of demographic variables. Correlation and regression analysis were used to test the relationship between the variables. Findings obtained from this study have revealed that the levels of religious coping and psychological resilience of healthcare professionals differ according to their demographic characteristics. Results have shown that while there is no significant difference between women and men in terms of using positive religious coping methods, men use negative religious coping methods more frequently than women. Results have also revealed that positive coping methods are used more frequently as age increases and psychological resilience increased with age. Correlation analysis has shown that there is a significant relationship between positive religious coping and psychological resilience. Results of regression analysis have shown that positive religious coping is a significant predictor of psychological resilience. This result shows that positive religious coping is an important variable that affects psychological resilience. Results have suggested that there is a need to develop a program with religious/spiritual content that can help healthcare professionals to overcome this difficult process more easily by increasing their psychological resilience. Results obtained from this study may not only contribute to other rehabilitative studies that can be carried out for healthcare professionals during and after the pandemic but also provide scientific data for possible academic studies on this subject. (shrink)

The COVID‐19 pandemic has shaken the world through its first wave, and we have yet to experience the second wave. Even resourceful countries have failed to adequately prevent epidemics in their country, and for countries like Bangladesh, which already has strained an ineffective healthcare system, the challenges to contain the SARS‐CoV‐2 virus are that much more severe. Due to the scarcity of resources and systematic failures the Bangladeshi people deeply mistrust the healthcare system. The mistrust is further magnified (...) as healthcare providers are hesitant to treat the patients because of the lack of proper protective gear. Physicians have a moral obligation to serve and treat patients; however, they have a moral obligation to protect their families. This dilemma places healthcare providers in situations where they experience moral distress. This article specifically discusses the importance of interpersonal relationships in driving change, using the framework of Responsiveness, while stating the need for complementary systematic change in order to rebuild trust in the Bangladeshi healthcare system. (shrink)

Public health and pandemic ethics frequently concern themselves with organizing principles, utility, and public policy. But the effects of pandemics, and the impact of measures to control them, are experienced by individuals and families. This is particularly true for those who are most vulnerable to COVID-19—the elderly and “infirm.” So while ethics must assist in articulating the policies that will determine the allocation of resources during this and future pandemics, it must, at the same time, be alert (...) to the intimate narratives of the infection. This is an account from someone looking down the muzzle of COVID-19. (shrink)

The COVID-19 pandemic exposed vulnerabilities in inadequately prioritized healthcare systems in low- and middle-income countries such as Kenya. In this prolonged pandemic, nurses and midwives working at the frontline face multiple ethical problems, including their obligation to care for their patients and the risk for infection with severe acute respiratory syndrome coronavirus 2. Despite the frequency of emergencies in Africa, there is a paucity of literature on ethical issues during epidemics. Furthermore, nursing regulatory bodies in African countries such (...) as Kenya have primarily adopted a Western code of ethics that may not reflect the realities of the healthcare systems and cultural context in which nurses and midwives care for patients. In this article, we discuss the tension between nurses’ and midwives’ duty of care and resource allocation in the context of the COVID-19 pandemic. There is an urgent need to clarify nurses’ and midwives’ rights and responsibilities, especially in the current political setting, limited resources, and ambiguous professional codes of ethics that guide their practice. (shrink)

Background:When the contagious COVID-19 spread worldwide, the frontline staff faced unprecedented excessive work pressure and expectations of all of the society.Objective:The aim was to explore healthcare workers’ stress and influencing factors when caring for COVID-19 patients from an altruistic perspective.Methods:A cross-sectional, descriptive study was conducted in a tertiary hospital during the outbreak of COVID-19 between February and March 2020 in Wuhan, the capital city of Hubei province in China. Data were collected from 1208 healthcare workers. Descriptive statistics (...) and multiple linear regression were used to analyze the data.Ethical considerations:Research ethics approval (with the code of TJ-IRB20200379) was obtained from Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology. Written informed consent was also received from participants.Results:Less than 60% of participants chose moderate or severe stress on all stressors, indicating a low stress level among healthcare workers. The main source of stress among frontline healthcare workers caring for COVID-19 patients came from the fear of being infected, the fear of family members being infected, and the discomfort caused by protective equipment. Frontline staff who were nurses, were married, and had worked more than 20 days suffered higher stress, whereas rescue staff showed lower stress.Conclusion:The healthcare workers caring for patients with COVID-19 had low stress level, although they still had the fear of being infected or uncomfortable feeling caused by personal protective equipment. A low stress level among healthcare workers indicated their professional devotion and altruism during COVID-19 epidemic. Medical institutions and the government should continue to strengthen infection prevention measures and provide more comprehensive care involving families of frontline healthcare workers, especially nurses and married staff. It will be a lesson to other countries that awaking healthcare workers’ inside motivation and providing necessary support from government and society were significant. (shrink)

For Albert Camus, plague was both a fact of life and a powerful metaphor for the human condition. Camus engaged most explicitly and extensively with the subject of plague in his 1947 novel, The Plague (La peste), which chronicles an outbreak of what is presumably cholera in the French-Algerian city of Oran. I often thought of this novel—and what it might teach us—during the recent COVID-19 pandemic. In this article, I discuss seven important insights from The Plague about (...) class='Hi'>epidemics, public health and morality. (shrink)

The ethical experience and lessons of China’s and the world's response to COVID-19 will be debated for many years to come. But one feature of the Chinese authoritarian response that should not be overlooked is its practice of silencing and humiliating the whistle-blowers who told the truth about the epidemic. In this article, we document the humiliation of Dr Li Wenliang, the most prominent whistle-blower in the Chinese COVID-19 epidemic. Engaging with the thought of Israeli philosopher Avishai Margalit, (...) who argues that humiliation constitutes an injury to a person’s self-respect, we discuss his contention that a decent society is one that abolishes conditions which constitute a justification for its dependents to consider themselves humiliated. We explore the ways that institutions humiliate whistle-blowers in Western countries as well as in China. (shrink)

Global health emergencies such as the COVID-19 pandemic are contexts in which it is critical to draw upon learning from prior research and to conduct novel research to inform real-time decision-making and pandemic responses. While research is vitally important, however, emergencies are radically non-ideal contexts for its conduct, due to exceptional uncertainty, urgency, disruption, health needs, and strain on existing health systems, amongst other challenges. This generates novel ethical challenges and a broader conception of research ethics is necessary (...) to effectively address the complexity of pandemic research contexts. Going beyond traditional approaches to research ethics centring on the design of specific studies, this broader conception requires consideration of fundamental questions relating to the exercise of power and influence throughout research pathways, and a broader attention to both salient ethical issues, and the ethical responsibilities of stakeholders. These include important questions about responsibilities to gather evidence and generate knowledge systematically during emergencies, to implement policy responses in ways that are amenable to evaluation, and even potential moral obligations to participate in research. In situations of heightened uncertainty, additional questions arise about what constitutes sufficient evidence to justify the development and implementation of policy responses, and the responsibilities of scientific and social science researchers involved in policy-making processes. The four cases in this chapter prompt reflection on evolving and at times competing values and responsibilities of policy-makers, regulators, health authorities and researchers during the design and conduct of research, and proposed early implementation of research findings. These cases highlight issues arising when conducting research of national importance in a pandemic, where researchers are required to liaise with authorities responsible for pandemic responses and address complex ethical issues, including protecting the interests of participants and publics when tensions arise between prioritising the completion of research and accelerating the rollout of novel health interventions. This chapter invites reflection on the practical ethical implications of commitments to undertake research during emergencies, including the nature and scope of the relevant responsibilities of a range of stakeholders. (shrink)

During an outbreak or pandemic involving a novel disease such as COVID-19, infected persons may need to undergo strict medical isolation and be separated from their families for public health reasons. Such a practice raises various ethical questions, the characteristics of which are heightened by uncertainties such as mode of transmission and increasingly scarce healthcare resources. For example, under what circumstances should non-infected parents be allowed to stay with their infected children in an isolation facility? This paper will examine (...) ethical issues with three modes of “family presence” or “being there or with” a separated family member during the current COVID-19 pandemic: physical, virtual, and surrogate. Physical visits, stays, or care by family members in isolation facilities are usually prohibited, discouraged, or limited to exceptional circumstances. Virtual presence for isolated patients is often recommended and used to enable communication. When visits are disallowed, frontline workers sometimes act as surrogate family for patients, such as performing bedside vigils for dying patients. Drawing on lessons from past outbreaks such as the 2002-2003 SARS epidemic and the recent Ebola epidemic in West Africa, we consider the ethical management of these modes of family presence and argue for the promotion of physical presence under some conditions. (shrink)

Solnicaet alargue that “Jewish law and modern secular approaches based on professional responsibilities obligate physicians to care for all patients even those with communicable diseases”. The authors base their viewpoint on the opinion of Rabbi Eliezer Waldenberg and apply it to suggest that physicians are obligated to endanger themselves during epidemics, such as COVID-19. It is argued that Solnicaet al’s analysis of Rabbi Waldenberg’s text and their conclusion that healthcare workers are obligated to endanger themselves while treating patient (...) who suffer from contagious illness during epidemics according to Jewish law suffer from various shortcomings. Indeed, Jewish law looks favourably on healthcare workers who take a reasonable risk in treating their patients in the context of epidemics. However, it is considered a voluntary supererogatory act—not obligatory. Solnicaet almay express a legitimate ethical viewpoint. However, it does not seem to represent the mainstream approach of what Jewish law would demand as obligatory from its practitioners. (shrink)

In this paper, we reflect on the COVID-19 pandemic based on medical philosophy. A critical examination of the Corona crisis uncovers that in order to understand and explain the unpreparedness of the health systems, we need a new conceptual framework. This helps us to look at this phenomenon in a new way, address new problems, and come up with creative solutions. Our proposal is that “health lag” is a concept that could help frame and explain this unpreparedness and unreadiness. (...) The term “health lag” refers to the failure of health systems to keep up with clinical medicine. In other words, health issues in most situations fall behind clinical medicine, leading to social, cultural, and economic problems. In the first step to define health lag, we have to explain the distinction between clinical medicine and health and address the role of individual health, public health, and epidemic in this dichotomy. Thereafter, the reasons behind health lag will be analyzed in three levels: theoretical, practical, and institutional. In the third step, we will point out the most important consequences of health lag: the medicalization of health, the inconsistency of biopolitics, inadequate ethical frameworks, and public sphere vulnerabilities. Finally, we try to come up with a set of recommendations based on this philosophical-conceptual analysis. (shrink)

The paper considers the recently published British Medical Association Guidance on ethical issues arising in relation to rationing of treatment during the COVID-19 Pandemic. It considers whether it...

The global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or coronavirus disease 19 (COVID-19) has led to the imposition of severely restrictive measures by governments in the Western hemisphere. We feel a contrast between these measures and our freedom. This contrast, we argue, is a false perception. It only appears to us because we look at the issue through our contemporary moral philosophy of utilitarianism and an understanding of freedom as absence of constraints. Both these views can (...) be substituted with more sophisticated alternatives, namely an ethics of virtue and a notion of freedom of the will. These offer a fuller picture of morality and enable us to cooperate with the current restrictions by consciously choosing to adhere to them instead of perceiving them as draconian and immoral. We ask whether we should collaborate with the restrictions and argue that considerations of virtue will lead to an affirmative answer. More broadly, virtue ethics permits to deal with the practical concerns about how an individual should behave during this pandemic, given the current lockdown measures or lack thereof. -/- In section 1, we present how utilitarianism and a notion of freedom as negative liberty support the opposition to restrictive measures. In section 2, we outline an alternative based on an ethics of virtue and a more elaborated notion of free will. In the concluding section 3, we argue that considerations of virtue should guide the individual and public response to the emergency. (shrink)

The events surrounding COVID-19, combined with the mandatory quarantines widely imposed in Asia and Europe since the virus outbreak, have reignited discussion of the balance between individual rights and liberties and public health during epidemics and pandemics. This article analyses this issue from the perspectives of precaution and necessity. There is a difficult relationship between these two seemingly opposite principles, both of which are frequently invoked in this domain. Although the precautionary principle encourages the use of quarantines, including (...) mandatory quarantines, and associated restrictive measures, the principle of necessity puts a break on such measures. The COVID-19 pandemic reveals once again the different interrelations between these two principles. However, the alleged conflict between the PN and the PP is based on a superficial analysis. The relation between these two principles is far more complex, as this article will demonstrate. (shrink)

While the world rushed to develop treatments for COVID-19, some turned hopefully to drug repurposing. However, little study has addressed issues of drug repurposing in emergency situations from a broader perspective, taking into account the social and ethical ramifications. When drug repurposing is employed in emergency situations, the fairness of resource distribution becomes an issue that requires careful ethical consideration.This paper examines the drug repurposing in emergency situations focusing on the fairness using Japanese cases. Ethical issues under these circumstances (...) addressed by the authors include: maintaining the evidence level, integrity of clinical research ethics, and voluntary consent by original indication patients. In order to address these issues, they argue that rapid accumulation of ethically and scientifically valid evidence is required, as is obtaining information on resource quantity. (shrink)

Recent weeks have seen an increased focus on the ethical response to the COVID-19 pandemic. Ethics guidance has proliferated across Britain, with ethicists and those with a keen interest in ethics in their professions working to produce advice and support for the National Health Service. The guiding principles of the pandemic have emerged, in one form or another, to favour fairness, especially with regard to allocating resources and prioritizing care. However, fairness is not equivalent to equity when (...) it comes to healthcare, and the focus on fairness means that existing guidance inadvertently discriminates against people from ethnic minority backgrounds. Drawing on early criticisms of existing clinical guidance (for example, the frailty decision tool) and ethical guidance in Britain, this essay will discuss the importance of including sociology, specifically the relationship between ethnicity and health, in any ethical and clinical guidance for care during the pandemic in the United Kingdom. To do otherwise, I will argue, would be actively choosing to allow a proportion of the British population to die for no other reason than their ethnic background. Finally, I will end by arguing why sociology must be a key component in any guidance, outlining how sociology was incorporated into the cross-college guidance produced by the Royal College of Physicians. (shrink)

This spotlight article reflects on President Xi Jinping's handling of the COVID-19 epidemic and evaluates its specificities by making a brief incursion into the history of Chinese official responses to epidemics. This analysis shows that Xi Jinping's response to the COVID-19 epidemic differs from official responses to the 2003 SARS epidemic and the cerebrospinal meningitis epidemic of 1966–1967, and is used to assert his legitimacy on both the local and the international stage. By sharing data, even if (...) it was not as accurate as claimed, Xi Jinping has presented himself as a trustworthy international partner, leading a country that is at the forefront of scientific research, capable of vigorously implementing epidemic preparedness measures, and destined to become a major player in global health. On the Chinese stage, he showed that the central government has regained control over local public health organizations and that public health is once again a key government priority. As part of his response, Xi Jinping also honored gods of the Chinese pantheon, in a seeming contradiction with communism and science. I argue that, by combining the most advanced technology with a religious heritage, Xi Jinping is skillfully creating an image of himself not only as powerful and modern, but also as a leader undeniably rooted in Chinese tradition. (shrink)

Background In the course of the COVID-19 pandemic, the biomedical research community’s attempt to focus the attention on fighting COVID-19, led to several challenges within the field of research ethics. However, we know little about the practical relevance of these challenges for Research Ethics Committees. Methods We conducted a qualitative survey across all 52 German RECs on the challenges and potential solutions with reviewing proposals for COVID-19 studies. We de-identified the answers and applied thematic text (...) analysis for the extraction and synthesis of challenges and potential solutions that we grouped under established principles for clinical research ethics. Results We received an overall response rate of 42%. The 22 responding RECs reported that they had assessed a total of 441 study proposals on COVID-19 until 21 April 2020. For the review of these proposals the RECs indicated a broad spectrum of challenges regarding social value, scientific validity, favourable risk–benefit ratio, informed consent, independent review, fair selection of trial participants, and respect for study participants. Mentioned solutions ranged from improved local/national coordination, over guidance on modified consent procedures, to priority setting across clinical studies. Conclusions RECs are facing a broad spectrum of pressing challenges in reviewing COVID-19 studies. Some challenges for consent procedures are well known from research in intensive care settings but are further aggravated by infection measures. Other challenges such as reviewing several clinical studies at the same time that potentially compete for the recruitment of in-house COVID-19 patients are unique to the current situation. For some of the challenges the proposed solutions in our survey could relatively easy be translated into practice. Others need further conceptual and empirical research. Our findings together with the increasing body of literature on COVID-19 research ethics, and further stakeholder engagement should inform the development of hands-on guidance for researchers, funders, RECs, and further oversight bodies. (shrink)

The editors of the JRE solicited short essays on the COVID‐19 pandemic from a group of scholars of religious ethics that reflected on how the field might help them make sense of the complex religious, cultural, ethical, and political implications of the pandemic, and on how the pandemic might shape the future of religious ethics.

To reduce the global burden of the COVID-19 pandemic, there is an urgent need to develop a safe vaccine. Vaccine development usually takes many years as it goes through several different phases. To hasten COVID-19 vaccine development, it has been suggested that the final stage could be replaced with a human challenge trial (HCT). Volunteers would be intentionally infected with SARS-CoV-2 to see how the vaccine candidate works. To intentionally infect a healthy human being with a potentially deadly (...) virus is contrary to the highest ethical standards in medical research. This article highlights the benefits and risks of COVID-19 HCTs and summarises what research ethics committees (RECs) need to consider during the ethical assessment of such trials including risk reduction, strict containment measures, specific informed consent measures and avoiding high monetary inducements. (shrink)

Cross jurisdictional collaboration efforts and emergency vaccine plans that are consistent with Tribal sovereignty are essential to public health emergency preparedness. The widespread adoption of clearly written federal, state, and local vaccine plans that address fundamental assumptions in vaccine distribution to Tribal nations is imperative for future pandemic response.

Background The global pandemic raised ethical issues for nurses about caring for all patients, not just those with COVID-19. Italy was the first European country to be seriously affected by the first wave, while Estonia’s infection and death rates were among the lowest in Europe. Did this raise different ethical issues for nurses in these two countries as well? Aim The aim was to describe and compare ethical issues between nurses working during the first wave of the COVID-19 (...) pandemic in Estonia and Italy. Research design A cross-sectional survey study with a self-administered questionnaire. The impact of COVID- 19 emergency on nursing care questionnaire was used. Participants and research context Convenience sampling was used to recruit 1098 nurses working during the first wave of the pandemic in 2020: 162 from Estonia and 936 from Italy. Ethical considerations Research ethics approvals were obtained, and the nurses provided informed consent. Results The most frequent ethical issues for Estonian nurses were professional communication and ensuring access to care for patients without COVID-19, and for Italian nurses, the end-of-life care and the risk of them getting the virus and transmitting it to their loved ones. There were no statistically significant differences in the frequency of ethical issues between Estonian nurses working with patients with and without COVID-19. Italian nurses caring for COVID-19 patients faced statistically significantly more (both p <.001) issues around prioritising patients and end-of-life. Nurses working with patients without COVID-19 in Italy faced more issues about access to care ( p <.001). Conclusions Estonian and Italian nurses, working in different clinical contexts during the first wave of the pandemic, faced different ethical issues. Local contextual aspects need to be considered to support nurses’ ethical decision-making in providing care during future crises and to ensure ethical care for patients. (shrink)

The disability viewpoint is the fundamental for understanding social justice in a given population. Disability rights need to be obeyed in the inclusive preparedness and response to all the disasters or during the crisis period including COVID-19 pandemic. COVID-19 pandemic jeopardized the health and rehabilitation services globally. The impact is much more in low resource developing countries like Bangladesh. In general, people with disability (PWD) suffer from multiple medical and rehabilitation complications and they need frequent rehabilitation consultations or (...) hospital admissions in comparison to people without disability. As a developing country, Bangladesh has poor ratios of doctors, nurses and technologists of 1:0.4:0.24 (WHO: 1:3:5) to face the COVID-19 challenge. Rehabilitation services have been disrupted in almost two-thirds (63%) of countries of the world. Even though rehabilitation is the key to recovery following severe illness from COVID-19. There are many concerns and debates about the preparedness, response and mitigation the process of COVID-19 on the part of the national government. According to recent study reports, the lives of about 100% of PWD have been impacted by the COVID-19 pandemic. COVID-19 National Technical Advisory Committee is working for strategic planning, response and mitigation process but omission of a representative of PWD or a rehabilitation physician in the committee has created much dissatisfaction. The difficult COVID-19 testing process due to country wide shutdown of rehabilitation essential services and central pulling of rehabilitation physicians have side lined the PWD inclusiveness. It is expected that the rehabilitation preparedness, response and mitigation of the pandemic should be based on an ethics driven process. (shrink)

Mobile applications are increasingly regarded as important tools for an integrated strategy of infection containment in post-lockdown societies around the globe. This paper discusses a number of questions that should be addressed when assessing the ethical challenges of mobile applications for digital contact-tracing of COVID-19: Which safeguards should be designed in the technology? Who should access data? What is a legitimate role for “Big Tech” companies in the development and implementation of these systems? How should cultural and behavioural issues (...) be accounted for in the design of these apps? Should use of these apps be compulsory? What does transparency and ethical oversight mean in this context? We demonstrate that responses to these questions are complex and contingent and argue that if digital contract-tracing is used, then it should be clear that this is on a trial basis and its use should be subject to independent monitoring and evaluation. (shrink)

The disability viewpoint is the fundamental for understanding social justice in a given population. Disability rights need to be obeyed in the inclusive preparedness and response to all the disasters or during the crisis period including COVID-19 pandemic. COVID-19 pandemic jeopardized the health and rehabilitation services globally. The impact is much more in low resource developing countries like Bangladesh. In general, people with disability (PWD) suffer from multiple medical and rehabilitation complications and they need frequent rehabilitation consultations or (...) hospital admissions in comparison to people without disability. As a developing country, Bangladesh has poor ratios of doctors, nurses and technologists of 1:0.4:0.24 (WHO: 1:3:5) to face the COVID-19 challenge. Rehabilitation services have been disrupted in almost two-thirds (63%) of countries of the world. Even though rehabilitation is the key to recovery following severe illness from COVID-19. There are many concerns and debates about the preparedness, response and mitigation the process of COVID-19 on the part of the national government. According to recent study reports, the lives of about 100% of PWD have been impacted by the COVID-19 pandemic. COVID-19 National Technical Advisory Committee is working for strategic planning, response and mitigation process but omission of a representative of PWD or a rehabilitation physician in the committee has created much dissatisfaction. The difficult COVID-19 testing process due to country wide shutdown of rehabilitation essential services and central pulling of rehabilitation physicians have side lined the PWD inclusiveness. It is expected that the rehabilitation preparedness, response and mitigation of the pandemic should be based on an ethics driven process. (shrink)

Governmental reactions to crises like the COVID-19 pandemic can be seen as ethics communication. Governments can contain the disease and thereby mitigate the detrimental public health impact; allow the virus to spread to reach herd immunity; test, track, isolate, and treat; and suppress the disease regionally. An observation of Sweden and Finland showed a difference in feasible ways to communicate the chosen policy to the citizenry. Sweden assumed the herd immunity strategy and backed it up with health utilitarian (...) arguments. This was easy to communicate to the Swedish people, who appreciated the voluntary restrictions approach and trusted their decision makers. Finland chose the contain and mitigate strategy and was towards the end of the observation period apparently hesitating between suppression and the test, track, isolate, and treat approach. Both are difficult to communicate to the general public accurately, truthfully, and acceptably. Apart from health utilitarian argumentation, something like the republican political philosophy or selective truth telling are needed. The application of republicanism to the issue, however, is problematic, and hiding the truth seems to go against the basic tenets of liberal democracy. (shrink)

影響全球的COVID-19已經進入第三年，在疫情時代或後疫情時代的種種爭論中，相關的倫理考量依然是學界關注的議題。本期的論文涉及具體的醫學倫理學問題，包括香港抗疫倫理焦點、ECMO的使用、疫情防控中的 道德兩難、現代科技大數據所引發的對個人隱私的焦慮、疫情處境中的善終和臨終關懷、審視傳統中醫學有關疫情控制的歷史研究、傳統墨家思想對現當下防疫管理的啟示作用。本期的論文的研究方法各有不同，包括哲學的、倫 理學的、實證的、歷史的、及比較的，其宗旨是引發人們對這些問題的反思和探討。.

The COVID-19 pandemic that struck New York City in the spring of 2020 was a natural experiment for the clinical ethics services of NewYork-Presbyterian (NYP). Two distinct teams at NYP’s flagship academic medical centers—at NYP/ Columbia University Medical Center (Columbia) and NYP/ Weill Cornell Medical Center (Weill Cornell)—were faced with the same pandemic and operated under the same institutional rules. Each campus used time as an heuristic to analyze our collective response. The Columbia team compares consults during the (...) pandemic with the same period during the year prior. The Weill Cornell service describes the phases of the pandemic to depict its temporal evolution and subsequent ethical challenges. Both sites report that the predominant ethical challenges centered around end-of-life decision making, setting goals of care, and medical futility, all complicated by resource allocation questions and the ambiguity of state law under crisis standards of care. The Columbia campus saw a statistically significant increase in ethics consultations provided to Hispanic patients, perhaps reflective of the disproportionate burden of COVID-19 suffered by this demographic. While Weill Cornell and Columbia saw a surge in clinical ethics consultations, the two services assumed a more expansive role than one normally played in institutional life. Serving as intermediaries between frontline clinicians and senior hospital administrators, consultants provided critical intelligence to hospital leadership about the evolution of the pandemic, disseminated information to clinicians, and attended to the moral distress of colleagues who were asked to provide care under truly extraordinary circumstances. The COVID-19 surge in New York City revealed latent capabilities in ethics consultation that may prove useful to the broader clinical ethics community as it responds to the current pandemic and reconceptualizes its potential for future service. (shrink)

Employers and governments are interested in the use of serological testing to allow people to return to work before there is a vaccine for SARS-CoV-2. We articulate the preconditions needed for the implementation of antibody testing, including the role of the U.S. Food & Drug Administration.

Background The early phase of the COVID-19 pandemic affected nursing homes and their residents heavily. Guidelines on how to mitigate the virus’s spread and ensuring safe healthcare delivery were continually evolving. Concurrently, nursing homes faced intense media scrutiny. This challenging environment severely impacted registered nurses and physicians employed within these facilities. Aim To understand the ethical challenges experienced by registered nurses and physicians working in nursing homes during the COVID-19 pandemic. Research design Qualitative descriptive research using thematic analysis. (...) Participants and research context Individual online interviews with four registered nurses and eight physicians clinically active at nursing homes in Sweden. Ethical considerations The study was approved by the Swedish Ethical Review Authority. All participants provided written consent. Results Registered nurses and physicians working in nursing homes perceived ethical challenges stemming from early COVID-19 pandemic guidelines and media coverage. The main theme generated was ‘Struggling to maintain professional and ethical standards under pressure’ incorporating two subthemes: ‘Guidelines developed without the profession put pressure on staff’ and ‘Media’s biased reporting was perceived as unethical and undermined care’. Guidelines from the authorities were considered as developed without professional involvement. It made them difficult to adhere to without deviating from professional and ethical compasses. Media coverage adversely influenced relatives’ perceptions, resulting in mistrust towards physicians’ and registered nurses’ in delivering optimal care for the residents. Conclusions Resilient care in nursing homes necessitates the collaborative development of guidelines involving registered nurses and physicians, particularly amidst crises. Moreover, it is vital to provide support to registered nurses navigating ethical dilemmas, especially during pandemics. Guidelines and principles for care during a crisis should be development with professional involvement, be transparent, and be available to the public, to promote neutral media coverage. Future research is crucial to enhance ethical standards and tackle challenges in this context. (shrink)

BackgroundAs the COVID-19 pandemic develops, healthcare professionals are looking for support with, and guidance to inform, the difficult decisions they face. In the absence of an authoritative national steer in England, professional bodies and local organisations have been developing and disseminating their own ethical guidance. Questions inevitably arise, some of which are particularly pressing during the pandemic, as events are unfolding quickly and the field is becoming crowded. My central question here is: which professional ethical guidance should the professional (...) follow?Main bodyAdopting a working definition of “professional ethical guidance”, I offer three domains for a healthcare professional to consider, and some associated questions to ask, when determining whether – in relation to any guidance document – they should “bin it or pin it”. First, the professional should consider the source of the guidance: is the issuing body authoritative or, if not, at least sufficiently influential that its guidance should be followed? Second, the professional should consider the applicability of the guidance, ascertaining whether the guidance is available and, if so, whether it is pertinent. Pertinence has various dimensions, including whether the guidance applies to this professional, this patient and/or this setting, whether it is up-to-date, and whether the guidance addresses the situation the professional is facing. Third, the professional should consider the methodology and methods by which the guidance was produced. Although the substantive quality of the guidance is important, so too are the methods by which it was produced. Here, the professional should ask whether the guidance is sufficiently inclusive – in terms of who has prepared it and who contributed to its development – and whether it was rigorously developed, and thus utilised appropriate processes, principles and evidence.ConclusionAsking and answering such questions may be challenging, particularly during a pandemic. Furthermore, guidance will not do all the work: professionals will still need to exercise their judgment in deciding what is best in the individual case, whether or not this concerns COVID-19. But such judgments can and should be informed by guidance, and hopefully these preliminary observations will provide some useful pointers for time-pressed professionals. (shrink)

The COVID-19 pandemic crisis has had profound effects on global health, healthcare, and public health policy. It has also impacted education. Within undergraduate healthcare education of doctors, nurses, and allied professions, rapid shifts to distance learning and pedagogic content creation within new realities, demands of healthcare practice settings, shortened curricula, and/or earlier graduation have also challenged ethics teaching in terms of curriculum allotments or content specification. We propose expanding the notion of resilience to the field of ethics (...) education under the conditions of remote learning. Educational resilience starts in the virtual classroom of ethics teaching, initially constituted as an “unpurposed space” of exchange about the pandemic’s challenging impact on students and educators. This continuously transforms into “purposed space” of reflection, discovering ethics as a repertory of orientative knowledge for addressing the pandemic’s challenges on personal, professional, societal, and global levels and for discovering (and then addressing) that the health of individuals and populations also has moral determinants. As such, an educational resilience framework with inherent adaptability rises to the challenge of supporting the moral agency of students acting both as professionals and as global citizens. Educational resilience is key in supporting and sustaining professional identify formation and facilitating the development of students’ moral resilience and leadership amid moral complexity and potential moral transgression—not only but especially in times of pandemic. (shrink)

Technologies to rapidly alert people when they have been in contact with someone carrying the coronavirus SARS-CoV-2 are part of a strategy to bring the pandemic under control. Currently, at least 47 contact-tracing apps are available globally. They are already in use in Australia, South Korea and Singapore, for instance. And many other governments are testing or considering them. Here we set out 16 questions to assess whether — and to what extent — a contact-tracing app is ethically justifiable.

On March 11, 2020 the World Health Organization classified COVID‐19, caused by Sars‐CoV‐2, as a pandemic. Although not much was known about the new virus, the first outbreaks in China and Italy showed that potentially a large number of people worldwide could fall critically ill in a short period of time. A shortage of ventilators and intensive care resources was expected in many countries, leading to concerns about restrictions of medical care and preventable deaths. In order to be prepared (...) for this challenging situation, national triage guidance has been developed or adapted from former influenza pandemic guidelines in an increasing number of countries over the past few months. In this article, we provide a comparative analysis of triage recommendations from selected national and international professional societies, including Australia/New Zealand, Belgium, Canada, Germany, Great Britain, Italy, Pakistan, South Africa, Switzerland, the United States, and the International Society of Critical Care Medicine. We describe areas of consensus, including the importance of prognosis, patient will, transparency of the decision‐making process, and psychosocial support for staff, as well as the role of justice and benefit maximization as core principles. We then probe areas of disagreement, such as the role of survival versus outcome, long‐term versus short‐term prognosis, the use of age and comorbidities as triage criteria, priority groups and potential tiebreakers such as ‘lottery’ or ‘first come, first served’. Having explored a number of tensions in current guidance, we conclude with a suggestion for framework conditions that are clear, consistent and implementable. This analysis is intended to advance the ongoing debate regarding the fair allocation of limited resources and may be relevant for future policy‐making. (shrink)