key: cord-0722935-gpb32l1h
authors: Maeckelberghe, Els; Schröder-Bäck, Peter
title: Covid-19: a test for our humanity
date: 2020-10-05
journal: Eur J Public Health
DOI: 10.1093/eurpub/ckaa180
sha: 8386b51fbc19c762ee0a335425b3a6d584a6ea2a
doc_id: 722935
cord_uid: gpb32l1h

nan

T he Covid-19 pandemic is not a war zone of combat and competing interests, but a 'test of our humanity', as the German president Frank-Walter Steinmeier said in his television speech on 11 April 2020. This is as time of carefully addressing ethical principles that both guide and challenge acts and policies, to investigate how these principles contribute to upholding humanity, and how they inform us about unsolvable dilemmas. These are times we have to act even though we might make the wrong decisions. Part of testing our humanity is preparing ourselves to face the wrong decisions that were made in times of uncertainty.

There seems to be confusion about what contributes to humanity. All over the world, groups claim that their humanity is under pressure because their right to freedom is restricted. But, is it the loss of some liberties that threatens humanity, or is it a sign of humanity that some take burdens to protect others? For some, herd immunity was the magic word to reach a most humane strategy: the idea that if only enough people fell ill to Covid-19 and recovered, based on their antibodies the disease cannot spread anymore. Yet, to reach herd immunity through a population-wide experienced disease, rather than vaccination, also means, to at least accept that some people will not fully recover from Covid-19 or even die.

Others argued that to prepare our health care facilities is a sign of humanity. In the heat of the crisis, images of quickly erected hospitals captured an undercurrent of implicit bias towards an idea that 'right to healthcare' can be narrowed to 'a right to ICU care'. Questions about access to scarce goods like protective clothing got a different understanding when heart-breaking appeals to our humanity from staff of care-and nursing homes drew attention to questions about who's protecting whom (e.g. supply of protective clothing) and to what end (health vs. family values)?

We contend that we need a moral language that offers conceptual clarity and does not shy away from normative guidance in this 'test of humanity'. It is necessary to identify ethical principles and rules that inform what claims are justified and consequently need to be acted upon. We propose the use of seven ethical principles that, in no particular hierarchical order, shed light on the problems at hand. These principles structure the questions we face and offer a framework of what at least should be addressed when trying to reach decisions defensible and transparent decisions. The principles that play a role in analysing the ethics of Covid-19 are population health maximization, justice, autonomy, harm avoidance ('harm principle'), public trust, solidarity and reciprocity and protection of the vulnerable. These principles, based on the six principles in Schröder-Bäck et al. 2020. 1 with the addition of the vulnerability principle are briefly explained in table 1.

Covid-19 has affected everybody's life but not in equal ways. In many European countries residents in long-term care facilities (LTCF) were affected in various ways: failed reporting, limited testing, shortage of protective measures, infectious staff, lack of training and lock down for visitors. 2 The principle of population health maximization demands monitoring systems that include the entire population, i.e., including residents in LTCF. Justice requires non-discrimination: where you reside should not matter, and age is not a valid argument as such. The vulnerability principle asks for specific identification of who is vulnerable to what 3 : not all elderly people are equally vulnerable (high socioeconomic-status still offers good protection) and vulnerability can be enhanced by the decisions other people make. Consequently, responsibilities need to be specified, e.g., 'outbreak management teams' have to give dedicated specialists the power to act upon the specific identified vulnerabilities. Having these dedicated specialists-with a Viewpoints 853 keen eye for the patient and public engagement 4 -contribute to trustworthy policies. Once the arguments resulting from these principles are arranged, the questions resulting from the principle of solidarity and reciprocity can be addressed: how much burden can be expected from different groups and who ought to be given some leeway? Finally, given the analysis based on the previous principles, the public needs to be informed to enable their autonomous decision-making about, e.g., supporting or protesting the isolation of people in LTCF.

Finally, we want to call upon the public health community not to shy away from openly discussing the moral distress. 5 The Covid-19 pandemic causes. We need to collect the stories about the situations where members of the public health community were hindered in doing what was the ethically appropriate action due to circumstances beyond their control, for example, institutionalized impediments. Sharing these stories is necessary first of all to avoid discouragement on both an individual and organizational level. Secondly, it creates insight into what the public health community deems as 'ethically appropriate actions'. Thirdly, these situations of moral distress are a treasure trove for an evaluation of where and when systems 'test our humanity'.

I n attempts to reverse the spread and prepare the curative care sector, and under huge uncertainties, many governments have responded to the COVID-19 outbreak with either voluntary or mandatory physical isolation and distancing measures. These have put state-society relationships in any political system under great pressure. In addition, many countries have shifted public decision-making authority from the democratic institutions to temporarily concentrated executive arrangements. With specialist expertise involvement, these arrangements enabled quick and invasive regulatory response. 1 To the extent evidence is available, such technocratic crisis administration offers policy rationality. Yet, it also tends to postpone or disregard public value assessments. It thereby increases a perceived contradiction between 'health' and 'the economy' while in fact the two are mutually reinforcing values. As a result, such shifts in decision-making authorities have consequences for public trust. News about unintended socioeconomic consequences affects the 'output legitimacy' of the COVID-19 policies and regulations. 2 Moreover, minority needs and impacts are easily overlooked as democratic policy deliberation (a policy's 'input legitimacy') is temporarily postponed or even shut down altogether. For instance, in an open letter 'A call to defend democracy', published 25th of June in international and national news media, 500 political and civil leaders, Nobel laureates and pro-democracy institutions from around the world observe that, besides the unsurprising repression of critics by authoritarian regimes, 'even some democratically elected governments 

Covid-19 morbidity and mortality should be as low as possible. Epidemiological guidance on how to minimize overall morbidity and mortality shall inform decision-making. Justice

Justice as fairness in the distribution of resources and opportunities reducing health inequalities, secures that everyone receives his or her due, according to health needs, and that no one is discriminated against due to personal characteristics such as gender, socio-economic status or age. Autonomy

People have the right to make their own informed decisions, and are free to act according to these informed norms, wishes and beliefs. Harm Principle

Self-determination is acceptable as long as one does not harm others.

Public institutions informing about, regulating and practicing health policies should be trustworthy, and decide and act according to shared moral and democratic values that are made transparent.

Distribution of benefits and burdens should acknowledge our socio-economic interdependence at different levels (solidarity). Priority should be given to those who face a disproportionate burden in protecting the public good (reciprocity). Vulnerability Principle

To protect the interests of (groups of) people who are especially vulnerable or in some way dependent on the choices and actions of 'others', special responsibilities must be fulfilled by these 'others'.

Vaccination Policy: Ethical perspectives on a future vaccination program against COVID-19 in Germany 2020, Internet-Portal Public-Health-Covid19.de-Netzwerk

European Centre for Disease Prevention and Control. Surveillance of COVID-19 in Long-Term Care Facilities in the EU/EEA

Identifying and evaluating layers of vulnerability -a way forward

Patient and public involvement and engagement: mind the gap

Nursing Practice: The Ethical Issues