key: cord-271582-xo2a4wnj
authors: Chew, Christopher; Ko, Danielle
title: Medical ethics in the era of COVID‐19: Now and the future
date: 2020-08-05
journal: Respirology
DOI: 10.1111/resp.13927
sha: 
doc_id: 271582
cord_uid: xo2a4wnj

nan

Coronavirus disease 2019 (COVID-19) should not have caught us so unprepared. For decades, public health organizations and experts urged better preparation for an inevitable zoonotic pandemic. Instead, as the pandemic ravaged developed nations in the early months of the pandemic, COVID-19 exposed conflicted political leadership, limited vital medical supplies including personal protective equipment (PPE) and under-funded public health system capacity. Europe, the United Kingdom and the United States-despite their wealth and well-resourced healthcare systems-all experienced social and economic disruption without peacetime precedent.

Similarly, COVID-19 has forced healthcare workers in developed countries to confront moral dilemmas that have received limited attention from policymakers, clinicians and ethicists until now, but are part of daily life for their counterparts in resource-poor nations. At the time of writing, over a hundred articles on COVID-19 clinical ethics have been published-a testament to one of the most clinically, personally and ethically challenging experiences in living memory. Nevertheless, few have broached truly new or unexpected ethical ground.

Take the early debate on how to allocate life-saving ventilators. As Italy became the first major outbreak outside China in March, their peak society for anaesthetics and critical care issued a then-divisive guideline about the allocation of intensive care resources. 1 Particularly contentious were suggestions of an upper age limit for ventilator eligibility, the implicit condoning of ventilator withdrawal if necessary and an explicitly utilitarian focus on maximizing clinical outcomes. Yet for all the controversy, the guideline mostly drew on longstanding and arguably well-accepted ideas in the allocation of scarce healthcare resources-the 'fair innings' argument; the ethical equivalence of withholding and withdrawing medical interventions; and the use of quality-adjusted life years and cost-benefit analyses Numerous authors have also previously argued for similar principles in the ethical allocation of ventilators in a pandemic. 2 Many other ethical discussions highlighted by the early months of COVID-19 are likewise issues that have been overlooked for too long. Public health ethics has seen renewed relevance, including highly charged debates about the provision of PPE and whether healthcare workers have a 'duty to treat'. 3 The ethics of clinical research and the use of experimental treatments in the face of emergent diseases has also been re-energized, 4 after interest following the 2013-2016 Ebola epidemic waned.

As we move forward into the long 'dance' with COVID-19 ahead, we must instead seek to pre-empt and promote robust discussion of the ethical challenges awaiting us. Attempts to develop effective treatments and vaccines are underway but likely remain some ways off. Even so, significant disagreement has already arisen about how we should fairly distribute the limited supplies obtained from this scientific endeavour. 5 In the meantime, second waves have stunted attempts to re-open economies and healthcare systems, even in countries lauded for their strict initial public health response. Despite this, the escalating consequences for financial and mental health from repeated population-wide lockdowns raise difficult questions about ethical trade-offs against reducing the harm and spread of COVID-19.

One struggle emerging at the clinical coalface is preserving the vital relationship between patients and healthcare providers despite unprecedented change in medical systems and delivery of care. Hospitals have cancelled elective surgeries to conserve vital PPE supplies, beds and manpower. Access to intensive care level (ICU)-level care has been restricted. Face-to-face outpatient clinics have been abruptly shifted to consultation by phone or digital screen. And more pervasively, stringent infection prevention controls have drastically altered the patient experience and quality of care. Many inpatients face prolonged precautionary isolation without the reprieve of visits from friends and family, attended by anonymous caregivers in protective gear. Indeed, no stories have been more emotionally moving than that of families denied access to dying loved ones spending their last hours in isolation.

That these changes have largely been accepted by the public is testament to both the extraordinary fear surrounding COVID-19 and the renewed global respect for 'healthcare heroes'. But, we should not presume that this goodwill is endless or indefinite. In the United Kingdom, for instance, clumsy attempts to fill do-notresuscitate orders by mail with aged care residents have drawn community ire, 6 as have hasty guidelines suggesting blanket bans on cardiopulmonary resuscitation. 7 The burden of diseases other than COVID-19 has not changed, and we must find ways to continue to deliver necessary care. Unless we continue to act with compassion and transparency, particularly towards our most vulnerable patients and at the end of life, we risk jeopardizing the vital trust of the communities we serve.

Finally, as cases of COVID-19 continue to rise in developing countries, our early experiences must also serve as a stark reminder of the global healthcare inequities that still exist today. Those of us in developed nations have been scarred by our encounter with the spectre of contagious infections, the grim choices necessitated by resource scarcity and sudden socioeconomic fragility. Yet these are day-to-day realities in poorer countries, and in even disadvantaged subgroups within developed nations. Even as we struggle with COVID-19 in our own neighbourhoods, we must find ways to correct these global issues. Without concerted action from governments, healthcare workers and civil society worldwide, these vulnerable populations will both endure disproportionate suffering from COVID-19 and serve as potent reservoirs for ongoing spread.

If anything, the COVID-19 pandemic must remind us once again that medicine is both 'science' and 'art'. It is not breakthrough scientific discoveries that have been most consequential thus far, but rather arduous deliberations and action on emerging ethical issues. Even as the scientific community frantically works towards a vaccine, it remains critical that clinicians, ethicists and the community come together to grapple with the ethical quandaries we face in a transparent, fair and inclusive manner. If we do not maintain the trust of our patients and communities; guard our healthcare workers against moral distress and burnout; and begin to correct the gaping health disparities that currently exist, we cannot truly be rid of COVID-19. Most crucially, how we act now will not just determine the future course of the pandemic-it will shape the nature of the society that emerges on the other side. 

Clinical ethics recommend ations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the Italian perspective during the COVID-19 epidemic

Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions

What healthcare professionals owe us: why their duty to treat during a pandemic is contingent on personal protective equipment (PPE)

Treating COVID-19-off-label drug use, compassionate use, and randomized clinical trials during pandemics

The equitable distribution of COVID-19 therapeutics and vaccines

UK healthcare regulator brands resuscitation strategy unacceptable

Covid-19: doctors are told not to perform CPR on patients in cardiac arrest