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

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. 

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). 

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. 

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. 

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. 

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. 

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. 

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.  

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.