key: cord-0846016-uckal0ny authors: Minielly, Nicole; Feehan, Chris; Wong, Alissa; Illes, Judy title: Neuroethical and Societal Challenges of 21st Century Epidemics date: 2020-10-22 journal: Trends Neurosci DOI: 10.1016/j.tins.2020.10.006 sha: 1d2affb512010b590d3fad9fc4cec9ead0602dce doc_id: 846016 cord_uid: uckal0ny Neurologic and neuropsychiatric manifestations of COVID-19 are affecting a growing number of people worldwide. We provide a brief overview of these manifestations, contrasting them with those of other 21st century viral epidemics, as well as mitigation strategies, and societal and moral considerations related to the pandemic. We highlight unique concerns relating to COVID-19 given the scale of infection, mental health challenges faced by healthcare providers and the general public, and the unprecedented social consequences, including benefits and possible harms associated with continuous connectedness using modern digital communication. neuropsychiatric ones [2] that have been given less attention in the academic literature and public sphere, and the intersections between the neurologic effects and the neuroethics implications of the pandemic have been scarcely considered. Here we reflect on lessons learned from this pandemic and other 21 st century viral epidemics, and suggest how these insights may be used to better plan for future ones. Alongside the farreaching practical challenges and critical healthcare decisions that all pandemics have raised involving, for example, access to health services, information dissemination, and support systems, are trade-offs and, at the heart of them, ethical and moral issues. Many involve balancing mental well-being on the one hand, with individual and collective responsibility on the other. This trade-off is exemplified by the practice of self-isolation that helps to reduce spread of infection, but comes at a personal cost. Unlike in most previous epidemics, some of the challenges associated with self-isolation are mitigated by the widespread use of modern digital communications technologies. No doubt, these new capabilities bring with them the enormous benefit of keeping people connected, but the double-edged sword lies in the unknown impacts of exposures to unprecedented amounts of screen time, not only on the developing brain of children, but on users of all ages along the lifespan. To understand the neurological correlates of 21 st century pandemics, we retrieved English language articles using the term neuro from the Center for Disease Control COVID-19 database (May 11, 2020). We reviewed 74 articles that met our criteria from a total of 427. When comparing 21 st century pandemics and epidemics, we find both common and distinct neurological phenomena (Table 1) . Common to many of them are headaches, and changes in mental state and level of consciousness. Less prevalent but shared across some of the epidemics are various types of cerebrovascular disease, seizures, and encephalitis. Some neurological conditions are specific to one or two of the epidemics/pandemics or have been reported in case studies but their prevalence remains unclear. We also identified commonalities in public health responses and mitigation strategies to these various epidemics/pandemics including quarantine, isolation of vulnerable populations, and vaccination programs when available [3] [4] [5] . Notably, face covering was an adjunct, but not a An effective collective response to COVID-19 relies in large part on a cadre of experts who can make difficult public health decisions based on the best available evidence, including the experience of past pandemics. The operationalization of these decisions, however, relies on the concerted efforts of both the general public and frontline health care workers. This creates an ethical dilemma where public health decisions are largely utilitarian, in that they are made for the greater good, but they may have disproportionately negative effects on the very people who must implement them. In this regard, posttraumatic stress has been well documented after past epidemics [2,6,7]; COVID-19, however, may also bring to bear not only post, but antecedent neuropsychiatric effects. COVID-19 struck the world in the modern age of technology that, for better and for worse, has created a flood of information -an infodemic [10] -and, with it, extensive internet-enabled engagement. The confluence of these forces has enabled people to remain socially connected while physically apart, created both opportunities for intervention as they pertain to the brain and mental health, and raised some new ethical dilemmas as well. No doubt, evidence-based guidance is essential for good public policy, and access to it is largely online today. There is no shortage of resources to pull from for information, and there is a Prior to the pandemic, the American Academy of Pediatrics, among other professional pediatric organizations worldwide, issued guidance for judicious screen time by children in particular. Digital media was discouraged for toddlers younger than 24 months other than for video chatting, and no more than one hour per day of high-quality programming was recommended for preschool children. Today, when screen time is a necessity rather than an option, these evidence-based guidelines have been set into a necessary rebalance. In fact, the American Academy of Child and Adolescent Psychiatry has emphasized the importance of the use of media to strengthen connections across homes and schools, alongside offline time and highquality resources that are educational and age-appropriate. The accelerated transition to online communication and work has profoundly changed the delivery of healthcare services, now relying on telemedicine not only to reach rural and remote communities as in the past, but for routine care in urban communities alike. In our ethical evaluation of this transition, we place issues of access in the foreground. Both for those who are historically underserved and those who are currently required or encouraged to limit physical contact outside the home, tele-care is clearly better than no care. Telemedicine has its challenges though: the physical examination is limited to words without touch; and, evaluations of behavioral health and family dynamics are limited by the availability and capabilities that technology affords to participants who seek to engage [11, 12] . Still, for conditions involving mental health, remote assessment has been shown to be effective; for movement disorders J o u r n a l P r e -p r o o f Journal Pre-proof requiring detailed neurological examination less so. Best practices to ensure not only the effectiveness of telemedicine, but also social justice around its use have yet to be developed. Online communication for professional and social activity has also been enabled by various online platforms such as Zoom, Microsoft Teams, and Facetime. While mitigating the adverse effects of social isolation and fractured togetherness with co-workers, much remains to be understood about the impact of continuous screen time for these purposes, for example on cognitive and executive functions such as attention, decision-making, and speed of information processing. Digital media has immense value because of its ability to connect people while allowing physical separation. Managing the potential harms of online excess, however, is a key challenge. COVID-19 continues to challenge society economically, socially and ethically, including through still unfolding effects on the brain and mental health. The pandemic has brought to the foreground debates on timely access and rights to health services. As in many of the 21 st century viral epidemics, health disparities have been magnified, particularly in relation to marginalized, rural and remote communities where comorbidities are prevalent [13, 14] . A spectrum of mental health challenges manifest during the course of a viral epidemic; front line workers are not alone in feeling the impact, but the anticipation they face for the care they must provide is a special case for concern. Efforts to establish empirical and authoritative guidance for screen time to ensure safe use, especially among youth, have been trumped.  How can the ethics, public health, social, and legal research of neuroethicists be situated to most closely align with and contribute impactfully to the neuroscience of COVID-19?  What will be the long-term impact of anticipatory stress on the mental well-being of healthcare workers at the frontlines of the COVID-19 pandemic?  What would be an adequate balance between the need for remote connectivity and managing screen time to preserve and promote brain health across different age groups during the pandemic? 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