Ethical Issues in Responding to the COVID-19 Pandemic; A Narrative Review
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Abstract
At present, the biggest challenge to health and economic systems around the world is the emergence of COVID-19 pandemic. Several ethical questions have been raised at the macro-, meso- and micro-levels with respect to proper management and control of this pandemic. The most important factor in creating fear and public anxiety and disturbances of social functions is the fatalities caused by the epidemic by an unknown pathogen in most countries. Decisions for epidemic control measures are made among many uncertainties, and prioritize public health over individual rights. People's trust and compliance with recommendations play a decisive role in public actions. Therefore, during an epidemic, necessities such as adherence to the values of honesty, respect, human dignity, solidarity, justice, reciprocity, transparency, and responsiveness in the response system need to be considered. The major ethical considerations in macro and micro levels of decision-making responding to the COVID-19 will be reviewed in this paper. Ethical dilemmas arise in different domains of a pandemic such as restriction on freedom of movement, individual’s refusal of preventive or therapeutic interventions, health care workers’ rights and duty to care, the allocation of scarce resources, off-label use of diagnostic and therapeutic measures and research. The purpose of this article is to pay attention to ethical principles in solving these challenges and does not necessarily respond to all ethical problems; however, it draws the reader's attention and moral sensitivity to the issues raised in this area.
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3. Cho SI. A new measure for assessing the public health response to a Middle East respiratory syndrome coronavirus outbreak. J Prev Med Public Health. 2015;48(6):277-9.
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6. DeBruin D, Liaschenko J, Marshall MF. Social justice in pandemic preparedness. Am J Public Health. 2012;102(4):586-91.
7. Gumel AB, Ruan S, Day T, Watmough J, Brauer F, Van den Driessche P, et al. Modelling strategies for controlling SARS outbreaks. Proc Biol Sci. 2004; 271(1554):2223-32.
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9. Takian A, Raoofi A, Kazempour-Ardebili S. COVID-19 battle during the toughest sanctions against Iran. Lancet. 2020;395(10229):1035-6.
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12. Harvey K, Wright K. Research in global health emergencies: ethical issues. London: Nuffield Council On Bioethics, 2020 Jan 28.
13. Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. Lancet Infect Dis. 2020;Epub ahead of print.
14. Niles-Yokum K. The Intersection of Vulnerability and Old Age: Ethical Consideration for Long-term Services and Supports Innov Aging. 2019;3(Suppl 1):S238.
15. Tangcharoensathien V, Mills A, Das MB, Patcharanarumol W, Buntan M, Johns J. Addressing the health of vulnerable populations: social inclusion and universal health coverage. J Glob Health. 2018;8(2):020304.
16. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med. 2020;Epub ahead of print.
17. Rosenbaum L. Facing COVID-19 in Italy—ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. 2020;Epub ahead of print.
18. Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. N Engl J Med. 2020;Epub ahead of print.
19. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020;Epub ahead of print.
20. World Health Organization. Guidance for managing ethical issues in infectious disease outbreaks. World Health Organization. 2016.
21. Madani M. Ethical considerations of futile care. Iranian J Med Ethics Hist Med. 2013;6(2):31-42.
22. Saeedi Tehrani S, Madani M. Bioethical principles and medical futility. Iranian J Med Ethics Hist Med. 2015;7(6):1-14.
23. Cetron M, Landwirth J. Public health and ethical considerations in planning for quarantine. Yale J Biol Med. 2005;78(5):329-34.
24. Gostin L, Berkman B, editors. Preparing for the pandemic influenza: legal and ethical challenges. Ethical and Legal Considerations in Mitigating Pandemic Diseases: Workshop Summary Washington, DC: Institute of Medicine; 2007.
25. Rothstein MA, Talbott MK. Encouraging compliance with quarantine: a proposal to provide job security and income replacement. Am J Public Health. 2007;97(Supplement_1):S49-56.
26. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in china. Int J Environ Res Public Health. 2020;17(5):1729.
27. Barrows Jr RC, Clayton PD. Privacy, confidentiality, and electronic medical records. J Am Med Inform Assoc. 1996;3(2):139-48.
28. Berman JJ, Moore GW, Hutchins GM, editors. Maintaining patient confidentiality in the public domain Internet Autopsy Database. Proceedings of the AMIA Annual Fall Symposium; 1996: American Medical Informatics Association.
29. Bowen JW, Klimczak JC, Ruiz M, Barnes M, editors. Design of access control methods for protecting the confidentiality of patient information in networked systems. Proceedings of the AMIA Annual Fall Symposium; 1997: American Medical Informatics Association.
30. Hull SC, Sharp RR, Botkin JR, Brown M, Hughes M, Sugarman J, et al. Patients' views on identifiability of samples and informed consent for genetic research. Am J Bioeth. 2008;8(10):62-70.
31. Rampling T, Page M, Horby P. International biological reference preparations for epidemic infectious diseases. Emerg Infect Dis. 2019;25(2):205-11.
32. Sprague E, Reynolds S, Brindley P. Patient isolation precautions: are they worth it? Can Respir J. 2016; 2016:5352625.
33. Asghari F. The Priority of Healthcare Providers' Safety and Health is an Ethical Duty in Public Health Management of the Infectious Outbreaks. Iranian J Med Ethics Hist Med. 2019;12(1):615-7.
34. Yin X, Zeng L. A study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory. Int J Nurs Sci. 2020;Epub ahead of print.
35. Wynia MK, Kurlander JF, Green SK. Chapter 6: physician professionalism and preparing for epidemics: challenges and opportunities. Ethics and Epidemics. 2006:135-61.
36. McCullough LB. Chapter 8: Ethically Justified Limits on the Obligations of Physicians and Health Care Organizations in Response to Epidemics and Bioterrorism'. Ethics and Epidemics (Advances in Bioethics, Volume 9) Emerald Group Publishing Limited. 2006:175-86.
37. Al-Amri S, Bharti R, Alsaleem SA, Al-Musa HM, Chaudhary S, Al-Shaikh AA. Knowledge and practices of primary health care physicians regarding updated guidelines of MERS-CoV infection in Abha city. J Family Med Prim Care. 2019;8(2):455-61.
38. Thu T, Anh N, Chau N, Hung N. Knowledge, attitude and practices regarding standard and isolation precautions among Vietnamese health care workers: a multicenter cross-sectional survey. Intern Med. 2012;2(4):1000115.
39. Kelland K. Speed science: The risks of swiftly spreading coronavirus research. Reuters. 2020 Feb 19.
40. Schopper D, Ravinetto R, Schwartz L, Kamaara E, Sheel S, Segelid MJ, et al. Research ethics governance in times of Ebola. Public Health Ethics. 2017;10(1):49-61.
41. Tansey CM, Herridge MS, Heslegrave RJ, Lavery JV. A framework for research ethics review during public emergencies. CMAJ. 2010;182(14):1533-7.
42. Mezinska S, Kakuk P, Mijaljica G, Waligóra M, O’Mathúna DP. Research in disaster settings: a systematic qualitative review of ethical guidelines. BMC Med Ethics. 2016;17(1):62.
43. Sethi N. Research and global health emergencies: on the essential role of best practice. Public Health Ethics. 2018;11(3):237-50.
44. Hunt MR, Anderson JA, Boulanger RF. Ethical implications of diversity in disaster research. Am J Disaster Med. 2012;7(3):211-21.
45. World Health Organization. Research ethics in international epidemic response: WHO technical consultation, Geneva, Switzerland, 10-11 June 2009: meeting report. World Health Organization, 2010.
46. Sharma H, Verma S. Authorship in biomedical research: A sweet fruit of inspiration or a bitter fruit of trade. Trop Parasitol. 2018;8(2):62-9.
47. Zarghami M. Authorship and contributorship. Iran J Psychiatry Behav Sci. 2011;5(2):1-4.
48. Tscharntke T, Hochberg ME, Rand TA, Resh VH, Krauss J. Author sequence and credit for contributions in multiauthored publications. PLoS Biol. 2007;5(1):e18.
49. Kalil AC. Treating COVID-19—Off-Label Drug Use, Compassionate Use, and Randomized Clinical Trials During Pandemics. JAMA. 2020;Epub ahead of print.
50. Kim AH, Sparks JA, Liew JW, Putman MS, Berenbaum F, Duarte-García A, et al. A Rush to Judgment? Rapid Reporting and Dissemination of Results and Its Consequences Regarding the Use of Hydroxychloroquine for COVID-19. Ann Intern Med. 2020:M20-1223.
51. Yazdany J, Kim AH. Use of Hydroxychloroquine and Chloroquine During the COVID-19 Pandemic: What Every Clinician Should Know. Ann Intern Med. 2020:M20-1334.
52. Kile Green AJA, Jana Suklan, Fiona R. Beyer, D. Ashley Price, Sara Graziadio. What is the role of imaging and biomarkers within the current testing strategy for the diagnosis of Covid-19? April 8 ed: The Centre for Evidence-Based Medicine; 2020.
53. ACR. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection: American College of Radiology; 2020 [updated March 22; cited 2020 April 14 ]. Available from: https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recomme ndations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection.
54. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology. 2020:200642.
55. FDA. What are the Radiation Risks from CT? : The U.S. Food & Drug Administration; 2017 [cited 2020 April 14]. Available from: https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/what-are-radiation-risks-ct.
56. Barrett DH, Ortmann LH, Dawson A, Saenz C, Reis A, Bolan G. Public health ethics: cases spanning the globe: Springer International Publishing; 2016.
57. Smith M, Upshur R. Pandemic Disease, Public Health, and Ethics. InThe Oxford Handbook of Public Health Ethics. 2019.
58. Taskinsoy J. Diminishing Dollar Hegemony: What Wars and Sanctions Failed to Accomplish, COVID-19 Has. (April 7, 2020). [cited 2020 April 14]. Available from: https://dx.doi.org/10.2139/ssrn.3570910
2. Kim OJ. Ethical Perspectives on the Middle East Respiratory Syndrome Coronavirus Epidemic in Korea. J Prev Med Public Health. 2016;49(1):18-22.
3. Cho SI. A new measure for assessing the public health response to a Middle East respiratory syndrome coronavirus outbreak. J Prev Med Public Health. 2015;48(6):277-9.
4. Kass N, Kahn J, Buckland A, Paul A, Group EW. Ethics guidance for the public health containment of serious infectious disease outbreaks in low-income settings: lessons from Ebola. Baltimore, MD: Johns Hopkins Berman Institute of Bioethics; 2019.
5. Uscher-Pines L, Duggan PS, Garron JP, Karron RA, Faden RR. Planning for an influenza pandemic: social justice and disadvantaged groups. Hastings Cent Rep. 2007;37(4):32-9.
6. DeBruin D, Liaschenko J, Marshall MF. Social justice in pandemic preparedness. Am J Public Health. 2012;102(4):586-91.
7. Gumel AB, Ruan S, Day T, Watmough J, Brauer F, Van den Driessche P, et al. Modelling strategies for controlling SARS outbreaks. Proc Biol Sci. 2004; 271(1554):2223-32.
8. Analytica O. Conflict legacy leaves Syria little COVID-19 recourse. Emerald Expert Briefings. (oxan-es). March 25, 2020. [cited 2020 April 10]. Available from: http://www.emerald.com/insight/content/doi/10.1 108/OXAN-ES251570/full/html.
9. Takian A, Raoofi A, Kazempour-Ardebili S. COVID-19 battle during the toughest sanctions against Iran. Lancet. 2020;395(10229):1035-6.
10. This pandemic is an ethical challenge [press release]. Financial Times, March 24 2020.
11. Mack A, Choffnes ER, Sparling PF, Hamburg MA, Lemon SM. Ethical and legal considerations in mitigating pandemic disease: workshop summary: National Academies Press; 2007.
12. Harvey K, Wright K. Research in global health emergencies: ethical issues. London: Nuffield Council On Bioethics, 2020 Jan 28.
13. Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. Lancet Infect Dis. 2020;Epub ahead of print.
14. Niles-Yokum K. The Intersection of Vulnerability and Old Age: Ethical Consideration for Long-term Services and Supports Innov Aging. 2019;3(Suppl 1):S238.
15. Tangcharoensathien V, Mills A, Das MB, Patcharanarumol W, Buntan M, Johns J. Addressing the health of vulnerable populations: social inclusion and universal health coverage. J Glob Health. 2018;8(2):020304.
16. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med. 2020;Epub ahead of print.
17. Rosenbaum L. Facing COVID-19 in Italy—ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. 2020;Epub ahead of print.
18. Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. N Engl J Med. 2020;Epub ahead of print.
19. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020;Epub ahead of print.
20. World Health Organization. Guidance for managing ethical issues in infectious disease outbreaks. World Health Organization. 2016.
21. Madani M. Ethical considerations of futile care. Iranian J Med Ethics Hist Med. 2013;6(2):31-42.
22. Saeedi Tehrani S, Madani M. Bioethical principles and medical futility. Iranian J Med Ethics Hist Med. 2015;7(6):1-14.
23. Cetron M, Landwirth J. Public health and ethical considerations in planning for quarantine. Yale J Biol Med. 2005;78(5):329-34.
24. Gostin L, Berkman B, editors. Preparing for the pandemic influenza: legal and ethical challenges. Ethical and Legal Considerations in Mitigating Pandemic Diseases: Workshop Summary Washington, DC: Institute of Medicine; 2007.
25. Rothstein MA, Talbott MK. Encouraging compliance with quarantine: a proposal to provide job security and income replacement. Am J Public Health. 2007;97(Supplement_1):S49-56.
26. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in china. Int J Environ Res Public Health. 2020;17(5):1729.
27. Barrows Jr RC, Clayton PD. Privacy, confidentiality, and electronic medical records. J Am Med Inform Assoc. 1996;3(2):139-48.
28. Berman JJ, Moore GW, Hutchins GM, editors. Maintaining patient confidentiality in the public domain Internet Autopsy Database. Proceedings of the AMIA Annual Fall Symposium; 1996: American Medical Informatics Association.
29. Bowen JW, Klimczak JC, Ruiz M, Barnes M, editors. Design of access control methods for protecting the confidentiality of patient information in networked systems. Proceedings of the AMIA Annual Fall Symposium; 1997: American Medical Informatics Association.
30. Hull SC, Sharp RR, Botkin JR, Brown M, Hughes M, Sugarman J, et al. Patients' views on identifiability of samples and informed consent for genetic research. Am J Bioeth. 2008;8(10):62-70.
31. Rampling T, Page M, Horby P. International biological reference preparations for epidemic infectious diseases. Emerg Infect Dis. 2019;25(2):205-11.
32. Sprague E, Reynolds S, Brindley P. Patient isolation precautions: are they worth it? Can Respir J. 2016; 2016:5352625.
33. Asghari F. The Priority of Healthcare Providers' Safety and Health is an Ethical Duty in Public Health Management of the Infectious Outbreaks. Iranian J Med Ethics Hist Med. 2019;12(1):615-7.
34. Yin X, Zeng L. A study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory. Int J Nurs Sci. 2020;Epub ahead of print.
35. Wynia MK, Kurlander JF, Green SK. Chapter 6: physician professionalism and preparing for epidemics: challenges and opportunities. Ethics and Epidemics. 2006:135-61.
36. McCullough LB. Chapter 8: Ethically Justified Limits on the Obligations of Physicians and Health Care Organizations in Response to Epidemics and Bioterrorism'. Ethics and Epidemics (Advances in Bioethics, Volume 9) Emerald Group Publishing Limited. 2006:175-86.
37. Al-Amri S, Bharti R, Alsaleem SA, Al-Musa HM, Chaudhary S, Al-Shaikh AA. Knowledge and practices of primary health care physicians regarding updated guidelines of MERS-CoV infection in Abha city. J Family Med Prim Care. 2019;8(2):455-61.
38. Thu T, Anh N, Chau N, Hung N. Knowledge, attitude and practices regarding standard and isolation precautions among Vietnamese health care workers: a multicenter cross-sectional survey. Intern Med. 2012;2(4):1000115.
39. Kelland K. Speed science: The risks of swiftly spreading coronavirus research. Reuters. 2020 Feb 19.
40. Schopper D, Ravinetto R, Schwartz L, Kamaara E, Sheel S, Segelid MJ, et al. Research ethics governance in times of Ebola. Public Health Ethics. 2017;10(1):49-61.
41. Tansey CM, Herridge MS, Heslegrave RJ, Lavery JV. A framework for research ethics review during public emergencies. CMAJ. 2010;182(14):1533-7.
42. Mezinska S, Kakuk P, Mijaljica G, Waligóra M, O’Mathúna DP. Research in disaster settings: a systematic qualitative review of ethical guidelines. BMC Med Ethics. 2016;17(1):62.
43. Sethi N. Research and global health emergencies: on the essential role of best practice. Public Health Ethics. 2018;11(3):237-50.
44. Hunt MR, Anderson JA, Boulanger RF. Ethical implications of diversity in disaster research. Am J Disaster Med. 2012;7(3):211-21.
45. World Health Organization. Research ethics in international epidemic response: WHO technical consultation, Geneva, Switzerland, 10-11 June 2009: meeting report. World Health Organization, 2010.
46. Sharma H, Verma S. Authorship in biomedical research: A sweet fruit of inspiration or a bitter fruit of trade. Trop Parasitol. 2018;8(2):62-9.
47. Zarghami M. Authorship and contributorship. Iran J Psychiatry Behav Sci. 2011;5(2):1-4.
48. Tscharntke T, Hochberg ME, Rand TA, Resh VH, Krauss J. Author sequence and credit for contributions in multiauthored publications. PLoS Biol. 2007;5(1):e18.
49. Kalil AC. Treating COVID-19—Off-Label Drug Use, Compassionate Use, and Randomized Clinical Trials During Pandemics. JAMA. 2020;Epub ahead of print.
50. Kim AH, Sparks JA, Liew JW, Putman MS, Berenbaum F, Duarte-García A, et al. A Rush to Judgment? Rapid Reporting and Dissemination of Results and Its Consequences Regarding the Use of Hydroxychloroquine for COVID-19. Ann Intern Med. 2020:M20-1223.
51. Yazdany J, Kim AH. Use of Hydroxychloroquine and Chloroquine During the COVID-19 Pandemic: What Every Clinician Should Know. Ann Intern Med. 2020:M20-1334.
52. Kile Green AJA, Jana Suklan, Fiona R. Beyer, D. Ashley Price, Sara Graziadio. What is the role of imaging and biomarkers within the current testing strategy for the diagnosis of Covid-19? April 8 ed: The Centre for Evidence-Based Medicine; 2020.
53. ACR. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection: American College of Radiology; 2020 [updated March 22; cited 2020 April 14 ]. Available from: https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Recomme ndations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection.
54. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology. 2020:200642.
55. FDA. What are the Radiation Risks from CT? : The U.S. Food & Drug Administration; 2017 [cited 2020 April 14]. Available from: https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/what-are-radiation-risks-ct.
56. Barrett DH, Ortmann LH, Dawson A, Saenz C, Reis A, Bolan G. Public health ethics: cases spanning the globe: Springer International Publishing; 2016.
57. Smith M, Upshur R. Pandemic Disease, Public Health, and Ethics. InThe Oxford Handbook of Public Health Ethics. 2019.
58. Taskinsoy J. Diminishing Dollar Hegemony: What Wars and Sanctions Failed to Accomplish, COVID-19 Has. (April 7, 2020). [cited 2020 April 14]. Available from: https://dx.doi.org/10.2139/ssrn.3570910
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| Issue | Vol 4 No 2s (2020): COVID-19 | |
| Section | Review article | |
| Keywords | ||
| COVID-19 Ethics Pandemics Public Health | ||
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Asghari F, Saeedi Tehrani S. Ethical Issues in Responding to the COVID-19 Pandemic; A Narrative Review. Front Emerg Med. 2020;4(2s):e60.
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