Context

Recently, the World Health Organization (WHO) Health Ethics & Governance Unit has organized a Global Ethics & Policy Summit.

Background

• From resource allocation and priority-setting, access to vaccines, vaccine mandates, lockdowns, travel restrictions, public health surveillance, and obligations to conduct clinical trials, the COVID-19 pandemic has raised profound ethical challenges on an unprecedented global scale.
• In an unprecedented manner, ethical values like equity, fairness, solidarity, and trust have figured prominently in global political discussions.

Analysis

About the Summit

• Organized by: The Summit is organized by the WHO Heath Ethics and Governance Unit in collaboration with the WHO’s Working Group on Ethics & COVID-19 and the ACT-Accelerator Ethics & Governance Working Group.
• Objective:
  • examining and reflecting on the role of ethics in policymaking during the COVID-19 pandemic
  • exploring how best to support and integrate ethical decision-making in preparing for and responding to future public health threats
• Theme: “Equitable access, solidarity, and global health justice: bridging the gap between ethics and decision-making in pandemics”

Agenda of the Summit

• This Summit provided a forum to discuss the-
  • translation of ethics into policy making in COVID-19
  • where the world has succeeded and failed
  • what are the major challenges
  • what steps need to be taken to improve ethics informed public health decision-making for pandemic preparedness and response

What are the ethical challenges posed by the pandemic?

• Resource allocation and priority-setting
• Physical distancing
• Public health surveillance
• Health-care worker's rights
• Obligations to conduct of clinical trials

What are the philosophical and moral issues thrown by Covid-19?

• Increasing aggression: People are getting highly restive and agitated in spite of social media connectivity.
• Domestic violence: Cases of domestic violence have more than doubled in the country during this period.
• Traumatic situation: Humans have evolved to be social creatures and are wired to live in interactive groups. Being isolated from family, friends and colleagues can be unbalancing and traumatic for most people and can result in short or even long-term psychological and physical health problems.
• Psychological effects: An increase in levels of anxiety, aggression, depression, forgetfulness and hallucinations are possible psychological effects of isolation.
• Deteriorating mental health: Mental conditions may be precipitated for those with underlying pre-existing susceptibilities and also show up in many others without any pre-condition.
• Emotional void: Personal relationships help us cope with stress, and if we lose this outlet for letting off steam, it results in a huge emotional void which, for an average person, is difficult to deal with.
• Alcoholism: Social isolation has been found to have a correlation with higher alcoholism.
• Issues with child’s mental health: Lack of playtime with peers is making children irritable and edgy.
  • It can be extremely oppressive and claustrophobic for large low-income families huddled together in small single-room houses.
  • Children here are not lucky enough to have many board/electronic games or books to keep them occupied. Add to it the deep insecurity of running out of funds for food and basic necessities.
• Toxic family issues: On the other hand, there are people with dysfunctional family dynamics, such as domineering, abusive or alcoholic partners, siblings or parents which makes staying home a period of trial.
• Violence against women: Incidence of suicide and physical abuse against women has shown a worldwide increase.
• Most affected class: Lower classes were worse off for living in closely packed, unhealthy environments. A large workforce had been destroyed; farms and factories were abandoned. Wages for labour shot up as did the cost of manufactured goods. There were some positive outcomes too, though at a huge price of death and destruction.

What are the ethical principles for decision-making during crisis?

There are seven ethical principles guide decision-making in a pandemic crisis. Such as:

• Minimizing harm: All attempts should be made to minimize physical, social, psychological, and economic harm of the population faced with the pandemic crisis. The measures taken to minimize harm should be rational, reasonable, and open for review. The exercise of harm minimization should always weigh the benefit and negative outcomes of action. The measures that cause minimal damage to an individual and greater good for the society should be the ethical principle of decision-making. In the majority of the hospitals, elective cancer surgeries were cancelled during the lockdown period to avoid COVID risk to cancer patients and to ration health-care resources for COVID patients. However, the benefit of these cancellations should be weighed against the possible risk of cancer progression and the harm caused due to cancer progression
• Proportionality: The steps that are taken or the decisions made should be proportional to the threat and sufficiently adequate for protecting the public from harm. However, overzealous extreme restrictive measures that are disproportionate to the danger can be counterproductive and could lead to resentment and bitter experiences. Being circumspect, communicating the actions, education, and compassionate approach often yields better outcomes than coercive or restrictive measures. During the initial stages of a pandemic, many hospitals decided to completely stop or restrict their non-COVID work. Care of patients with non-COVID illnesses was significantly compromised due to these disproportionate measures
• Solidarity: Pandemic crisis demands solidarity where the society gears up to the challenges beyond self-interest and territoriality. Individuals, institutions, and administration have to work together for the collective good. People should be ready to be redeployed to situations beyond their expertise, and the system should exhibit readiness and responsive behavior. Health-care professionals without an intensive care focus in their routine work may have to receive rapid training to make themselves available for COVID work. Moreover, both the public and private hospitals have to work in unison across the territorial boundaries to ensure solidarity in a pandemic crisis
• Fairness: Fair allocation of scarce resources effectively for maximizing benefit is an important ethical consideration. It is pertinent to recognize moral equality while making resource allocation decisions. Moreover, resource allocation should be based on sound reasoning and evidence. Intensive care resources are often scarce in a pandemic situation. These scarce intensive care resources should be allocated appropriately considering the age, comorbidities, and other factors. A patient with older age with end-stage organ impairment or advanced cancer with serious COVID illness has a lesser likelihood of benefit from intensive care measures compared to a younger person with no comorbid illness
• Duty to provide: All health care workers are ethically bound with an obligation to provide their services during a pandemic crisis. The health care workers may have to accommodate a contradictory role and continue to work despite risks. Even in the presence of a competing personal and family obligations, pandemic crisis calls for a commitment. Majority of health-care professionals in India live with their families that include elderly parents and young children. There is a heightened risk of contracting the illness and transmitting it to the families. However, acknowledging these risks, the health-care providers have a duty to provide care with maximum precautions to avoid any collateral damage
• Reciprocity: It is the responsibility of the administration and the government to empower health-care providers to meet the demand of their role. Both the professional and personal needs of the health-care providers have to be met on priority. They should be empowered by providing them adequate guidance, protection, and resources to care for themselves and their families. There were instances where the health-care providers were barred from their housing complexes due to perceived risk by the neighbors about them to be the carriers of infection. It puts undue stress on the health- care providers who are already working in a distressful situation. It is imperative for the society to be reciprocal to the needs of the frontline health-care providers battling COVID-19 on behalf of society
• Privacy: There has to be a balance between protecting a person’s right versus safeguarding public interests. Privacy of an individual should be adequately protected to prevent discrimination, stigmatization, and criminalization of illness. The level of access to disease demographics data and its public disclosure should be limited to protecting public interests without compromising the confidentiality of the individuals. There were many instances during the pandemic situation where private information of an individual affected with COVID was available for public consumption in the websites and social media. It only compromises individual liberty and safety with no added benefit to the public.

Procedural values guide Along with the ethical principles, five procedural values guide ethics-based decision-making in a pandemic crisis. Reasonableness: The decisions made should be based on the best available evidence, proportionate to the threat, made by credible people having expertise and experience in the field, and should have a reasonable chance of being successful Openness: The decisions should be made openly and transparently. It should be accessible to scrutiny and audit. Moreover, the public should be able to avail this information through appropriate communication and media portals Inclusiveness: The decision-making process should be inclusive and should involve all the relevant stakeholders. The voices of all the stakeholders should be taken into account while making a decision Responsiveness: The decisions made must be continually revisited and revised based on new information. There has to be a redressal system to address disputes and disagreements in decision-making Accountability: A multilevel network of accountability relationship is required to facilitate accountable decision-making. There has to be clear documentation of the trail of decisions made with justification, which is open for future audit.

Conclusion

In the future, history will judge our responsiveness and our ability to navigate the pandemic crisis. It will solely depend on timely and appropriate decisions made. Ethics-based decision-making should underpin our moral purposes to place us on the right side of history.