Damian Sendler Ethical Implications of Public Health Actions and Policies During COVID-19
Damian Sendler: During pandemics, ethicists, public health professionals, and human rights advocates raise a red flag about different public health actions that should at best be addressed through integrated, global policies. Health care resources must be rationalized and prioritized, but the real concern is how to do so without increasing the vulnerability of the underserved population. Health care providers use a variety of scoring systems in their decision-making to better allocate resources to patients with known health outcomes and prognoses and to more accurately classify them. But the value of existing scoring systems for COVID-19 cases has not yet been established. While dealing with the pandemic's medical needs, it's important to keep non-COVID patients' chronic medical conditions like non-communicable diseases from getting worse while also making sure that the development of comprehensive standards for dealing with COVID-19 isn't hindered. In this article, we discuss this dilemma and the way COVID-19 challenged existing ethical standards. An equally important issue is making sure that ethical standards are followed consistently when testing new drugs, vaccines or medical interventions that have not yet been proven.
Damian Jacob Sendler: Decisions and strategies made by federal and non-governmental agencies are part of health policy. It is possible for policies to be geared toward individuals, hospitals and insurance companies alike, or even health services. Public health policies aimed at preventing tobacco use are just two examples. The review of a country's legal powers and responsibilities guides policymaking in order to ensure that people are healthy and that the country has the ability to limit the autonomy, freedom, privacy, and other legal interests of individuals for the general good. Both legal actions and optimal health and well-being goals are covered in great detail in the high-quality data required for these strategies to meet ethical requirements. Public health rules must be implemented in accordance with bioethics, and politicians have a moral obligation to ensure that this is the case. Current and future policy preferences are shaped by scientific research that examines the implications of current legislation and returns evidence from that research for consideration in decision-making (1, 2).
Dr. Sendler: In response to an enormous rise in the influence of medicine and biological sciences during this century, the modern field of bioethics was born around 1960. Bioethics is still a hot topic, with submissions from moral philosophers as well as doctors, healthcare providers, social scientists, and attorneys. Patients, health professionals, and government officials are debating the issues of organ transplantation, disparity in access to life-saving drugs and new contraceptives, and a significant increase in clinical trials (3). Ethics in recent health policy and system research (HPSR) lack a wide range of relevant questions. It is important to HPSR's ethical principles that health disparities be reduced. The fairness of HPSR is therefore highly affected by legal issues (4).
Public health regulation faces new ethical challenges as a result of globalization and its accompanying shifts in the way people live and access health care. Public health's primary goal has always been to prevent disease rather than to treat it. The success of public health is focused on population health, as opposed to medical practice, which is concerned with the health of the patient being treated. In clinical and public health, the implementation of ethical standards is different because of the differences in procedures. Health care providers are constantly confronted with issues of acceptable scope and moral conflict with personal autonomy in terms of their work, according to public health theory (5).
Using public health data in specific communities requires data on the effectiveness of public health initiatives, the relative harm and benefit they cause, as well as information on how they can be implemented, whether or not they affect the most vulnerable members of society, and the logistics involved in putting them into action (6).
The need for a broader approach is gradually being realized. Well-being, social rights, and collective concerns about social determinants are at the heart of public health ethics and policy. These and other issues, such as how to respond to new technology and how healthcare systems should respond to rationing and other possible scenarios are being discussed (7).
International cooperation and justice for all communities are essential to global health, regardless of race or ethnicity. It is an interdisciplinary and multidisciplinary system that takes into account, directly or indirectly, issues related to health. However, international health is primarily concerned with issues in other countries, particularly in LMICs, so cross-border coordination between two countries is a common solution. The goal of global health is to provide assistance by bridging the gaps between various fields, but this does not constitute multidisciplinarity (8).
Without effective vaccination, people are forced to resort to some of the simplest methods of controlling contagious diseases, such as quarantine, exclusion, physical separation and the construction of barriers. If you're suffering from this condition, you'll be able to see how important it is to get proper diagnosis, treatment and most importantly, a vaccine. However, the manufacturing of a vaccine raises a number of public health ethics questions that are currently being debated, including the implications of a quick-started search for vaccines, the equal distribution of a scarce vaccine in the beginning, and the effects of a relatively high degree of enrollment in the global immunization program (9).
Although there are no universal ethical public health theories, the core principles and simple assumptions are shared by all of them. There are three main tasks in applying an ethical framework to public health policymaking: (1) assessing and explaining the ethical questions raised; (2) evaluating possible action paths and their impact; and (3) dealing with the issue by assessing all of the steps in action and integrating ethical principles into them. The following four ethical principles will help establish the ethical recommendations: (1) ensure maximum benefit and minimal harm, (2) achieve justice, (3) eliminate inequality in health, and (4) achieve transparency (10–12). More than 200 governments from around the world responded to COVID-19 between January 1st, 2020 and October 1st, 2020, and this data is now available to serve as evidence for policymakers and economists (13). Figure 1 illustrates how we can study an emerging problem of concern, utilizing all previous studies, trials, and research, and discussing the expected outcomes by various stakeholders, including study participants to researchers and policymakers. Thus, the best results are achieved through continuous improvement and expansion of the implementation strategy (14).
Ethical guidelines stress the importance of ensuring an international justice perspective. Global interdependence has made it more important than ever before, making it more important now than ever before. Health research in low and middle income countries (LMICs) has been described as a means to improve global health. Medical and health studies should be conducted in accordance with research ethics, according to Benatar and Singer (15). The harmonization of ethics in the field of health, particularly in countries with similar geographic distribution (16–18), is also a goal of this work. In times of pandemics, this is even more important because even countries that aren't thought to be at risk need to have public health, healthcare, and animal programs ready for good pandemic preparation. It's critical to coordinate with all countries involved (19).
Furthermore, one of the sustainable development goals is to provide universal health coverage, which ensures that everyone, regardless of their financial situation, can access quality healthcare. In regions like Africa and others with limited resources, there is a significant disparity in access to health care, and it is critical that health policies in those regions be given more sway (20). Universal health coverage should be a priority for global health policymakers, especially in this era of pandemic (21). As a result, long-term growth prospects are jeopardized, while governments are left vulnerable to pandemics due to the absence of universal access to reliable healthcare. People and their families will be more vulnerable as the world's aging population and the rising burden of non-communicable diseases increase if developing countries do not take immediate action to close the gap between demand for healthcare and available public resources (22).
Additionally, in low and middle income countries (LMIC), access to high-quality but affordable medicine is a major issue due to the lack of financial resources and the fact that most health policy research is driven by resources rather than needs. This is especially true in dynamic environments. To ensure the availability of high-quality medicine, policymakers must take into account the impact of non-ethical promotion activities on access to even informal pharmaceutical markets (23).
Damian Jacob Markiewicz Sendler: For researchers in the field of health policy, ethical issues must be addressed by bringing together and paying attention to the appropriate representation of primary stakeholders to ensure that this policy can be implemented in the real world. It is necessary for scientists to rationally reflect on the strategy of these "partnerships" (24).
According to this list: utility, evidence-based performance; distributive equity; equality; social responsibility; empowerment; public participation; transparency and accountability; confidence; and equal representation. Even after considering the aforementioned ethical principles, the final ethical assessment rarely results in a definitive rejection or acceptance of a public health intervention. Instead, a stronger or weaker decision, such as implementing or forgetting the intervention in the event of a negative assessment, is made. Researchers and research ethics bodies need to gain a better understanding of the various applications of ethical values in clinical study and health policy and system research if they hope to improve the ethical analysis and conduct of these fields. They all lead to the creation of stable social systems, the empowerment of individuals' talents, the development of their mental faculties, and the enhancement of their individual autonomy in line with the philosophy of social justice (5, 25, 26).
Prioritizing limited resources during a pandemic is an ethical dilemma for health workers and decision-makers. During COVID-19, the intensive care unit (ICU) was in high demand among a variety of populations, making the common rule, such as "First come, first served first," inapplicable. This contentious subject has been around for a while (27, 28). Chronic renal failure patients could receive hemodialysis three times a week thanks to a device developed by Belding Scribner and his colleagues at the University of Washington in 1960. Acute renal failure could only be treated with hemodialysis prior to this (29). As dialysis machines and trained staff are in short supply, access to this life-long and expensive treatment had to be prioritized. To prioritize treatment, a committee of seven non-health professionals and two doctors was formed back in 1961.
The criteria were not limited to medical evaluation alone, but also included social aspects. Youngsters and their families were prioritized over those who could financially support a large family. In addition, because the program relied on state tax revenues, they prioritized patients who were Washington residents (29). Prioritizing patients who will benefit from access to scarce resources, such as ventilators, ICUs, vaccinations, etc., should be justified in emergency and pandemic contexts. Making decisions must adhere to the following guidelines: openness, inclusivity, consistency, and responsibility (30). It's much easier to say than to do, however, because there are so many variables to consider. In order to make medically justified decisions about investing more money in cases with better predicted health outcomes and prognoses, prognostic scoring systems such as the Sequential Organ Failure Assessment (SOFA) score for adults (31) and the Pediatric Logistic Organ Dysfunction (PELOD) score for children have been suggested (32). While SOFA's ability to predict respiratory failure due to COVID-19 has not been proven, the pandemic influenza pandemic influenza pandemic influenza pandemic influenza performed very well (29). As a result, it is best to use the scoring system in conjunction with other clinical judgments while we wait for a more reliable system to emerge.
In addition, the right of health workers to be prioritized beneficiaries when they become infected is a hotly debated issue. Combating the pandemic is a top priority for healthcare professionals. To benefit society as a whole, they are willing to put their own health at risk. Medical personnel needed to combat and respond to an emergency would be severely hampered if they put their health at risk while receiving inadequate medical care. Is this reason enough to prioritize their access to scarce resources? As a matter of fact, health workers are a critical component of the pandemic fight. As a result, they are prioritized for medical care and protective measures, such as PPE, ICUs, ventilators, and vaccines, when they are available (29, 33, 34).
Patients with life-threatening illnesses other than COVID-19 are also prioritized for access to care. Non-critical, non-COVID-related medical conditions may or may not be entitled to the same level of access. However, those who can wait out the pandemic's critical period will have lower priority than those who are in stable condition but must seek medical attention immediately (29).
Damien Sendler: There is still a debate about how cultural factors should be taken into account when drafting regulations governing the allocation of resources and the extent to which they should be considered (35). Taking into account the importance of involving the general public in the formulation of such policies, the argument is consistent with WHO's call for greater openness, accountability, and participation in decision-making processes (36).
A comprehensive policy guidance for healthcare resource reallocation and rationalization in a pandemic context is essential.. It is imperative that this process address a wide range of ethical considerations while ensuring that the affected community has some influence on the decision-making process. The following sections on COVID-19 go into greater depth on this topic.
To ensure that everyone in need has access to the highest quality medical care is a responsibility shared by healthcare systems, governments, and international organizations. As a result of healthcare systems' limited capabilities and resources, meeting the ever-increasing demands of the population is especially difficult during times of crisis. This challenge is currently being demonstrated by the Covid-19 pandemic. Health care systems around the world are struggling to accomplish their primary objectives. Prioritization, regulations, and ethical considerations are critical in this situation.... It's imperative that the allocation of limited healthcare resources is done in an ethical and rational manner. A medical team may be forced to prioritize some patients over others in order to get the most out of their limited resources and save as many lives as possible in the process (37). The main areas of concern, where ethical prioritization decisions must be made, are ventilators, medications, vaccines, and testing and admission to hospitals. (38).
Prioritization and decision making are guided by three main considerations: first, equal distribution of limited medical resources among all patients. Prioritize patients who will get the most out of medical resources in order to achieve the best possible results. It's possible that medical teams have to prioritize some patients over others in order to get the most benefit from limited resources and save many lives. As a third step, prioritize those most in need of medical attention or who are most at risk.
Ethical values in resource allocation must be protected by ensuring that the process is transparent, inclusive, consistent, and accountable (38). Covid-19 test kits are scarce, but the sheer volume of testing required to obtain reliable results justifies the expense and time involved in obtaining them. As a result, information on how to handle COVID-19 testing should be available. Because most infections spread through patients with symptoms, it's critical to test them as soon as they present symptoms in order to ensure they get the treatment they need. Asymptomatic healthcare workers should also be screened to reduce the risk of infecting patients who are already at high risk for transmission of the virus (39).
Allotment of ventilators as life-saving devices is yet another service that must be prioritized. When COVID-19 struck Italy, the country's top anesthesia and critical care society issued a guideline for ICU resources allocation, which included some limiting criteria for the use and withdrawal of ventilators, such as an age limit for use and the maximum clinical benefit to be realized (40).
Using a clinical scoring system that focuses on "quality-of-life" years can result in significant advantages. Although the clinical scoring system is objective, it has the potential to give an incorrectly precise outcome because it can give different mortality rates for patients with the same clinical picture. A fair and ethical decision must be made by the healthcare team using the scoring system and clinical judgment (29). For this reason, an experienced and well-trained medical team is essential in order to ensure the best possible outcomes for patients (41).
Damian Sendler
In times of resource scarcity, health care providers can use a variety of scoring systems to aid in their decision-making. The medical teams and clinicians of the triage committees must be fully aware of the exact use of each scoring system and in order to select the most appropriate one. Physicians can use scoring systems to help them decide whether or not to perform an operation in an elective situation.. To keep up with the rapid evolution of COVID-19 scientific data, this scoring system must be constantly updated.
Calibration is required before a computerized clinical scoring system can be established. It should be able to adapt to constantly changing conditions, new observations, and the results of investigations. Comorbidities must be taken into account when developing scoring systems because they can harm vulnerable populations who already suffer from diseases other than COVID-19, resulting in an unfair distribution of limited resources (42).
A study comparing ventilator triage policies in many North American hospitals found that clinical need and patient benefit were the most common principles for allocating ventilators. There were inconsistencies in the criteria used by hospitals to allocate ventilators aside from these two guiding principles, resulting in unfairness. Either a patient is admitted to a hospital with unfavorable policy criteria or a patient chooses a hospital with a favorable policy criteria; both situations are unfair. It is critical to have a unified policy for ventilator triage that is based on ethical considerations and includes specific criteria for allocating resources in order to maximize patient benefit and minimize any harm caused by unfairness or bias (43).
It is critical to have a triage officer who is completely independent of the medical team treating the patient, and who is supported by a respiratory disease expert medical team, in charge of allocating scarce resources fairly. To avoid bias and inequities, these resource allocation decisions should be reviewed on a regular basis by a higher-level committee (44). Additionally, this triage committee will spare treating clinicians from having to decide on who to treat (34).
First-come, first-served arguments will inevitably be used in COVID-19 treatment, but this method may discriminate against the less fortunate with limited access to healthcare facilities and no means of transportation (45).
Non-essential health care services are another ethical dilemma for healthcare providers during COVID-19. For the time being, a number of Canadian provinces have decided to curtail or eliminate non-essential medical interventions altogether in favor of using telemedicine in their place. Non-essential medical interventions are expected to be decided by healthcare providers based on specific criteria, including risk proportionality, harm principle (minimizing harm), fairness and reciprocity (mutual benefit) (46).
For patients who do not have COVID-19, standard treatment may not be available and will have to be substituted by another treatment. In order to obtain a patient's full and informed consent, doctors must first inform the patient of the current situation, and then explain the nature of the substitute treatment as well as the type of routine treatment (47).
Damian Jacob Sendler
Non-communicable diseases (NCDs) patients, on the other hand, must be able to get the medical care they need in order to avoid deterioration of their health, especially in emergency situations or in cases where health services must be provided in a medical facility (e.g., chemotherapy sessions and dialysis). In order to protect patients with NCDs from contracting COVID-19, healthcare facilities must treat them separately from COVID-19-infected patients. Telemedicine can be useful for NCD patients who just need a physician's consultation or follow-up (48, 49).
Patients infected with COVID-19 should not be guaranteed priority in the ICU over other patients with different diseases, but this should not be a dealbreaker (45). Ethical considerations include whether health care workers should be prioritized because they are on the front lines of the COVID-19 fight and are at risk of infection and death due to inadequate PPE while they help many patients to survive. In order to control a pandemic and treat both COVID-19 and non-COVID-19 patients, a well-trained and healthy medical team is crucial, so should they only be prioritized in preventive medical care (vaccines and medications) and not prioritized in cases that require critical care (ventilators and ICU)? (34).
Enough personal protective equipment (PPE) must be provided by healthcare facilities' employers so that healthcare workers can treat patients safely and without risk (41). As a result, it is critical that healthcare workers' duties and rights are clearly defined based on transparency and equity. There is a legal obligation to work in public health if the expected benefits of public health outweigh the risks to health workers (50).
In the care of patients with COVID-19, the role of the nurse cannot be overstated. When a pandemic occurs, it is critical for employers to protect nurses both physically and legally, by providing clear protocols on how to operate (51).
How many nurses a patient has can have an impact on their recovery. There will be one critical care nurse, two ICU-experienced nurses, two nurses with no ICU experience, and four other support staff caring for six ICU patients, according to the National Health Service (NHS). Several ethical and clinical questions may arise, such as the type of nurse-to-patient ratio required during the pandemic and whether patient prioritization is valid in terms of medical team care (41).
Governments, on the other hand, need to shift the medical workload during the COVID-19 pandemic by shifting tasks, for example, using non-medical governmental staff for simple medical tasks after receiving short training (49).
To deal with the scarcity of medical resources, it has been suggested that governments try to move the necessary resources to areas with the highest infection rates or where the health system lacks PPEs, ventilators, or medications. This is an option to consider. An additional suggestion is to bring back former healthcare professionals who are no longer practicing. in order to free up space in the medical system to accommodate emergency cases, non-urgent medical services or procedures can be deferred without putting patients' lives at risk (52).
Reallocation of medical personnel can assist in the management of the COVID-19 pandemic workload. Maintaining a mitigation plan and providing basic medical care services is an ethical rule that must be followed when reallocating staff. This is the best way to ensure that no patient is abandoned. This should be reviewed on a regular basis and openly with patients in light of the current situation. In the meantime, it is imperative that the medical professionals who have been relocated to new positions receive the training and assistance they require in order to be fully prepared for their new roles (53).
Each country's medical and ethical rules must be followed. The right of a patient to receive life-saving medical treatment cannot be denied in Egypt because another patient has a better chance of survival (54).
Laws regarding online diagnosis and follow-up without a physical examination by the treating doctor must be reviewed because online diagnosis is not permitted in some countries, such as Egypt, where online consultations are commonplace (54).
For the COVID-19 pandemic, the main challenge is the limited medical resources (ICUs, ventilators, medications, PPEs, doctors, and nurses). Ethical policies must be established to avoid bias and unfair treatment of patients.
Patients' and providers' interests should be taken into account when crafting health policies. Health policies affect the entire health care system. Furthermore, bioethical standards should be incorporated into the development of these policies, especially during pandemics. Public health professionals and ethicists have learned from previous health crises, and they are working to build on this knowledge and prepare for the next one. The COVID-19 outbreak, on the other hand, raises a slew of questions and illuminates the need for new regulations. Health-care system rationalization during pandemics is a multi-faceted decision that policymakers should take into account when developing international guidelines. Prioritizing cases based on medical assessments and predicted outcomes is one of the most important aspects. All health care workers assigned to triage should be made aware of these measures, which should be clearly stated and based on solid research and evidence. The second aspect is ensuring that the health workers who are on the front lines of the pandemic fight get the support they need to do their job effectively. There will be a need for protective gear (PPE), as well as training if necessary, along with timely information dissemination. There should be a clear system for determining the urgency of patients' medical needs even if they don't have COVID, so that they can be treated accordingly. Bioethical considerations must be taken into account when using untested medical interventions, unlicensed drugs, and experimental procedures. Every aspect of the policy implementation process should be done in a way that includes the participation from different shareholders, transparency and cultural consideration. The provision of health services and triage should not exacerbate any forms of inequality, including but not limited to those based on gender, ethnicity, religion, or any other form of intolerance.