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Updated: November 1, 2020

What are the ethical considerations associated with the public health response to COVID-19?

Summary

The following is a brief summary of the available evidence and existing guidance related to the ethical considerations associated with the development, implementation and assessment of COVID-19 public health measures. For additional information about each of the sources mentioned here, see the Table below.   For additional information about each of the sources, see the Table below.

Decision makers are often confronted with challenging dilemmas in determining appropriate responses to the COVID-19 pandemic in terms of who these decisions disproportionally affect and how. The Government of Canada states in its Public health ethics framework: A guide for use in response to the COVID-19 pandemic in Canada, that a public health ethics framework should use trust and justice as the main values to guide and support ethical deliberations and decision making for the COVID-19 pandemic [4].  The World Health Organization and the British Columbia Centre for Disease Control (BCCDC) state that respectutilityreciprocityequityliberty, and solidarity are key ethical principles to guide the development of a public health response [1,6]. Two commentaries note that while there is rarely a single solution to ethical dilemmas caused by a pandemic, the general structure of a response should be based on legal and ethical principles and frameworks, such as the life cycle principle approach described below [8,9].  
 
As the Canadian Nurses Association (CNA) outlines in Nurses’ Ethical Considerations During a Pandemic, frontline healthcare workers have a responsibility to promote safety, dignity, health and wellbeing for their patients [7]. The CNA argues that ethical considerations that help to guide practice during a pandemic should minimize moral distress among nurses and provide the capacity for moral agency and moral community [7]. Guidance from the United Nations Educational, Scientific and Cultural Organization (UNESCO) and one commentary note that health care workers should be given priority for COVID-19 treatment (although it appears that there is debate about this approach), and that triage criteria for admittance to the intensive care unit should apply equally to non-COVID-19 and COVID-19 patients [2,10].  
 
Specific guidelines and suggestions have been developed to inform public health interventions and non-adherence. In its guidance COVID-19 Ethics Analysis: Intervening When Patients of Residents Pose a Risk of COVID-19 Transmission to Others, the BCCDC describes an ethical analysis that suggests legislative authority be considered appropriate during interventions when individuals engage in activities that put others at intolerable risk of harm [5]. This includes potential exposure to COVID-19, where physical distancing measures are not followed [5].  In terms of school re-opening, the American Academy of Pediatrics notes in its guidance COVID-19 Planning Considerations: Guidance for School Re-entry, that policies should consider the application of ethical principles, including considering the needs of a diverse student population, only excluding students when public health guidance mandates, or if doing so would increase their risk of contracting COVID-19 [3]

Evidence

What‘s Trending on Social Media and Media

This article on ‘Plague Raves’ published on September 9, 2020 discusses crowded music events that were legally permitted, hosted by high-profile DJs in Europe during the COVID-19 crisis. Ed Gillett investigates the complex ethics of raving, and DJing at events, during a pandemic through interviews with DJs to understand why they are willing to host such events. 
 
The Harvard Gazette released this article that explores the ethics of what we owe each other in a pandemic. The article presents an interview with Harvard professor Michael Sandel who is teaching the course “Justice: Ethics in an Age of Pandemic and Racial Reckoning” this Fall. 
 
This Psychiatric Times article describes the ethics of reopening during the COVID-19 Pandemic, and which tries to answer the question of how to keep the public safe and reopen the economy at the same time. A key take-away from Dr. Powell’s article is that strategies should be dynamic because what works one week may not work the next, and as facts on the ground change, so too should the response. 

Organizational Scan

The Gowling Wragge Lawrence Graham law firm state that ethical issues related to working health care professionals in the era of COVID 19 should be based off the principles of proportionality (i.e. the idea that an action should not be more severe than is necessary), the harm principle, fairness and reciprocity [11].  
 
The Canadian Nurses Association states that leaders should be visibly present, honest, and transparent when making difficult decisions. Messages from all levels of leadership are essential to ensure expectations are clear and decisions while working on the frontline can be made confidently [12].  

Review of Evidence

Resource Type/Source of Evidence Last Updated
Ethical considerations in developing a public health response to pandemic influenza
— WHO: World Health Organization
International Guidance

The WHO notes that public health responses should focus on priority settings within healthcare systems and equitable access to resources, restriction of individual movement as a result of non-pharmaceutical interventions, the respective obligations of health-care workers and their employers and governments, and the obligations of countries towards each other. The key ethical principles emphasized include utility/efficiency, reciprocity, equity, liberty and solidarity. 

Last Updated: December 31, 2006
UNESCO provides Ethical Frameworks to COVID-19 Responses
— UNESCO: United Nations Educational, Scientific and Cultural Organization
International Guidance

UNESCO provides many short videos describing ethical frameworks to COVID-19 responses. Key actions within responses should include: 1) healthcare workers should be given priority access to PPE; 2) healthcare workers are given priority access under triage condicitons (ventilator allocation, ICU admissions, etc.); 3) governments should be accountable for the highest standard of healthcare possible; and 4) triage systems must be transparent, accountable, and reasonable while also factoring in these ethical principles: autonomy (i.e., respect for individual choice), beneficence (i.e., act in the best interests of the patient), maleficence (i.e., do no harm), and justice (i.e., treat everyone fairly). 

Last Updated: April 14, 2020
COVID-19 Planning Considerations: Guidance for School Re-entry
— American Academy of Pediatrics
National Guidance

This guidance states that school re-entry policies should consider the following ethical principles: 1) policies should be practical, feasible, and appropriate for child and adolescent development stage and address teacher and staff safety; 2) special considerations and accommodations for the diversity of youth, more so for vulnerable populations; 3) vulnerable populations should not be excluded from school unless required in order to adhere to local public health mandates or if doing so would put them at an increased risk for contracting COVID-19; and 4) every child with a disability is entitled to a free and appropriate education and special services based on individualized education program if needed.     It is recommended that support systems be in place as needed. For example, providing communication in languages other than English based on languages spoken in the community, and making mental health support be accessible to all, particularly to those from lower socio-economic communities. 

Last Updated: August 18, 2020
Public health ethics framework: A guide for use in response to the COVID-19 pandemic in Canada
— Government of Canada
National Guidance

The Government of Canada states that their framework is intended to support ethical deliberations and decision-making in the public health response to the COVID-19 pandemic. The ethical values that underpin this framework are trust and justice and outlines key considerations for any decisions made including: 1) respect for persons, communities and human rights; 2) promoting well-being and minimizing harm by weighing effectiveness, proportionality, reciprocity and precaution; 3) working together; and 4) procedural considerations such as accountability, openness and transparency, inclusiveness, responsiveness and intersectionality. 

Last Updated: June 4, 2020
COVID-19 Ethics Analysis: Intervening When Patients of Residents Pose a Risk of COVID-19 Transmission to Others
— BCCDC: British Columbia Centre for Disease Control
Provincial Guidance

The BCCDC describes an ethical approach to intervening for a patient or resident who cannot or will not adhere to infection control measures and thus poses a risk of harm to others. It assesses that it may consider a greater degree of intervention when individuals engage in activities or behaviors that put others at intolerable risk of harm, including potential exposure to COVID-19, where physical distancing measures are not followed. Relevant legislative authority may also be considered during interventions. 

Last Updated: June 22, 2020
COVID-19 Ethical Decision-Making Framework
— BCCDC: British Columbia Centre for Disease Control
Provincial Guidance

The BCCDC describes a framework that identifies ethical principles and values that should guide ethical decision making such as: respect, the ‘do no harm’ principle, fairness, working together, proportionality, procedural justice and the least coercive and restrictive means. It also provides a step-by-step guide to ethical decision making and a checklist of values for evaluating options and articulating a decision. 

Last Updated: March 27, 2020
Nurses’ Ethical Considerations During a Pandemic
— Canadian Nurses Association (CNA)
Professional Organization

The CNA recommends that leaders be visibly present, honest, and transparent when making difficult decisions. Messages from all levels of leadership are essential so nurses know what is expected of them and feel confident and supported in their decision to provide care. Furthermore, drawing on the collective intelligence and experience of direct-care nurses can provide insight towards ethical decision making. 

Last Updated: December 31, 2019
Ethical dilemmas in pandemics – lessons from COVID-19
— Mohideen et al.
Commentary

This commentary states COVID-19 should not be used to erode civil liberties. Restrictions of rights and freedoms should have a legal basis and not be arbitrary or discriminatory. Exploring less intrusive evidence-based alternatives will make public health actions less controversial and more acceptable to the public. Good public health that respects civil liberties will enhance public health action.  

Last Updated: June 15, 2020
Ethical Advice for an Intensive Care Triage Protocol in the COVID-19 Pandemic: Lessons Learned from The Netherlands
— Verweij M. et al.
Commentary

This commentary states there are many ethical principles  to consider for triage including, but not limited to: 1) every human being has equal moral worth; 2) a justified objective of Intensive Care Unit (ICU) triage is to save as many lives as possible; 3) mental or physical impairments, social or legal status, wealth, ethnicity, gender, sexual orientation and personal relationships are irrelevant; 4) considerations about responsibility for getting ill are irrelevant as well; 5) age is relevant as a matter of priority for the most vulnerable worst off; and 6) triage criteria for admittance to the ICU should apply equally to COVID-19 and non-COVID-19 patients.        This commentary also suggests that health care workers should not be given priority for COVID-19 treatment. The main reason for this suggestion is health care workers are likely given access to PPEs at any given time. 

Last Updated: September 22, 2020
Ethical issues for regulated health professionals in the era of COVID-19
— Gowling WLG
Organizational Scan Last Updated: November 1, 2020
Nurses’ Ethical Considerations During a Pandemic
— Canadian Nurses Association
Organizational Scan Last Updated: November 1, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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