Lessons learned from the COVID-19 pandemic.

The coronavirus disease 2019 (COVID‐19) outbreak raises unique ethical dilemmas because it makes demands on society from all sectors of life, nationally and across the globe. Health professionals must deal with decisions about the allocation of scarce resources that can eventually cause moral distress and may affect one's mental health. Everybody must deal with restrictions on freedom of movement that have shut down whole economies in an attempt to flatten the epidemic curve. Moving forward, there will be questions of when and how it will all end? In due course, some will question the ethics behind the search for effective treatments and the development of vaccines in a time of uncertainty and distress. These sorts of predicaments—and the people that they effect—are very different. While the lasting implications of the pandemic are yet to become apparent, we here outline some of the potential lessons and address its ethical dilemmas.

LIMITED RESOURCES

This pandemic is a stark reminder of the divide that exists in countries without universal health care, between those who can afford health care and those who cannot and may be forced into poverty as a result. Good hygiene practices such as effective hand washing and physical distancing are effective means to flatten the curve and reduce the economic burden. In poorer societies, these simple measures may not be feasible.

Sadly, we live in a world that allows people to die when it costs too much. It happens all the time in areas like humanitarian aid, road safety and the funding of orphan drug research. A financial limit on our efforts to save lives will always be present in every nation's healthcare budget. The ideal is for transparency in budget allocation that involves all stakeholders, guided by the ethical principles of utility and equity. While the principle of utility requires allocating resources to maximise benefits and minimise burdens, the principle of equity requires attention to the fair distribution of benefits and burdens. Health equity is an ethical concept based on the principle of distributive justice. While an equal distribution of benefits and burdens may be considered fair, it may be fairer to give preference to groups that are more vulnerable. There is no easy solution to resolve potential tensions between utility and equity, but a balanced consideration between both is crucial.

The pandemic will require resource allocation decisions. We will have to decide who gets a ventilator or an intensive care bed when not everyone can. Decision‐making tools need to be developed to ensure that no person receives better or worse treatment due to his or her social status. Such efforts must be made to avoid unintended discrimination during pandemics. The Clinical Frailty Scale score and a decision‐making committee are two exemplary options that can aid decisive factor for triage and admission to critical care. No matter what tools are used, it needs to be simple and regularly reviewed as the pandemic evolves. We learnt that many doctors succumbed to COVID‐19 while performing their duties. Preferential treatment for healthcare workers who risk their lives as front liners may be justifiable. This ethical principle of reciprocity implies that society have a duty to support individuals who risk their own health for protecting the public good. This must not be limited to healthcare providers alone, but also the hospital cleaners, technicians and security personnel among others.

MENTAL HEALTH

We need to be aware that the COVID‐19 pandemic will have mental health consequences. Resource allocation decisions generate conflicts and mixed sentiments for both healthcare providers and the general public. Moral distress affects all of us and must be respected and openly discussed. Such moral distress is a healthy sign, not a pathologic one.remuneration It means that we are trying to do the right thing, know that sometimes we cannot, yet must go on. There will be conscientious objectors when it comes to risking their own lives, and potentially the lives of their families when undertaking duties in a contagious outbreak. A compromise approach strikes a balance between the needs of the patients and the healthcare workers’ conscience. A referral can then be made to a willing colleague. However, this approach might not be practical during pandemics. Applying the above‐mentioned principle of reciprocity, conscientious objection could be discouraged by offering better incentives and remuneration to non‐conscientious objectors.

There will be psychological impact to those who are stereotyped as being disease carriers. Racism and discrimination lead to chronic stress. They are barriers in realising the principles of equality, a core principle of human rights. The rights to non‐discrimination must remain central to all government responses. We must advocate countermeasures to address widespread stigmatisation that have adverse public health impact. Being a role model in our practice encourage people to come forward to seek treatment without fear.

For all of us to stay mentally healthy, every effort counts. Talking to our patients and their families about COVID‐19 helps people cope, especially when the situation remains fluid and where the public has many doubts. Answering, sharing facts and letting children know that it is fine to be upset, or scared help us face reality too.

RESTRICTION ON FREEDOM OF MOVEMENT

Quarantine, travel restrictions advisory and authorised measures to reduce transmission such as school and work closure can cause loneliness, confusion, anger, frustration, boredom and constant feeling of inadequate information. While these measures are justified to safeguard the best interest of society, they impose a significant burden on individuals and indirectly violate the fundamental human rights of freedom of movement. Reports have shown of increased domestic violence and even alcohol abuse during quarantine. Children are at risk, simply because they are powerless. Appeals to altruism might mitigate some of these problems. Strategies and social awareness should be put in place to offer support and protection to minimise such risk to children and women.

In the hospital setting, quarantine can change the norms of death and dying. No one wants to die alone in isolation, amid chaos and with burnout healthcare providers. We have a moral imperative to ensure good care for dying patients that incorporates their spiritual needs. Our sense of empathy means we must ensure that modern technologies are available to enable families to interact with loved ones during isolation. Likewise, video‐based communication with families will give emotional support and ease the anxiety surrounding death and dying. In this challenging time, such small gestures mean a lot.

ECONOMIC IMPACT

While we focus on saving lives, an economic collapse is a catastrophic health risk, too. Access to health care will be a heightened concern for those in economic hardship, especially as the pandemic brings additional risks for less secure workers. Many companies have instructed staff to work from home, but for many this is not an option. Eventually, the pandemic will economically impact everyone, and a global recession is imminent. A range of economic policy responses will be required. Cutting interest rates and massive stimulus package are possible effective responses. However, the impact is not only a demand management problem but also a multifaceted one that requires coordinated fiscal and health policy implementation.

There needs to be more investment in public health in all economies particularly in less developed countries where healthcare systems are less developed and population density is high. Ultimately, we want to avoid the dilemma of affordability when a cure is found.

All this leads us to conclude that cross‐cultural global values and ethical standards are crucial for the success of the global market economy. Such a global ethic should be based on the principles of humanity and reciprocity and the basic standards of non‐violence, fairness, truthfulness and partnership. The Global Economic Ethic Manifesto reminds each one of us in our diverse roles as entrepreneurs, investors, creditors, workers and consumers to bear a common responsibility for humanising the functioning of the global economy.

RESEARCH ETHICS

There is a need for interventions to curb the problem. We have an ethical obligation to learn as much as possible quickly to develop effective health policies, drugs and vaccines. Clinicians, researchers, administrators, ethics committees, regulators and sponsors have a duty to ensure that this is done without delay. Protocols can be developed to ensure accelerated ethics review without undermining basic ethical principles of beneficence, respect for persons and justice. One option is to authorise the advance review of generic protocols for conducting research, which can then be rapidly adapted and reviewed. International collaboration can help ensure the research is viable. We need international collaboration and data sharing so that clinical trials can be done without delay. We need licensing agreements that cross international borders.

In conclusion, zoonotic diseases will continue to pose a threat to humanity with imminent potential for panic and fear that disrupts our everyday lives. Today, we witnessed solidarity, the justification of collective action in the face of a common threat. International community are slowly coming together as one to collaborate, coordinate, share lessons learnt and help one another. Yet, we must be mindful of the gap between social acceptance and ethical acceptability. While global cooperation, especially in the sphere of public health, research and economic development, is essential, politicians and leaders must not ignore scientific facts. We are working together for the good of mankind. What we must not do is to blame one another in this time of uncertainty. Until every country is safe, no country will be safe.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.