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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 28-31

Ethical aspect of duty of care and resource allocation during COVID-19 pandemic: An Indian overview


1 Department of Forensic Medicine and Toxicology, Rampurhat Government Medical College and Hospital, Rampurhat, West Bengal, India
2 Department of Forensic and State Medicine, Medical College Kolkata, West Bengal, India

Date of Submission29-Nov-2020
Date of Acceptance20-Dec-2020
Date of Web Publication26-Jul-2021

Correspondence Address:
Asst Prof. Abhishek Das
Department of Forensic Medicine and Toxicology, Medical College Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jphpc.jphpc_20_20

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  Abstract 


Ethical practice is always considered to be a safe practice. Pandemic is one situation where the execution of ethical principles becomes a bit difficult as differences of opinion are to be taken into consideration. We have faced dilemmas previously during the AIDS outbreak or Avium Influenza pandemic. Similar ethical dilemmas if not more we are facing during the COVID-19 pandemic. Ethical concerns are mainly related to duty of care towards COVID patients, scarce resource allocation, telemedicine service, and COVID death cases. In this article, we will discuss ethical issues in relation to the duty of care and scarce resource allocation. We will also highlight guidelines to minimize ethical dilemmas and the role of the administration to make ethically correct policies as much as possible. This will not only help us to face the current pandemic but also will help to create a root map for making policies if any such pandemic hits the community in future.

Keywords: COVID-19, duty of care, ethical dilemma, pandemic, resource allocation


How to cite this article:
Biswas S, Das A. Ethical aspect of duty of care and resource allocation during COVID-19 pandemic: An Indian overview. J Public Health Prim Care 2021;2:28-31

How to cite this URL:
Biswas S, Das A. Ethical aspect of duty of care and resource allocation during COVID-19 pandemic: An Indian overview. J Public Health Prim Care [serial online] 2021 [cited 2021 Oct 16];2:28-31. Available from: http://www.jphpc.com/text.asp?2021/2/2/28/322305




  Introduction Top


After being announced as Pandemic on February 11, 2020, and Public Health Emergency of International Concern on last week of March 2020; COVID-19 is still threatening the entire civilization across the world.[1] Though ethical principles like patient autonomy, beneficence, nonmaleficence, and justice remain unaltered during any situation, its application in providing patient care and in adopting various policy-making strategies bring down skepticism, criticism, and differences of opinion. As a result, ethical dilemmas arise. We can't get rid of it completely and conclusively, but we can minimize these dilemmas by adopting ethical values as much as possible in formulating and implementing public health decisions. The ethical issue may arise in various sectors like: duty of care, resource allocation, telemedicine, death due to COVID-19 and health research. In this article, we will discuss such ethical issues in relation to the obligation of health care workers (HCW) to attend patients of highly contagious disease and the scientific use of scarce resources to maximize the benefit of society during a pandemic phase.


  Duty of Care Top


Duty to mankind can be a General Positive Duty and a Special Positive Duty. Caring a sick person on humanity ground is a general positive duty for every individual of the society whereas serving a patient in the hospital or serving a community during riot are special positive duties of HCWs and police as they are getting wages against these aids and also, they are risking their lives while doing so.[2] The question is how much risk can be ethically permissible? Is there any provision where an HCW can refuse to attend a patient of COVID-19 or a similar highly contagious disease?

During outbreak of AIDS, the American College of Physician Ethics Manual stated that refusal to provide care to any class of patient because of their disease status is unethical.[2] However, duration of quarantine after exposure, speed of transmission and chance of death is many times more in COVID-19 than all previous pandemics. Ethicists may argue that one HCW when enters into this field is duty-bound to attend any patient including highly contagious one as it is considered implied consent. Moreover, if HCWs get infected in a good number, the entire health-care system of that particular institution may get affected badly and collapse in turn.

Ethical dilemmas which may arise in this issue are:

  1. Specialists who are not concerned with the management of infectious disease may not agree to treat such patients as any mismanagement by them may result in medical negligence both at the individual and institutional level
  2. HCW may refuse to attend COVID-19 patients in different institutions if they are not provided with the protective gears properly which may increase the chance of infection among them and their family members
  3. Argument in favor of doctor's obligation to serve such patient is broad and not specific in COVID scenario
  4. Training may be offered to those who do not want to be involved because of a lack of knowledge in the clinical field but the real so training does not mean that all trainees will be equally effective in managing the situation
  5. Undoubtedly HCWs have ethical duty toward patients. Simultaneously they are also duty bound toward their near and dear ones. As duty of care towards patients will increase the chance of contamination for the family members of HCWs, balancing between these two duties will cause conflict of interest.


Ethical issues in relation to maintaining the confidentiality of patient:[3]

Ethically health care providers are not supposed to divulge patient profile with out their consent. However, breach of confidentiality is not very challenging in COVID-19 keeping in mind its contagious nature. Following measures can be taken while dealing with the confidentiality of patient of COVID-19:[3]

  1. Those who are involved in patient care service in an institution should be informed about the status of COVID positive patients to secure their safety
  2. On contact tracing, those who are found to be at high risk of exposure from positive patients should be aware of the patient profile
  3. Data tabulation in terms of exposure, disease, duration of disease, response to therapy etc., is very important for deciding future policy. Therefore, divulging this information to public health agencies is ethically acceptable.


Communication with patient relative

The entry of patient's relatives in the COVID ward is restricted due to the chance of contamination. Here also some ethical issues may arise as long-term abstinence from near and dear one may affect one psychologically. Therefore, if not allowed to meet the patient in person, family members should be communicated with the patient over video call and messaging system.[4] Simultaneously doctor should continue to meet the family members either in person or using teleconferencing service.

Recommendations on the ethical ground:

  1. Doctor may refuse to attend an asymptomatic or mild symptomatic patient at individual level particularly if the doctor is specialized in some subject which is not concerned with management of such infectious disease
  2. Very sick patient who needs immediate care should not be refused even at individual level from ethical, legal and medical point of view
  3. At institutional level patient should not be refused if proper protective measures are provided
  4. If protective measures are not provided, one HCW may refuse to attend a patient of such highly contagious disease particularly if he/she is suffering from some comorbid condition or at high risk due to age. The reason should be documented properly.


Institution should not refuse any such patient to avoid charge of composite or corporate negligence.


  Resource Allocation Top


During pandemic this is obvious that at some point of time demand of medical resources will exceed its supply. If such a situation is not planned well ahead in a scientific way, it can cause a disastrous. During planning, there must be criticism and differences of opinion which will create dilemma in various issues. This can't be avoided but can be minimized by applying ethical principles as much as possible while planning for scarce resource allocation during a pandemic. Ethical theories which can be applied to prioritize beneficiary in health care system are

  1. Deontological ethics: Here, the decision is taken based on the morality of the action but not its consequences. This the most familiar practice in day-to-day health-care service. Various codes of ethics get priority in this ethical theory[5]
  2. Consequentialism ethics: Here the decision is taken based on the consequences or outcome of the action. The initial action may deprioritize those who need the medical aid most at that point of time, but it saves maximum life and minimizes the suffering in the community level. This ethical theory is often preferred over Deontological ethics during pandemic, mass disaster, and other emergency situations.[5]


Ethical concerns related to resource allocation:

  1. Whatever may be the approach, every individual of the community will not get equal access to health-care service. Prioritizing one group of individuals mean some other group will be affected
  2. Question of feasibility about surveillance of outbreak and dissemination of outbreak information
  3. Question of restriction of elective surgeries and access to intensive care units (ICUs) which have been practiced in different medical institutions till now.[6]</sup



  Triage Top


During pandemic, demand of medical resources exceeds its availability. Therefore, it becomes impossible to provide medical care to all who need it. Scarce resources should be sorted and beneficiaries should be prioritized scientifically and ethically so that best outcome can be obtained in terms of saving human life. This process is known as triage. Triage is applied for finite and infinite resources like mechanical ventilators, ICU beds, vaccines, therapeutic and prophylactic drugs, Personal Protective Equipment (PPE) etc.

Criteria for triage policy:[7]

  1. It must be transparent. Whatever be the policy, should be informed to community
  2. Those who will be deprioritized should have a right to ask for revision if they can provide some additional evidence or argument
  3. It should be consistent. No one should have such perception that someone is being favored
  4. Whatever be the outcome, decision makers will be accountable for that. Team decision is always preferred over individual decision
  5. Standardized guideline should be followed for decision making.


Standard ethical guideline for mechanical ventilator triage:

  1. The number of lives saved in the community should get priority over individual patient care
  2. Patients who have a better chance to survive after short-term ventilator support should get priority over those who need longer support. The decision should be considered for every patient[5]
  3. Younger individuals should be prioritized over older one though this criterion is not applicable for COVID-19 as per the WHO as most high-risk patients are of extreme age group[6]
  4. Those who will be deprived from mechanical ventilator should be referred to another center after providing adequate palliative care. Palliative sedation to minimize suffering is not unethical
  5. Those who already on ventilators should not be withdrawn from support. Passive euthanasia can be approached if the next of kin gives consent
  6. Non-COVID patients should not be deprioritized for ventilator support over COVID patients if the indication for such support is present.[7],[8]


Following principles can be adopted for standardization of scarce resource allocation:

  1. First come first served basis irrespective of the severity of illness
  2. Those who need the care most. Here, severity of illness matters and very sick people will get priority
  3. Those who are at the most risk like priority to HCW for PPE and vaccine
  4. To maximize the benefit for society. Here individuals who have higher chance of survival will get priority
  5. Those who help others like HCW.


Single principle or a combination can be adopted depending upon the magnitude of scarcity and size of the population to be served.

Administrative recommendations:

  1. Institutions should form a triage team. The team will score the beneficiaries. Criteria for scoring may be age, life expectancy, and comorbidity
  2. To make HCW aware about triage strategies
  3. To organize training for health-care providers
  4. To arrange for quarantine and isolation space for HCW
  5. To prepare an SOP for quarantine and responsibility of HCW.[9]



  Conclusion Top


Basic principles of bioethics never change. Patient autonomy, beneficence, nonmaleficence, justice towards patients will have to respected in every situation. A pandemic creates dilemma during the application of these principles of ethics. The dilemmas, ethical approaches, administrative roles which have been discussed here are not limited to the COVID-19 pandemic only. These approaches will help to face any pandemic if hit the community in future. The role of strategy makers will get tougher when the vaccine of COVID-19 will come into action. Present discussion will help to minimize the ethical dilemmas by helping rational distribution of vaccine, therapeutic drug, and other medical equipment across the community.

Key points

  • Ethical dilemma arises in relation to duty of care during a pandemic
  • Doctors specialized in different field are not ethically duty bound to treat asymptomatic or less symptomatic patients of COVID pandemic as this is considered a special positive duty
  • At institutions, HCWs must be provided with PPEs to claim their services
  • Critical patients must be provided emergency care at all levels of health care
  • Transparency, inclusiveness, consistency, accountability and standardization must be kept in mind while allocating scarce resources
  • Consequentialism to be preferred over Deontological ethics during a triage.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eurosurveillance Editorial Team. Note from the editors: World Health Organisation declares novel coronavirus (2019-nCoV) sixth public health emergency of International concern. Euro Surveill. 2020;25(5):pII=200131e. Available from: https://doi.org/10.2807/1560-7917.ES.2020.25.5.200131e.  Back to cited text no. 1
    
2.
Malm H, May T, Francis LP, Omer SB, Salmon DA, Hood R. Ethics, Pandemics, and the Duty to Treat. Am J Bioethics. 2008;8:4-19. Available from: https://doi.org/10.1080/15265160802317974  Back to cited text no. 2
    
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Kramer JB, Brown DE, Kopar PK. Ethics in the time of coronavirus: Recommendations in the COVID-19 pandemic. J Am Coll Surg 2020;230:1114-8.  Back to cited text no. 3
    
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Robert R, Barnes NK, Boyer A, Lauren A, Azoulay E, Reignier J. Ethical dilemmas due to the Covid-19 Pandemic.Ann. Intensive Care (2020) 10:84. https://doi.org/10.1186/s13613-020-00702-7.  Back to cited text no. 4
    
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Ethical Issues in Pandemic Planning and Response. Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary. In: Institute of Medicine (US) Forum on Microbial Available from Threats. 1. Washington (DC): National Academies Press (US); 2007. Available from: https://www.ncbi.nlm.nih.gov/books/NBK54169/. [Last accessed on 21 Feb 2021].  Back to cited text no. 5
    
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Christopher C, Danielle KO. Medical ethics in the era of COVID-19: mow and the future. J Asian Pac Soc Respirol 2020;25:1033-4.  Back to cited text no. 6
    
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Ethics and COVID-19: resource Allocation and Priority-setting. World Health Organization. Available from: https://www.who.int/ethics/publications/ethics-covid-19-resource-allocation.pdf?ua=1. [Last accessed on 21 Feb 2021].  Back to cited text no. 7
    
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Kompanje EJ. Ethics in the time of corona. Eur Respir Soc 2020. Available from: https://www.ersnet.org/covid-19-blog/ethics-in-the-time-of-corona. [Last accessed on 21 Feb 2021].  Back to cited text no. 8
    
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Menon V, Kumar Padhy S. Ethical dilemmas faced by health careworkers during COVID-19 pandemic: Issues, implications andsuggestions. Asian J Psychiatr. 2020;51:102116. Available from: https://doi.org/10.1016/j.ajp.2020.102116  Back to cited text no. 9
    




 

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  In this article
Abstract
Introduction
Duty of Care
Resource Allocation
Triage
Conclusion
References

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