Ethical Standards in a Pandemic

By Jane Jankowski, DPS, MSW

As caregivers, we share a goal to remain centered on deeply held values, and to answer questions that arise in times of public health concern. Together with my colleagues in the Cleveland Clinic Center for Bioethics, we have prepared a concise summary to help frame some of the ethical considerations at the forefront of this stage of COVID-19 management. Harder questions may come, and we are preparing to help with those as well.

The below Q&A summarizes current and anticipated ethical dimensions of the COVID-19 pandemic. It is adapted from a report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group published in 2005. The points noted here will not be the only ethical issues that the world will face as we navigate COVID-19, but they are critically important values that serve as the underpinning for ethical decision making during a pandemic.

Q: Are the restrictions on normal activities ethically justified?

• Restrictions challenge our notion of individual liberty. Responding with empathy can facilitate the recognition that these decisions are made with integrity.
• During a public health crisis, all stakeholders share heightened responsibilities for the collective safety of the community.

A: Yes, restrictions that impinge on individual liberty should be applied equitably when relevant and necessary to protect the public from serious harm. Personal and professional practices must be regularly reviewed and amended for the duration of the pandemic to assure fairness of application.

Q: How much more restrictive can the measures ethically become for individuals and communities?

• Social values of justice and autonomy are preserved when restrictions are proportional to the known risk and are deployed equitably.
• Protecting the public from harm is a collective core value shared by those who live, work and otherwise serve a community.

A: In a public health crisis, health care organizations and public health authorities may be required to implement restrictions. Reasoning for the restrictions should be based on what is minimally necessary to protect the public/individuals from the harm of infection-transmission.

Q: I don’t want anyone to know I have COVID19. Isn’t it a HIPPA violation to report my diagnosis to public health officials?

• Although rare, there are sometimes exceptions to absolute privacy in healthcare when the safety of others may be impacted.
• The overriding obligations to all our patients’ health will sometimes take priority over individual privacy.

A: In a public health crisis, the right to privacy typically afforded individuals may be overridden to protect the public from serious harm. Report the minimum information necessary to accomplish public health goals with full transparency to patients.

Q: Who has the greatest right to PPE?

• The professional ethical duty of healthcare workers to provide care to the sick helps protect all employees and the community they serve.
• Protecting and supporting healthcare workers provides a substantial benefit for the community.

A: Healthcare workers have a duty to care for the sick even when this places them at greater risk of harm. To mitigate these elevated risks, healthcare workers should be prioritized when distributing personal protective equipment.

Q: How will public health officials and healthcare leaders decide how to distribute the resources if supplies become scarce?

• During normal times, providing what each patient needs is a core value facilitating the distribution of resources. A pandemic disrupts this ability and expectations may have to shift.
• Responsible stewardship of scarce resources includes a focus on utility.

A: The distribution of testing and treatment will be equitable and measured by the expectation of benefit. During a pandemic, the parameters for distribution of scarce goods may shift to a focus on rescue of the sick who are expected to recover.

Q: What can the public expect regarding updates and communication about how healthcare institutions will make decisions?

• Expending time and resources to provide timely updates to the public will continue to be essential for public safety.
• Open and transparent communication will facilitate public compliance and cooperation during a pandemic.

A: Decisions should be made applying an open and transparent process that is accessible to the public. The basis for procedural and allocation decisions will be based on evidence, principles and shared values.