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Abstract

WHO states five ethical principles for the care of patients with COVID-19: Equal moral respect, duty of care, non-abandonment, protection of the community, and confidentiality. Healthcare professionals might have to make difficult decisions such as selecting patients and withholding or withdrawing mechanical ventilation of critically ill patients. In such difficult situations, a well-prepared action plan which considers ethical principles and prioritizes both public health and the safety of healthcare professionals, can help them. In this case, the development of an effective pandemic action plan, together with a triage plan based on emergency and disaster medicine is necessary. The only parameter of selection in this plan must be the correct application of triage, which respects every human life and depends on the criteria of clinical suitability. In this context, the fundamental ethical principles and human rights must be considered when allocating resources and prioritizing patients. Additionally, all protective measures for healthcare professionals must be taken, including all necessary equipment being adequately provided. If healthcare professionals become infected or face a life-threatening risk, then their obligations will be limited. Therefore, it is necessary to realize these limitations which may arise while providing appropriate health services.
Acta Medica 2021; Early Online: 1-10
1
© 2021 Acta Medica. All rights reserved.
Sevim Coşkun1, [MD, PhD candidate]
ORCID: 0000-0003-4509-404X
Nüket Örnek Büken1, [MD, PhD]
ORCID: 0000-0001-9166-6569
1History of Medicine and Medical Ethics, Hacettepe
University Faculty of Medicine
Corresponding Author: Sevim Coşkun
History of Medicine and Medical Ethics, Hacettepe
University Faculty of Medicine, Ankara, Turkey.
Phone: +90 312 305 43 61
E-mail: sevimcoskun@hacettepe.edu.tr
https://doi.org/10.32552/2021.ActaMedica.505
Received: 10 September 2020, Accepted: 16 April 2021,
Published online: 7 June 2021
acta medica REVIEW
ABSTRACT
WHO states five ethical principles for the care of patients with COVID-19:
Equal moral respect, duty of care, non-abandonment, protection of the
community, and confidentiality. Healthcare professionals might have
to make diicult decisions such as selecting patients and withholding
or withdrawing mechanical ventilation of critically ill patients. In such
diicult situations, a well-prepared action plan which considers ethical
principles and prioritizes both public health and the safety of healthcare
professionals, can help them. In this case, the development of an eective
pandemic action plan, together with a triage plan based on emergency
and disaster medicine is necessary. The only parameter of selection
in this plan must be the correct application of triage, which respects
every human life and depends on the criteria of clinical suitability. In
this context, the fundamental ethical principles and human rights must
be considered when allocating resources and prioritizing patients.
Additionally, all protective measures for healthcare professionals must
be taken, including all necessary equipment being adequately provided.
If healthcare professionals become infected or face a life-threatening
risk, then their obligations will be limited. Therefore, it is necessary to
realize these limitations which may arise while providing appropriate
health services.
Keywords: COVID-19 pandemic, medical ethics, human rights, the
allocation of resources, vulnerable populations
Medical Ethics during the COVID-19 Pandemic
INTRODUCTION
Novel Coronavirus Disease (COVID-19) was first
detected in Wuhan, China, in December 2019. It
is caused by a newly emergent coronavirus which
is called SARS-CoV-2 [1]. COVID-19 has spread
rapidly around the world and it was declared as a
pandemic by the World Health Organization (WHO)
on March 11, 2020 [2]. As the pandemic continues,
many ethical issues have arisen. These ethical issues
mainly revolve around how patients with COVID-19
who need critical care can access necessary health
services and how to allocate limited resources such
as intensive care unit (ICU) beds, ventilators, and
medications when there is not enough to treat
everyone. Recently, ethical discussions on the
distribution of COVID-19 vaccines have become
increasingly important since many countries have
started their own vaccination programs.
This article will start by covering the ethical
principles relating to the care of patients with
COVID-19, later provide some examples of the
ethical challenges faced during the COVID-19
pandemic, and finish by discussing these challenges
in context of the said ethical principles.
Ethical Principles for the Care of Patients with
COVID-19
WHO published an updated clinical management
(living) guidance of COVID-19 on 25 January 2021.
According to this guidance, WHO aims to slow and
stop transmission of COVID-19, provide optimized
care for all COVID-19 patients, and minimize the
impact of the COVID-19 pandemic on health
systems, social services and economic activities.
Medical Ethics and COVID-19
2© 2021 Acta Medica. All rights reserved.
Thus, WHO intended to optimize the clinical care
of patients with suspected or confirmed COVID-19,
and ensure they have the best possible chance of
survival. This guidance also includes the ethical
principles that are important for the optimal care
of patients with COVID-19. As reported by WHO,
important ethical considerations in the context of
COVID-19 are equal moral respect, duty of care, non-
abandonment, protection of the community, and
confidentiality [3].
1. Equal Moral Respect
Equal moral respect means treating every human
being equally, regardless of discriminatory features
like age, sex, disability, religion, ethnicity, or
political ailiation, so only medical need should
be determinative in making treatment and care
decisions. Patients who have similar health
problems must be given equal treatment and care.
Patients and their caregivers also should be in the
decision-making process and understand options
and limitations in treatment [3].
The right to health, along with the ethical principles
surrounding it, is a human right. Article 14 of the
UNESCO Universal Declaration on Bioethics and
Human Rights says [4, 5]: “the highest attainable
standard of health is one of the fundamental
rights of every human being without distinction
of race, religion, political belief, economic or social
condition. Thus, each person should be able to
access quality and the highest available healthcare
and essential medication.
1.1. Caregiving for Vulnerable Populations
Vulnerable populations are prone to easily being
abused, aected, and hurt. Vulnerability is related
to discrimination, age (children and elderly), gender
(girls and women), gender identity and sexual
orientation (LGBTI), illness, loss of functionality
or autonomy, disability, poverty, imprisonment,
ethnicity, undocumented migration, and the status
of refugees and stateless persons. Vulnerable
persons become even more vulnerable in a
pandemic [4, 6]. UNESCO declares that protecting
the vulnerable from any form of stigmatization
and discrimination, which can be both verbal
and physical, is our collective responsibility.
Measures like isolation and quarantine also aect
the vulnerable disproportionately [4]. Especially
the elderly and the disabled who need intensive
care due to COVID-19 may become even more
vulnerable. Article 8 of the UNESCO Universal
Declaration on Bioethics and Human Rights calls
for “respect for human vulnerability and personal
integrity”, saying that human vulnerability should
be considered while applying and developing
scientific knowledge, medical practice and
associated technologies [5]. This Article gives us
fundamental principles that must be respected:
human dignity, human rights, and freedoms. In this
context, the vulnerable must be protected with
regard to their personal integrity, respecting the
principles of autonomy, dignity, utility, equality,
and justice [5, 6].
The COVID-19 pandemic is aecting the elderly
and the disabled in particular, and increasing their
vulnerabilities. This section will therefore cover the
vulnerabilities thay face during the pandemic.
1.2. Caregiving for the Elderly
Old age is a risk factor for increased mortality in
those aected by COVID-19. Since the elderly
are often aected by other risk factors such
as hypertension, chronic lung disease, and
cerebrovascular disease; they are potentially at the
highest risk for fatality. They are thus one of the
most vulnerable populations in the context of the
pandemic [1, 3]. It is important to realize that the
elderly have the same right as others to receive
high-quality healthcare, including intensive care,
as stated in the principle of equal moral respect.
Therefore, they should benefit from health services
without any discrimination [7].
WHO recommends that the elderly should be
screened for COVID-19 at the first point of access
to the healthcare system. If they are suspected to
have COVID-19, this should be recognized quickly
and treated appropriately, according to established
COVID-19 care pathways. This approach should
be in all places where the elderly might seek care,
including facility-based emergency units, primary
care, prehospital care settings, and long-term care
facilities (LTCFs). For the elderly with suspected
or confirmed COVID-19, person-centered
assessment should be provided, including not only
conventional history taking, but also a thorough
understanding of the person’s life, values, priorities,
and preferences [1]. Healthcare professionals
should identify if there is an advance care plan for
older patients with COVID-19 like their desires for
intensive care support, also respect their priorities
Coşkun and Örnek BükenActa Medica 2021; Early Online: 1-10
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© 2021 Acta Medica. All rights reserved.
and preferences. Likewise, the care plan should be
parallel with the expressed wishes of patients, and
healthcare professionals should provide the best
care regardless of patients’ treatment choices [3].
Physiological changes with age lead to declines in
the intrinsic capacity such as malnutrition, cognitive
decline, and depressive symptoms. Those conditions
might interact at several levels and require an
integrated approach to the screening, assessment,
and management of the elderly. Hearing and vision
impairments are more common among older adults
and may cause a communication barrier, especially
when masks prevent lip reading and decrease vocal
clarity. Healthcare professionals should consider
cognitive decline, too, when communicating with
older patients. Healthcare professionals should also
identify those impairments as early as possible for
adjusting their communication in older patients’
care [3].
There should be multidisciplinary collaboration
among physicians, nurses, pharmacists,
physiotherapists, psychologists, social workers, and
other healthcare professionals to decide functional
decline and multi-morbidity in older patients.
Older patients might be with atypical symptoms
of COVID-19, including delirium. Healthcare
professionals should consider this during the
screening process. Healthcare professionals must
be sure that chronic infections are diagnosed
and treated appropriately in this group. Other
infections such as tuberculosis may look like, or co-
exist with COVID-19. If unrecognized, these chronic
infections may cause increased mortality. Older
patients with COVID-19, including those admitted
to the ICU, treated with protracted oxygen therapy
and bed rest, are more likely to experience
functional decline and require coordinated
rehabilitation care after acute hospitalization. The
elderly are also at higher risk of polypharmacy
because of newly prescribed medications and a
lack of coordination. WHO recommends a review of
medication prescriptions to reduce polypharmacy
for the elderly with COVID-19, to prevent them
from medicine interactions and adverse eects [3].
1.3. Caregiving for the Disabled
The European Disability Forum (EDF) published
an updated statement on 24 March 2020, entitled
“Ethical Medical Guidelines in COVID-19 – Disability
Inclusive Response. In this statement, EDF
declared that some reports about the medical
guidelines for COVID-19 in some countries were
extremely worrying because those reports stated
that mentioned guidelines are discriminatory
against people with disabilities. For this reason,
EDF demands non-discriminatory ethical medical
guidelines, and explains how they should be
prepared. In this context, EDF states that if
healthcare professionals cannot provide the same
level of care to everyone because of insuicient
funds and equipment in some countries, then
medical guidelines must follow international
law and ethics guidelines for caring in disasters
and emergencies. Ethical medical guidelines in
COVID-19 must thus be non-discriminatory, and
they certainly must not discriminate against people
with disabilities [8]. These guidelines also must be
compatible with the UN Convention on the Rights
of Persons with Disabilities. Particularly Article 11 of
the UN Convention which states that all necessary
measures to ensure the protection and safety
of persons with disabilities in situations of risk,
including situations of armed conict, humanitarian
emergencies and the occurrence of natural
disasters” should be taken under international
law, including international humanitarian law and
international human rights law [8, 9].
2. The Duty of Care
Under the duty of care principle, it is an ethical
and legal responsibility to give each patient
the best possible care and treatment under any
given circumstances [3]. There exist high risks for
everyone in a pandemic, and UNESCO underlines
that our right to health can be ensured only by our
duty to health both on individual and collective
levels [4].
Even if resources have to be allocated during the
pandemic, healthcare professionals have a duty
of care to ensure the well-being of patients using
the resources available. Healthcare professionals
also have a right to care, so appropriate Personal
Protective Equipment (PPE) and medical equipment
must be provided for their safety and well-being
[3, 10]. Healthcare professionals will then be able
to support clinical services as long as possible.
WHO recommends that healthcare professionals
be able to access both appropriate and adequate
equipment, and training in caregiving, including
IPC (Infection Prevention and Control). Healthcare
professionals are at risk for the same types of
Medical Ethics and COVID-19
4© 2021 Acta Medica. All rights reserved.
distress as patients, so they should also have access
to psychological, social, and spiritual care together
with respite and bereavement support when they
need it [3].
2.1. Allocating Limited Healthcare Resources
During the COVID-19 Pandemic
Pandemics make visible the strengths and
weaknesses of healthcare systems, they also make
visible the obstacles and inequities in access to
healthcare in dierent countries. According to
UNESCO, the allocation of resources in health
is central to many problems. Political choices at
macro-allocation levels have unavoidable results
on the micro-allocation of resources in health, and
they become even more challenging in a pandemic
while the demand for access to treatment is
increasing exponentially and rapidly. The eects
of choices can easily be seen at patient triage.
When there are limited resources, clinical need
and eective treatment should be the primary
consideration in patient selection. Procedures
should be transparent and they should respect
human dignity. Both macro and micro allocations
of healthcare resources are ethically justified if
only they are based on the principle of equity,
beneficence, and justice [4].
WHO recommends that health systems prepare
plans at local, regional, national, and global levels
to be ready to increase clinical care capacity in order
to provide appropriate care and maintain essential
health services for all COVID-19 patients. Each
health institution should also prepare a plan with
a clear objective for how to cover the allocation
or access to critical medical interventions such as
oxygen, intensive care beds, and ventilators. In
this context, the objective might be to provide the
best possible use of limited resources based upon
chosen medical criteria. Such a plan should ensure
a fair system of decision-making to allocating
resources in place, too. Allocation decisions
should then be made according to the plan and
regularly reviewed. If necessary, there should be
a reallocation of resources where the previous
allocation was not proving beneficial. The chosen
method for a fair process should use the following
procedural principles: inclusiveness, transparency,
accountability, and consistency. The main focus
should be on the most aected populations for the
necessary information. People should easily access
the allocation mechanism and understand it at an
elementary school level in all major languages in
the area. The allocation mechanism should apply
allocation principles consistently, and also be
available to review the approved triage protocol in
light of novel and updated clinical information [3].
2.2. Triage During the COVID-19 Pandemic
Triage criteria to apply should be valid for all patients
with similar levels of need without considering their
COVID-19 status, and also should balance medical
utility and equity and ease of implementation [3].
Ethical medical guidelines in COVID-19 should
follow the World Medical Association Statement
on Medical Ethics in the Event of Disasters for
the best practice [8]. According to this statement
[10]: “in selecting the patients who may be saved,
the physician should consider only their medical
status and predicted response to the treatment,
and should exclude any other consideration based
on non-medical criteria. Likewise, EDF mentions a
specific guideline for COVID-19, which is prepared
by the Bioethics Committee of the San Marino
Republic. This guideline underlines that the
fundamental ethical principles must be taken into
account when allocating resources and prioritizing
patients. The only parameter of selection must be
the correct application of triage, which respects
every human life and depends on the criteria of
clinical suitability. Any other selection criteria
would be ranking lives by evaluating them as being
more or less worth living. This kind of selection
would constitute a violation of human rights, so it
is ethically unacceptable [11, 12].
World Medical Association (WMA) states that
physicians and other healthcare professionals
are confronted with exceptional circumstances
requiring the continuous need for professionals
and the ethical standard of care in disasters. This
is necessary for providing treatment to disaster
survivors conforms to basic ethical principles
without being inuenced by other motivations.
Insuicient or disrupted medical resources and
a large number of patients in a short time bring
specific ethical challenges. At the same time, the
ethical principles that apply to physicians in such
situations should also apply to other healthcare
professionals [10].
WMA recommends a system of triage that might be
necessary to specify treatment priorities. Although
triage usually provides only symptom control
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such as analgesia to some of the patients, those
systems are ethical when they adhere to normative
standards. The fundamental aspect of triage is
demonstrating care and compassion despite the
need to allocate limited resources. Authorized and
experienced physicians or physician teams that
are assisted by competent sta should perform
the triage. Since cases may change category, it is
necessary to regularly assess the situation during
triage [10].
It is ethical for physicians not to persist treating
patients “beyond emergency care” at all costs since
that would be wasting scarce resources needed
elsewhere. The decision to not treat patients due
to the peculiar priorities arising from the disaster
situation cannot be considered as an ethical or
medical failure when it comes to the assistance of
a person in mortal danger. It is justified to do so,
in order to save a maximum number of lives, but
physicians must show compassion and respect for
the dignity of such patients. For example, physicians
can separate such a patient from others and give
appropriate pain relief and sedatives, and also, if
possible, ask somebody to stay with the patient
and not to leave them alone. After all, physicians
must act in consideration of the needs of patients
and the available resources. They should give the
most appropriate treatment with the patient’s
consent under the given conditions. Decisions
about whom to give priority to in treatment, should
be aimed at saving the maximum number of lives
and decreasing morbidity to a minimum [10].
3. Non-abandonment
The principle of non-abandonment requires that
nobody who needs medical care should ever be
neglected or abandoned. Care should also contain
families and friends of the patients, and options
should be explored for maintaining communication
with them. All patients with respiratory failure from
whom ventilatory support will be withheld or
withdrawn should be able to access palliative care.
In this respect, palliative care aims to improve the
quality of life of patients and their families facing
the problems associated with a life-threatening
illness like COVID-19. It means prevention and relief
of suering by early identification, assessment, and
treatment of physical and psychosocial stressors.
Palliative care includes but is not limited to end-
of-life care and should be with curative treatment.
WHO recommends the integration of palliative care
and symptom relief into responses to humanitarian
emergencies and crises. Hence, necessary palliative
care that includes the relief of dyspnea and other
symptoms should be given to patients with
COVID-19, too, during the pandemic. Palliative care
can be provided in any setting and does not require
a separate zone in hospitals. Patients should be
able to access palliative care at each institution that
provides care for people with COVID-19, and eorts
should be made to make intervention at home
accessible. Furthermore, healthcare professionals
should identify if there is an advance care plan for
patients with COVID-19 and respect the priorities
and preferences of them [3].
In extraordinary conditions like the COVID-19
pandemic, healthcare professionals may have
to make very diicult decisions in the frame
of bioethics, especially for end-of-life issues.
Nevertheless, they should always respect human
rights and dignity and adhere to the UNESCO
Universal Declaration on Bioethics and Human
Rights while making any bioethical evaluation [5,
12].
4. Protection of the Community
The protection of the community means there
should be an appropriate Infection Prevention and
Control (IPC) system that is enforced and respected.
This system would protect patients, healthcare
professionals, and the whole community. During
a pandemic, the main focus should be on both
the quality of clinical care for patients and the
improvement of public health [3]. In Statement
on Covid-19: Ethical Considerations from a Global
Perspective, UNESCO states that this challenging
COVID-19 pandemic necessitates a global
bioethics reection and response. In this respect, a
bioethics perspective with the ethics of science and
technology that is rooted in human rights should
play a critical role in this pandemic [4].
The UNESCO International Bioethics Committee
(IBC) and the UNESCO World Commission on the
Ethics of Scientific Knowledge and Technology
(COMEST) have declared that we need to
concentrate on our common need and shared
responsibility to overcome this dramatic situation.
The role of bioethics and ethics committees at both
national and international levels is to sustain a
constructive dialogue with the belief that political
decisions need to be both scientifically grounded
and ethically guided in such emergencies [4].
Medical Ethics and COVID-19
6© 2021 Acta Medica. All rights reserved.
The IBC and COMEST have highlighted that it is
essential to institutionalize a political strategy that
prioritizes the health and safety of individuals and
the community. This strategy should provide an
interdisciplinary open dialogue between science,
ethics, law, and politics. It is especially necessary
during such a crisis with many unknowns [4]. All
information related to public health should be
shared by governments timely and accurately.
The society should thus be informed and
involved in the pandemic process. In this context,
governments should avoid the spread of rumors
and misinformation that can cause potential panic
and discrimination in societies [10, 13].
Although political decisions should be made in the
frame of sound scientific knowledge, science should
not legitimize them alone. In this setting, there are
concerns about some policies which are inspired
by retrospective analysis of epidemiological data.
Some policies such as ‘herd immunity’ necessitate
careful ethical review because they may risk the
safety of the general population under uncertain
and changing circumstances. Likewise, the
herd immunity policy may impact medically
unsustainable conditions and the number of life-
threatening cases because of the lack of availability
of intensive care units even in developed countries
[4].
According to the IBC and COMEST, policies that
do not rely on sound scientific knowledge and
practices are unethical because they work against
building a common reaction to the pandemic [4].
In communities, governments are responsible
for public safety, raising the awareness of the
public and the protection of health. On the other
hand, communities are responsible for abiding by
the rules that protect everyone as a community,
and healthcare professionals are responsible for
treating and caring for patients to preserve public
health [4, 10].
5. Confidentiality
The principle of confidentiality requires that all
communication between patient and physician
must remain confidential, and private personal
data must be kept secure except for public health
concerns (surveillance and contact tracing,
etc.) or other accepted justifications for breach
of confidentiality [3, 13]. WMA also states that
physicians have a duty to each patient to ensure
confidentiality when dealing with third parties
such as filming and social media use. Those must
be done only with the explicit consent of each
patient. In this regard, physicians must respect
patient privacy [10].
DISCUSSION
The COVID-19 pandemic has shown that
people’s access to available health services varies
depending on how their country is managing
the current pandemic. In particular, the health
policies and public health approaches of countries
are determinant in those changes. In this respect,
having a national pandemic plan and developing
strategies for the fair allocation of limited resources
has gained importance for countries while fighting
against COVID-19. Likewise, the number and
capacity of intensive care units, the number of
available ventilators, the number of healthcare
workers and their competence, accessing PPE,
necessary medications and vaccines, and solving
safety problems have also become very important
[13].
There should have been well-structured and
applicable national pandemic action plans that are
non-discriminatory, that consider basic bioethical
principles, and prioritize the public health in each
country for minimizing ethical problems [13].
However, there are many examples of ethical
challenges faced during the COVID-19 pandemic.
Nacoti and his colleagues reported in March that
in Italy, their hospital was highly contaminated,
and they were far beyond the tipping point. The
hospital reserved 70% of ICU beds for critically ill
COVID-19 patients who had a reasonable chance
to survive. The waiting period for an intensive care
bed was hours long. Older patients were not being
resuscitated and died alone without appropriate
palliative care. Moreover, the families of the
deceased were notified over the phone often by
a well-intentioned but exhausted physician with
whom they had had no prior contact. Furthermore,
the situation in the surrounding area was even
worse in Italy. Most hospitals were overcrowded
and near collapse. Necessary medications,
mechanical ventilators, oxygen, and PPE were not
available. Patients were lying on oor mattresses.
The healthcare system was also struggling to
deliver regular services, and cemeteries were
overwhelmed [14].
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According to Emanuel and his colleagues, there
are diiculties in accessing and distributing the
necessary resources in many countries. For example,
healthcare professionals could not obtain adequate
N-95 masks in the United States. PPE requirements
for healthcare professionals were downgraded in
the United Kingdom and the necessary protective
properties of the PPE were not provided. South
Korea faced a hospital bed shortage, and some
COVID-19 patients died at home while awaiting
admission [15]. The Turkish Medical Association
(TMA) reported a surveys results in March 2020
that healthcare professionals had diiculties
obtaining PPE, such as masks, gloves, and aprons,
so they were at high risk for being infected with
COVID-19 [16, 17]. TMA also published a statement
in August 2020. According to this statement, the
COVID-19 pandemic was gradually worsening, and
the number of deaths were increasing in Turkey.
TMA stated that Turkey’s health system had started
to become unable to bear this burden, and they
were worried about the exhaustion of healthcare
professionals while fighting against the pandemic
[18]. Likewise, Council of Europe has stated that
management of the crisis appears to be fragmented
and chaotic in many countries. For example, the
elderly in long-term care facilities were neglected or
abandoned in Spain, although they were infected.
This situation raised many legitimate doubts about
whether all of those people, who lost their lives, had
access to adequate healthcare, including both life-
saving treatments and end-of-life care to reduce
their suering. There were also disturbing reports
coming from dierent Council of Europe states
which described hospitals refusing to admit the
elderly since hospitals and emergency healthcare
services had become saturated. Moreover,
hospitals might have inappropriately refused the
elderly even when there were still places available,
like in Sweden [19]. Many countries have similarly
faced a rapidly increasing imbalance between the
supply and demand for medical resources during
the pandemic [15].
As mentioned in Article 3 of the Council of Europe
Convention on Human Rights and Biomedicine
concerning the principle of equity of access to
healthcare, it should be kept in mind that everyone,
without exception, has the right to the highest
attainable standard of health [19]. The statements
of UNESCO also make it necessary to act by aiming
at the “highest healthcare standard” for all patients
with COVID-19. Receiving treatment within this
standard should be the fundamental right of every
person. Thus, as emphasized before, all patients
with COVID-19 must be given the best possible
treatment. In this frame, necessary healthcare
services should be equal, accessible, and qualified
for all, in order to fulfill the right to health, as TMA
stated [20].
Physicians and other healthcare professionals are
especially important in the pandemic. They should
approach the patients with the principle of “first,
do no harm. If physicians have to make treatment
decisions, they should decide in the frame of their
medical knowledge and medical ethics. They
should be objective and fair while allocating health
resources. Hence, healthcare services should ensure
the highest level of safety and justice for patients,
complying with professional medical standards
during the pandemic [21]. In this process, those
who need medical treatment should be informed
about the risks, benefits, and alternatives of the
proposed treatment, then the patients should
make the final decision. However, TMA states that
if there would be significant risks for public health
in the case of not treating patients, then necessary
measures, including isolating the patient, may
have to be taken to eliminate those risks to public
health. Obtaining consent from patients may not
be necessary in such situations [20].
On the other hand, we know that health systems and
healthcare professionals are under deep pressure
during the COVID-19 pandemic. They often have to
make diicult decisions to provide care to patients
in diicult conditions. They are extremely busy
and under stress. They are also concerned about
both the health of themselves and their families.
In emergencies, they might have to perform some
medical procedures beyond their competence to
treat and prevent patients from serious harm. In
this context, those procedures might be subjected
to consideration in terms of ethical and legal
obligations. Also, it should be recognized that
obligation to provide healthcare services may have
limits. So the working conditions of healthcare
professionals, who are in a great struggle during
the pandemic, should be reviewed very carefully.
Since physicians and other healthcare professionals
are at high risk of contracting the disease during
the pandemic, the government should protect all
healthcare professionals, their families, and those
Medical Ethics and COVID-19
8© 2021 Acta Medica. All rights reserved.
who contact them. Suitable working conditions
should be provided for healthcare professionals in
a way that they would not have to make a choice
between the lives of patients and their own lives.
Hence, all protective measures must be taken
in all workplaces and all necessary equipment
adequately provided for them. Moreover, the
government and all employers have both legal
and ethical responsibilities to protect healthcare
professionals. There should be a balance between
the duty of care and the taking of risks. If healthcare
professionals get infected or face life-threatening
risks, then they would be restricted in providing
treatment [22]. Therefore, it is necessary to realize
these limitations which may arise while providing
appropriate health services.
Recommendations and Future Perspectives
The COVID-19 pandemic is still threatening public
health all over the world. Policies which are non-
discriminatory and which prioritize public health
should be developed. This would be important
in the future as well. Recently, there are some
discussions about long COVID in the Lancet [23-
25]. According to these discussions and WHO [3],
long COVID can be defined as the post-COVID
syndrome, but there should be a worldwide
consensus on terminology and clinical definition
of this syndrome. Thus, it would be important to
define long COVID and prepare updated guidelines
for its correct and ethical management. Long-
term health consequences of COVID-19 should be
understood better with large and long-term cohort
studies and scientific evidence. Diverse populations
from dierent income countries and ethnic
groups should be included, too, in those studies.
Multidisciplinary, multicentre, and multinational
collaborations and approaches would be necessary
for data collection. Healthcare professionals must
listen to their patients, try to understand their
concerns, and manage their symptoms with clear
acknowledgment, honest communication, and
careful patient-centred research for long COVID.
Multidisciplinary healthcare, rehabilitation services,
telemedicine and social and financial support
would gain importance as well. The capacity of
primary care services and adequate occupational
health provision would be important for healthcare
professionals because of the high burden of long
COVID. Certain populations such as the elderly
and the disabled might be impacted more by long
COVID-19. So, appropriate actions and protective
measures must be taken by the governments
to support vulnerable populations. Therefore,
action has to be taken against long COVID related
problems immediately [23, 26-27]. Also, the
discussions about vaccines will continue since many
countries focus on vaccination for the pandemic
response [23]. UNESCO states that the availability
of vaccines for all will take time and require a global
eort since many people don’t have access to
eective treatments and vaccines. Thus, ethics must
have a very important role in the prioritization of
vaccines. As an unequivocal right, everyone should
access adequate health services and treatments,
and vaccines should be a global common good.
UNESCO rejects vaccine nationalism and defends
that it is an essential ethical issue that all people
can access vaccines in all countries [28]. Therefore,
the regulation, patenting, and ownership rights of
vaccines still would be part of ethical discussions.
Limitations
Since the COVID-19 pandemic is still going on, new
ethical issues come up, every day. This review has
only covered the major topics related to medical
ethics which have arisen during the current
pandemic.
CONCLUSION
In conclusion, some factors such as age, clinical
condition, having a comorbid disease, vulnerability,
and especially the need for intensive care will
strongly aect the patients’ quality of life and
survival chance during the COVID-19 pandemic.
Moreover, available resources and the number
of people who have similar needs will be very
significant for patients to access the necessary
healthcare. Besides, pandemic preparedness in the
country and developing eective health policies
will be important for providing necessary health
services. While delivering healthcare services,
both healthcare professionals and patients should
have rights based on human rights and the ethical
principles of medicine. Also, the action plan for the
COVID-19 pandemic should conform to universal
ethical principles.
If patients need to be intubated and cared for in
ICU, the treatment, including palliative and end-of-
life care, should be given in a way that is respectful
Coşkun and Örnek BükenActa Medica 2021; Early Online: 1-10
9
© 2021 Acta Medica. All rights reserved.
to the wishes, decisions, and dignity of patients.
Especially for patients who are nearing end of
life, healthcare professionals should obtain their
consent for the procedures to be performed, if
possible, and act in agreement with their end-of-life
decisions if they have any. Healthcare professionals
also should reduce their pain and suering and
provide for them to spend their last days with
dignity and saying goodbye to their relatives.
On the other side, health policies should protect
healthcare professionals, too. In this context,
healthcare professionals should have access to
all necessary protective and medical equipment
adequately. Healthcare professionals might have
to make diicult decisions such as withholding or
withdrawing mechanical ventilation of critically ill
patients. In such diicult situations, a well-prepared
action plan considering ethical principles can help
them. Therefore, health policies that are non-
discriminatory and prioritize public health and also
the safety of healthcare professionals are necessary
for the correct management of the COVID-19
pandemic. The current COVID-19 pandemic process
is a public health problem rather than an intensive
care problem. Moreover, this diicult period is
a humanitarian crisis involving many crises, and
there are very dierent sad stories around the
world regarding the pandemic. Every step taken to
manage this crisis should be in the frame of human
rights and universal ethical principles.
CONFLICT of INTEREST
The authors have no conict of interest.
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Article
Full-text available
COVID 19 Pandemisinin etik yönlerini konu alan bu makalede öne çıkan konular şunlardır; sınırlı tıbbi kaynakların adil dağıtımı ve triaj kararları, tıbbi yararlılık konusu, ABD ve İtalya örneklerinde daha sık gördüğümüz özellikle yaşlılara ve örselenebilir/etkilenebilir savunmasız gruplara yönelik ayrımcı yaklaşımlar, tedaviye hiç başlamamak ya da başlanmış tedavileri kesmek şeklindeki kararlar, tedavinin önceliklendirilmesi konusunda doğrudan ya da dolaylı ayrımcılıklar, sağlık çalışanlarına yönelik riskler ve risk yönetimi konuları, hekimin tedavi etme sorumluluğunun sınırlılıkları ve yasal yükümlülükler, kişinin özerkliği sorunu, mahremiyet, “eşitlik, özgürlük, adalet” kavramlarının özellikle pandemi günlerinde ne ifade ettiği ya da etmesi gerektiği konuları. Anahtar Kelimeler: COVID 19 Pandemisi, Etik konular, Kaynakların dağıtımı, Triaj, Kişisel özsayrılık Abstract: The prominent topics in this article on the ethical aspects of COVID 19 Pandemic are; fair distribution and triage decisions of limited medical resources, the issue of medical usefulness, discriminatory approaches to the elderly and vulnerable groups, which we see more frequently in the USA and Italy examples, decisions about withdrawing or withholding treatment, direct or indirect discrimination in prioritisation decisions, management of risk to health professionals, limitations of physician’s responsibility to treat and liability issues, the problem of autonomy, privacy, and what the concepts of “equality, freedom, justice” mean especially in pandemic days. Keywords: COVID 19 Pandemic, Ethical issues, Resource allocation, Triage, Self induced illness
COVID 19 Pandemisinin Eşitlik, Özgürlük, Adalet Adına Düşündürdükleri Üzerine
  • N Ö Büken
Büken NÖ. COVID 19 Pandemisinin Eşitlik, Özgürlük, Adalet Adına Düşündürdükleri Üzerine. Hekim Postası 2020; 101: 4-6.
COVID-19 Pandemic and Fair Allocation of Limited Medical Resources in Elderly People
  • S Coşkun
  • N Ö Büken
Coşkun S, Büken NÖ. COVID-19 Pandemic and Fair Allocation of Limited Medical Resources in Elderly People. In: Demirhan AE (ed). COVID-19 Pandemics and Ethics. 1st Ed. Ankara; Türkiye Klinikleri, 2021: 18-25.
Updated Statement: Ethical Medical Guidelines in Covid-19 -Disability Inclusive Response
  • European Disability Forum
European Disability Forum. Updated Statement: Ethical Medical Guidelines in Covid-19 -Disability Inclusive Response. http://www.edf-feph.org/newsroom/news/ updated-statement-ethical-medical-guidelines-covid-19-disability-inclusive-response-0 (accessed June 2020).
WMA Statement on Medical Ethics in The Event of Disasters
World Medical Association. WMA Statement on Medical Ethics in The Event of Disasters. https://www.wma.net/ policies-post/wma-statement-on-medical-ethics-in-theevent-of-disasters/ (accessed June 2020).
COVID-19 pandemisi ve etik. Pandemi ve Sağlık Hukuku Disiplinlerarası Yaklaşımla.1. Baskı. Ankara; Yetkin Yayınları
  • S Coşkun
  • N Ö Büken
Coşkun S, Büken NÖ. COVID-19 pandemisi ve etik. Pandemi ve Sağlık Hukuku Disiplinlerarası Yaklaşımla.1. Baskı. Ankara; Yetkin Yayınları, 2020: 45-78.
At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation
  • M Nacoti
Nacoti M, et al. At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation. NEJM Catalyst Innovations in Care Delivery 2020; 1(2): 1-5.