The NCCHPP has collected relevant resources that discuss ethical issues linked to COVID-19. Each resource is presented with a brief synthesis of what you will find in the document.
Last updated in November 2021.
The resources are organized by category. Click to access them directly.
Ethics frameworks and guidance for pandemics and public health emergencies
A Survey of Ethical Principles and Guidance Within Selected Pandemic Plans
National Collaborating Centre for Healthy Public Policy. (2011).
This document provides a survey of the explicit goals, ethical principles, and ethics-related recommendations put forward by a selection of national, sub-national and international pandemic preparedness plans and policies.
Cadre de réflexion sur les enjeux éthiques liés à la pandémie de COVID-19
Désy, M., St-Pierre, J., Leclerc, B., Couture-Ménard, M-È., Cliche, D., & Maclure, J. (2020).
This framework, published in French by the Institut national de santé publique du Québec, sets out to clarify ethical issues and support decision making during the Covid 19 pandemic. The authors outline the key guiding values as beneficence, precaution, justice, responsibility, non-maleficence, solidarity, confidence, transparency, respect for confidentiality, proportionality and liberty. Four main categories of ethical issues are identified. They are: (i) distancing, isolation and quarantine (which balance beneficence and precaution against liberty, calling for proportionality); (ii) health monitoring and surveillance (calling into play the importance of respect for confidentiality, beneficence and non-maleficence); (iii) communications with the public (which rely on the public’s confidence and transparency, and which can reinforce solidarity and responsibility); and (iv) resource allocation and access to health services (which call into play beneficence, equity, and justice).
Covid-19 ethical decision making framework
BC Centre for Disease Control & BC Ministry of Health. (2020).
The authors of this ethics framework begin by identifying two central dilemmas in public health ethics as balancing the autonomy and privacy of individuals with the greater good of the population, and making resource allocation decisions if need is greater than supply. It proceeds in three steps, going through a consideration of ethical principles and values, an ethical decision-making process, and a checklist for evaluating options and articulating a decision. The key principles and values are identified as: respect, the harm principle, fairness, least coercive and restrictive means, working together, reciprocity, proportionality, flexibility and procedural justice (including transparency, inclusiveness, accountability, and reasonableness). The decision-making process asks users to: (1) define the issue, (2) clarify the facts, (3) identify stakeholders/perspectives, (4) identify and analyze the principles and values, (5) identify alternative actions, (6) make a decision, (7) implement the decision, and (8) review and document. The checklist calls upon users to go through a structured process, responding to specific questions, to ensure that the ethical values are used to analyze proposed actions.
Covid-19 ethics framework information for providers
Shared health/Soins communs Manitoba. (2020).
This framework provides a set of considerations for healthcare providers, focusing on maximizing benefits and ensuring that they are equitably distributed in resource allocation and triage decision making. They outline key principles that should inform decisions (harm principle, least restrictive means, reciprocity and transparency), principles for fair processes (reasonable, transparent, inclusive, responsive, accountable), and guiding values (liberty, solidarity, protection of the public, proportionality, privacy, duty to provide care, equity, and stewardship). The framework includes a workbook with guiding questions related to the above values and principles, as well as a step-by-step decision-making guide.
Difficult trade-offs in response to Covid-19 The case for open and inclusive decision making
Norheim, O. F., Abi-Rached, J. M., Bright, L. K., Bærøe, K., Ferraz, O. L. M., Gloppen, S., & Voorhoeve, A. (2020).
In this article, the authors call for open and inclusive decision making through deliberative processes. They support deliberative processes for practical, legal and moral reasons, but also because such processes produce better decisions, more public trust, and better adherence to restrictions and legal requirements that are necessary to limit the spread of Covid-19. To make their case, they present a set of supporting reasons for open, inclusive decision making under Covid-19: i) political equality and human rights (9 reasons); ii) scrutiny and communication (3 reasons); iii) trust and adherence (1 reason). The authors outline the key elements of transparent and inclusive decision making as involving political leaders, experts and the public, with accountability mechanisms being essential and they suggest three types of participative institution that would be particularly useful for inclusive decision making in the context of Covid-19.
Ethical considerations in responding to the COVID-19 pandemic
Nuffield Council on Bioethics. (2020).
This document outlines four principles that must be taken into account by states developing public health measures to address Covid-19.
1. Interventions should be based on evidence, they should be proportionate, and the aims, science, values and judgments underpinning those interventions should be clearly communicated to the public.
2. Coercion and intrusion should be kept to the minimum necessary to achieve the public health aims.
3. People should be treated with respect, as moral equals. People’s sacrifices for the common good (self-isolation, quarantine) should be recognized in intervention design and implementation.
4. Solidarity is crucial at every level: internationally (between governments), by states (in bearing costs of interventions), by businesses (in social responsibility) and by individuals (in our day to day lives).
Ethical considerations highlighted in the document include (for states) proportionality, effectiveness, necessity, public justification, maintaining trust, fair and respectful treatment, and solidarity; and (for individuals and companies) solidarity, trust and corporate social responsibility.
Ethical dimensions of Covid 19 for frontline staff
Royal College of Physicians. (2020).
The authors propose fairness as the best model for approaching the ethical issues that will arise in the pandemic. The principal values to consider are accountability, inclusivity, transparency, reasonableness and responsiveness. They make eleven ethical recommendations: (1) care must be equitable and not disadvantage any group; (2) care should not favour either Covid-19 or non-Covid-19 patients; (3) decisions to start, withhold or withdraw care should be made in teams, documented, and as per national guidance; (4) staff remain fully accountable for their decisions under all circumstances; (5) support from ethicists and others is available for difficult decisions; (6) staff should discuss advance care plans with patients and be aware of their wishes; (7) intensive care beds should be continually assessed and prioritized subject to national guidelines (UK-specific guidelines are referenced); (8) doctors’ duty to care may require them to work outside of their area of practice but not outside of their sphere of competency; (9) staff over 70 or with pre-existing conditions have a right to protect themselves that may require that they be reassigned outside of direct contact areas; (10) staff must be provided with personal protective equipment; and (11) certain specialities may develop specific advice for practitioners.
Ethical framework for health care institutions responding to novel coronavirus SARS-CoV-2 (COVID-19) & Guidelines for institutional ethics services responding to COVID-19
Berlinger, N., Wynia, M., Powell, T., Hester, D. M., Milliken, A., (…) & Jenks, N. P. (2020).
This document, published by the Hastings Center, sets out to balance the ethics of clinical duties (i.e., patient-centred care) with the ethics of public health (i.e., considerations of equity and the just distribution of benefits and harms) by drawing population-level thinking into the clinical context. The document identifies two competing sources of moral authority that must be held in balance, the duty to care for individuals and duties to promote equity and just distribution. States and public authorities, as represented by health care leaders, have three principal duties to practitioners and community during a public health emergency. They are the duty to plan for the ethical challenges that arise (i.e., anticipating triages with respect to staff, supplies and space); a duty to safeguard (i.e., supporting healthcare workers and vulnerable populations); and a duty to guide (i.e., contingency planning across a range of resource stresses during a surge). The document includes 24 institutional policies and processes and 6 guidelines for institutional ethics services to take into account for the context of Covid-19.
Ethical principles and a practical approach to support policy making through the next phases of the COVID-19 pandemic and beyond
Fritz, Z., Huppert, J. L., Liddell, K., Holton, R., & Fuld, J. P. (2020).
In this article, the authors attempt to bridge clinical and public health goals with a program for an ethics that will guide clinicians during and beyond the pandemic. It is based on four key commitments: (1) identifying the “needs, rights and interests of the different stakeholders affected by any policy”; (2) “to be accountable and transparent, recognising that people are autonomous individuals with values and concerns of their own”, a commitment that implies deliberative processes to find out where citizens stand; (3) “to consider the impact of our actions on the sustainability of the National Health Service (NHS), infrastructure, service demands and staff welfare”; and (4) “to treat everybody equitably, with all deserving of consideration and care” (p. 1). The article includes a discussion of the legal and ethical challenges relating to the emergency-context tendency to save the most lives possible at the expense of equity considerations. The authors recommend that frameworks be established to advocate for competing objectives; that policy and practice be clearly communicated to the public; that decision making across the care spectrum be integrated to stop unnecessary interventions and reduce inequalities; that interventions minimize inequalities; and that spare capacity be built into the health system to accommodate extra demand.
Ethics guidance on issues raised by the novel coronavirus disease (COVID-19) pandemic
Pan American Health Organization. (2020).
This document underlines the importance of obtaining good surveillance data during an emergency, and distinguishes surveillance from research. It focuses on equity, solidarity, responsibility and transparency as essential to developing appropriate public health responses to a pandemic, with particular emphasis on not increasing inequalities and on developing clear, transparent criteria for priority-setting in the allocation of scarce resources such as ventilators. The document highlights the importance of clear, comprehensible and non-stigmatizing communication for advancing public engagement and trust. Finally, the document discusses issues related to research, including fast-tracking projects, ethics review, consent of participants, secondary use of data and the duty to share research data and results.
Guidance for managing ethical issues in infectious disease outbreaks
World Health Organization. (2016).
This document was produced in the context of Ebola but was intended to “look beyond issues specific to particular epidemic pathogens and instead focus on the cross-cutting ethical issues that apply to infectious disease outbreaks generally” (p. 7). It identifies six key ethical principles: justice, beneficence, respect for persons, liberty, reciprocity and solidarity. These underlie 14 guidelines that address key aspects of responding to an epidemic. For each guideline there is a set of questions to aid in deliberation. Guidelines cover a broad range of issues, including governments’ responsibilities, engaging communities, attending to vulnerability, allocating scarce resources, surveillance, restrictions on liberty, medical obligations to treat, research, emergency use of unproven interventions, data sharing, storage of samples, sex- and gender-based differences, response workers’ rights and duties, and issues relating to humanitarian aid workers.
Public health decisions in the COVID-19 pandemic require more than ‘follow the science’
de Campos-Rudinsky, T. C. & Undurraga, E. (2021).
In this paper, the authors argue that while good decision making depends on reliable data and sound analyses, it depends above all upon “sound ethical reasoning that ascribes value and normative judgement to empirical facts” (p. 1). In an effort to challenge the overly simplistic view summed up by ‘follow the science’-type thinking, they point to the complex relationship between empirical data and ethical thinking. For example, even when accuracy and transparency are prioritized in communicating with the public about the situation as well as the reasons for decisions, the complexity of decision making, uncertainty about outcomes, weighing priorities, balancing between values, and a host of other factors make it clear that seeking a “good” outcome from policy choices calls for thinking and valuation that are informed by scientific evidence but go well beyond what a ‘follow the science’ attitude alone can offer. The authors call for greater transparency about the ethical considerations and underpinnings of decisions in order to help build public trust.
Public health ethics framework: A guide for use in response to the COVID-19 pandemic in Canada
Public Health Agency of Canada. (2020).
5 pages (approx.).
This framework is intended for policy makers and public health practitioners in Canada in the context of Covid-19. The first part articulates the relevant values and principles to consider: trust; justice (with a strong equity focus); respect for persons, communities and human rights; promoting well-being; minimizing harm (including effectiveness, proportionality, reciprocity and precaution); working together; and procedural considerations (accountability, openness and transparency, inclusiveness, responsiveness and intersectionality). The second part articulates the five-step framework. The steps draw on the principles above and are supported with guiding sub-questions. They are: (1) identify the issue and gather facts to clearly understand the problem; (2) identify ethical considerations and prioritize values to uphold; (3) in light of those values, identify options; (4) select and implement the best course of action; and (5) evaluate.
Public Health Ethics. Selected Resources: Ethics in a Pandemic
National Collaborating Centre for Healthy Public Policy. (2011).
This document provides an introduction to the field of Public Health Ethics (PHE) as applied to policy and practice responses in times of pandemic. It contains a selection of works that provide a foundation for exploring the ethical implications of infectious disease control and pandemic response. This includes: short summaries of a selection of papers, frameworks and guidelines; links to additional resources on ethics and pandemics, including articles, presentations, case studies and other learning tools, websites, blogs, and news sources.
Quick reference ethics support for health care providers
Nova Scotia Health Ethics Network (NSHEN). (2020).
This document highlights issues that may arise for care providers due to conflicts between individual freedom/common good, duty to care/safe working environment and resource allocation. The document succinctly raises: changing priority from individual- to population-level thinking (autonomy to community); redeployment of skilled workers; concerns arising from changing structures; concerns that arise from a perception of excessive authority; moral distress; conflicting interests (e.g., duty to care and feeling unprotected); conflicting roles (e.g., parent and care worker); conflicting views about safety and risk; conflicting views about fairness (e.g., institutional triage protocols); physical, emotional and psychological well-being; and balancing solidarity with boundaries.
Responding to Covid-19: How to navigate a public health emergency legally and ethically
Gostin, L. O., Friedman, E. A., & Wetter, S. A. (2020).
This article in the Hastings Center Report touches upon several issues to provide a broad scan of the ethical and legal issues we face in responding to Covid-19. The authors briefly address the following issues/questions, among others: triage and resource allocation in a surge; physical distancing (flattening the curve) to reduce the strain on the health system; physicians’ duties to individual patients as compared to broader responsibilities in a system strained by overwhelming demand for care; equity considerations and fair access to scarce resources; health and justice concerns relating to access to care for the most vulnerable; physical distancing and public cooperation; reciprocal concern for some populations obliged to practise distancing; communications issues; isolation and quarantine issues – legal and ethical; balancing public health and civil liberties; and deciding how far governments should go vis-à-vis the exercise of powers.
Roles for ethicists in Covid-19 response
Warren, M. (2020).
3 pages (approx.).
In this blog article from Impact Ethics, the author observes that ethicists should help to minimize the difficult choices that health care providers must make, and when that is not possible, to ensure that they are equipped with what they need to make decisions and to act. The best time to do this is in planning for pandemics, not during them. That said, ethicists can contribute during pandemics by: clearly articulating relevant values, building ethics capacity, developing tools and frameworks, translating values into guidance, showing how values are balanced against one another, providing consultation support for difficult decisions, reducing moral distress by affirming that there is no one “right” answer, supporting the justifiability of decisions made by tracing the ethical values and decision-making processes, and following-up after an emergency to strengthen processes and to reflect.
Statement on COVID-19: Ethical considerations from a global perspective
UNESCO International Bioethics Committee and UNESCO World Committee on the Ethics of Scientific Knowledge and Technology (COMEST). (2020).
This March 2020 statement outlines 11 vital ethical issues from a global perspective, calling for urgent action to affirm that: (1) policies must be interdisciplinary (politics, science, ethics and law) and evidence-based; (2) policies “not based on sound scientific knowledge and practices are unethical” (p. 2); (3) pandemics test healthcare systems and reveal the importance of resource allocation, which must be based on justice, beneficence and equity; (4) it is of great importance to attend to the vulnerable; (5) it is important to recognize the rights and duties of individuals, communities and governments; (6) “information issued by politicians, scientists, authorities and the media need to be timely, accurate, clear, complete and transparent” (p. 3); (7) in the search for a vaccine, there should be international coordination and a common understanding for ethical review processes; (8) it is important that the urgency of the situation does not preclude responsible research practices; (9) ethical, social and political issues relating to digital technologies be attended to; (10) extreme measures like barriers across borders should not impair international collaboration and must not perpetuate xenophobia or discrimination; and (11) pandemics show the interdependency of states, calling for international collaboration and solidarity.
Addressing human rights as key to the Covid-19 response
World Health Organization. (2020).
This WHO document addresses the moral imperative of integrating human rights protections into responses to the pandemic, focusing on six categories of note. (1) Stigma and discrimination: these have been directed against infected persons, persons of Asian descent, care workers and others. These practices should be identified and stopped. (2) Gender equality and prevention of violence against women: social norms put girls and women more at risk of the virus, their access to essential health services is affected, and stay at home orders put them at increased risk of violence. Societies must address these. (3) Support for vulnerable populations: the dignity and rights of the most vulnerable demand additional attention in Covid-19 responses. (4) Quarantine and restrictive measures: restrictions must be part of comprehensive public health and social responses that integrate rights, with appropriate oversight and accountability in place. (5) Shortages of supplies and equipment: governments must take all measures to protect healthcare workers; WHO has published guidance on this. (6) Obligations of international assistance and cooperation: wealthy states have obligations to lower- and middle-income states that are not subordinate to their obligations within their own borders.
A relational account of public health ethics
Baylis, F., Kenny, N. & Sherwin, S. (2008).
This document is important for many reasons, but among those is its critically contrasting individualistic approaches to pandemic planning with collective approaches. The authors call for an ethics of public health that focuses on common good and the public interest through attending to relational personhood, relational autonomy, social justice, and relational solidarity. This document provides an essential critical lens for approaching public health emergencies like Covid-19: notably, it ensures that our focus does not stray far from the vulnerable and marginalized, and it helps us extend the boundaries of our solidarity from us/them to us all.
Beyond sex and gender analysis: An intersectional view of the COVID-19 pandemic outbreak and response
Hankivsky, O. & Kapilashrami, A. (2020).
The authors call for an intersectional approach to inform Covid 19 responses. They critique singular approaches (like male-female, racialized-non) to understanding vulnerability and advantage, as these fail to account for the interplay of factors such as age/health status, disability, sex/gender, socioeconomic status, Indigeneity, migration status, geographic location, and race/ethnicity. These factors do not operate in isolation. An intersectional approach would have us understand humans as “shaped by the interaction of different social locations … within a context of connected systems and structures of power” (p. 1.) creating systemic privilege and oppression through racism, ableism, patriarchy, colonialism, etc. Because the impacts of Covid 19 such as physical distancing, unemployment, increased care work and resource allocation affect people differently, Covid responses should also reflect this. The authors conclude with recommendations for enriching data, undertaking intersectional analyses, prioritizing support for those most at risk, making policy responses cross-sectoral, moving beyond a deficit model, and committing to diversity in leadership.
Covid-19 structural racism and migrant health in Canada
Tuyisenge, G. & Goldenberg, S. M. (2021).
In this short commentary, the authors explore the role of structural racism “(the macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities faced by racialised communities)” (p. 1) in the disproportionate impacts experienced by migrant communities due to Covid-19. They consider precarious work, barriers to health care, human rights, and immigration policies to be key areas for focus to reduce inequalities, and propose interventions such as universal health care coverage, culturally appropriate health care, anti-oppression training for providers, changes to labour and immigration policies, and in particular listening to and amplifying the voices of migrant communities and those organizations representing them.
Health justice strategies to combat Covid-19: Protecting vulnerable communities during a pandemic
Benfer, E. A. & Wiley, L. F. (2020).
In this document, the authors present guidance and actions that (US) authorities can take to support the ability of low-income and marginalized communities (including low-income workers, people with disabilities, people experiencing homelessness or unstable housing, people of colour, immigrants, refugees and others more prone to neglect or mistreatment by government authorities) to safely shelter in place. They start out by taking a health justice approach by focusing on (i) addressing the social determinants of health, (ii) ensuring that interventions focusing on changes in behaviour have the necessary protections and supports, and (iii) ensuring that responses address both immediate (emergency) needs and root problems. The article indicates that state and local plans should: protect workers, place a moratorium on eviction, protect the homeless and increase affordable housing, place a moratorium on utility shut-off, proactively enforce safe and healthy homes regulations, ensure access to food and other necessities, and ensure that any mandatory order is consistent with civil liberties.
Les inégalités sociales et raciales amplifiées par la crise sanitaire dans certains quartiers, déplore la Commission des droits de la personne et des droits de la jeunesse
Gouvernement du Québec. (2020).
This note (in French) reports on an announcement from Québec’s commission for human rights and the rights of youth (la Commission des droits de la personne et des droits de la jeunesse). Reacting to the development that Montréal’s lowest-income neighbourhoods have become the city’s Covid-19 hotspots, the commission calls upon different levels of government to take immediate measures to address social and racial inequalities, in particular by supporting community organizations. The commission notes the high percentage of recent immigrants from racialized minorities, especially women, in the care sector most affected by Covid-19. It highlights the social and economic disparities faced by Indigenous, racialized, and immigrant personas and those living with disabilities and notes how these disparities are amplified by the pandemic. For the commission, a fight against racism and discrimination is indistinguishable from a fight against poverty. It recommends several immediate policy measures relating to housing, food security, and access to computers. The commission calls for leaving behind business as usual approaches to governmental programming and policy making, and recommends taking on discrimination using an intersectional approach.
Navigating inequities: A roadmap out of the pandemic
Ismail, S. J., Tunis, M. C., Zhao, L., & Quach, C. (2021).
The authors of this article present a tool that can help users avoid pitfalls that can arise when navigating equity. Applying a one size fits all model to equity can increase inequalities and produce stigma. Instead, the authors propose the equity matrix, which “illuminates an array of overlapping factors that compound health inequity” (p. 5). The equity matrix applied to Covid-19 considers the spectrum of health inequities (including canvassing their causal factors), considers their intersections and their sources (by asking where the inequities came from, including an intersectional analysis), and attempts to avoid deepening health disparities by implementing ethically-just interventions (by identifying policies and interventions that reduce inequities). While the matrix is intended to be polyvalent, in this instance the authors focused its application on shorter-term equity goals relating to appropriate distribution of vaccines during the Covid-19 pandemic.
Plus que jamais, les inégalités sont nocives pour la santé
Chung, R. (2020).
4 pages (approx.).
In this blog article (in French), the author discusses health as a basic right, social determinants of health and global health in the context of the pandemic and what it reveals about our societies. The current crisis highlights and amplifies health effects of inequalities, at home and globally, both in terms of the effects of the virus but also the measures taken in response, which affect people differentially according to social status. The crisis reveals the unethical and costly structural inequalities that we are willing to tolerate under normal circumstances, which ought to inspire deep reflection as well as preventive measures to health systems and policy to ensure that the more disastrous effects of inequalities do not arise in future crises. At the level of global health, the author highlights the importance of multilateralism, universal human rights, solidarity, cooperation, and social, international and intergenerational justice as antidotes to insularity, profound inequalities and xenophobia.
Reimagining safety in a pandemic: The imperative to dismantle structural oppression in Canada
Khare, N., Shroff, F., Nkennor, B., & Mukhopadhyay, B. (2020).
The authors of this article consider the notion of safety in a pandemic and hold it up to a critical, intersectional lens to ask what keeps us safe and who is kept safe during Covid-19, focusing on four broad categories to serve as examples. Encouraging people to stay at home implies home to be a place of safety, but it places tens of thousands of women at increased risk of violence. Expanded policing powers to enforce distancing and other orders places those at the intersections of indigeneity, racialization and/or poverty at increased risk of further marginalization, notably through punitive enforcement. Border control measures place migrants making land crossings at even greater risk due to hard borders, refugee camps and detention centres. Migrant farm workers, meat packing workers and marginalized health care workers do essential work but are treated as disposable. The authors call for us to challenge state-defined safety measures, to “replace oppressive institutions with equity-affirming ones” (p. E1220) and to direct resources towards upstream supports.
Social distancing is a privilege
Blow, C. (2020).
3 pages (approx.).
This short opinion piece takes on the popular notion that viruses are equal opportunity, infecting any and all regardless of social status. However, based on the emerging evidence, “in the real world, this virus behaves like others, screeching like a heat-seeking missile toward the most vulnerable in society. And this happens not because it prefers them, but because they are more exposed, more fragile and more ill” (p. 1). In Milwaukee, Chicago and Detroit, African-Americans are vastly overrepresented among the dead due to Covid 19. Disproportionately, black and brown people cannot practise social distancing because they must go out to work, or starve. And some of those who have the privilege to stay home may then chastise those who take crowded transit, those who line up for work or for take-out food. The author calls upon those of us who occupy positions of privilege to stop scolding those scratching to survive.
The trickle-down tragedies of the pandemic
Tharoor, I. (2020).
5 pages (approx).
In this Washington Post article, the author begins by framing the gravity of the Covid-19 pandemic in the United States as a humanitarian disaster, but quickly turns to consider those living precariously around the world to describe how the pandemic is making things much worse for refugees, children recruited into armies, girls forced into marriage and women more generally. The present situation is exacerbating the incidences of underage marriage, gender-based violence and other harms to girls and women. Humanitarian agencies lack funding and support and are documenting worsening situations for the world’s most vulnerable during this pandemic.
What does it mean to be made vulnerable in the era of COVID-19?
Ahmad, A., Chung, R., Eckenwiler, L., Ganguli, A. M., Hunt, M., […] & Wild, V. (2020).
This short editorial letter questions and analyzes issues around the framing of the concept of vulnerability, proposing a shift in understanding from the notion of “being” vulnerable to that of “being made” vulnerable. The authors argue that if we set out to address what it means to be vulnerable, we may not sufficiently shift the ground away from individualizing and pathologizing people’s capacity and agency. Instead, they argue that we should focus on the contextual social factors that make people vulnerable. In a pandemic or emergency context, attending to and taking seriously the needs, interests and knowledge of socially-marginalized groups is essential for preventing further health disparities and discrimination. “We can prevent the epistemic injustices of not listening and of silencing, and avoid delineating moral agency in ways that perpetuate vulnerability in a global pandemic.”
Covid-19 and the decolonization of Indigenous public health
Richardson, L. & Crawford, A. (2020).
In this article, the authors discuss Indigenous public health in the context of Covid-19 and call for decolonization. Equitable access to housing, water, food and income (all related to policies that affect the “distribution of money, power and resources” in society) is necessary for communities to be able to respond to a pandemic. Beyond long-standing inequities in determinants of health, Indigenous peoples’ health experiences are also linked to systemic racism in society and the health system. The authors note that in spite of inequities and colonization (both past and present), Covid-19 rates in Indigenous communities have so far been lower than overall, and highlight numerous strengths and successes in Indigenous communities’ public health and emergency preparedness. They call for self-determined Indigenous public health in Canada that draws key elements from western approaches to public health and that is “anchored in the principles of self-determination for Indigenous Peoples as articulated in the 2007 United Nations Declaration on the Rights of Indigenous People to determine their own paths to healing and to health for their communities”.
Covid 19 update from the Waakebiness-Bryce Institute for Indigenous Health
Waakebiness-Bryce Institute for Indigenous Health. (2020).
2 pages (approx.).
This update provides context for understanding that Indigenous peoples are already highly marginalized and that Covid 19 will hit them harder, notably through: economic hardship, difficulty in distancing or self-isolation due to crowded and inadequate housing, access to and quality of health care, existing health burdens, lack of water, difficulty travelling to access treatment or supplies, and precarious employment, among others. The authors note several current issues: Indigenous peoples are more vulnerable to community spread; urban Indigenous populations are being ignored by authorities; Indigenous communities are not getting clear messaging, and misinformation is circulating among them; Healers and Elders are not being consulted; government is imposing colonial models of public health and health on-reserve and in urban settings, focusing on biomedical-only services. The Waakebiness-Bryce Institute for Indigenous Health and Well Living House are developing an Urban Indigenous Response to COVID-19, to be released as soon as possible.
Highlights from a Covid-19 fireside chat with Indigenous health professionals
Yellowhead Institute. (2020).
This document provides highlights from a webinar hosted by Idle no More and Indigenous Climate Action, featuring Indigenous health professionals and leaders. It is intended to inform Indigenous health planners who are preparing to address Covid-19. The speakers emphasized that “now is the time to reflect, to find grounding in Indigenous ways and to consider what Indigenous strategies to support the health and wellbeing of families and communities could look like” (p. 1). The document provides guidance on social distancing, gloves and masks, caring for kids, traditional medicines, gathering and participating in ceremony, and concludes with words of hope and encouragement: find strength in family and community, honour elders, practice self-care, and trust in what we know.
A framework for the systematic consideration of ethics, equity, feasibility, and acceptability in vaccine program recommendations
Ismail, S. J., Hardy, K., Tunis, M. C., Young, K., Sicard, N., & Quach, C. (2020).
This framework sets out to harmonize the systematic consideration of programmatic factors (ethics, equity, feasibility and acceptability) with traditionally scientific factors to guide decision making in vaccine guidance development. The authors developed supporting tools for each programmatic factor such that each may be systematically considered within the context of the overall framework. The ethics tool is adapted from the Public Health Agency of Canada’s 2017 ethics framework, which proceeds in five steps, and considers both core ethical dimensions (respect for persons and communities, beneficence, non-maleficence, trust, and justice) and procedural considerations (accountability, inclusiveness, responsibility, responsiveness, and transparency). The equity matrix enables one to identify potential inequities, the reasons for those inequities and interventions to reduce them, adapted to the context of vaccination programs. The feasibility and acceptability matrices provide similarly systematic guidance. The authors say that the extensive work that went into producing this framework and supporting tools can reduce the time and work for others in producing guidance.
An ethical framework for global vaccine allocation
Emanuel, E. J., Persad, G., Kern, A., Buchanan, A., Fabre, C., […] & Richardson, H. S. (2020).
The authors of this document set out to define a fair process for the international distribution of vaccines when they become available, proposing the Fair Priority Model. They call upon international health organizations, national governments and vaccine producers to adopt this model in the hope of avoiding “vaccine nationalism,” appealing instead to the values of “benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern” (p. 1309-10). The Fair Priority Model focuses on reducing three kinds of harm: direct harms related to the disease; secondary harms due to health system strain, effects upon mental health, etc.; and the harms related to unemployment and poverty engendered by economic impacts. The authors propose that country-level allocations should roll out in three phases: (1) start with life-years saved per dose to reduce premature deaths; then (2) life-years combined with poverty-reduction potential per dose to favour economies and to reduce deprivation); then (3) target countries with higher transmission rates to reduce community transmission.
Application of the EEFA framework: Ethical analysis of options for the delivery of a second dose of Covid-19 vaccine in the context of a limited vaccine supply. Appendix C from Recommendations on the use of Covid-19 vaccines.
Government of Canada. National Advisory Committee on Immunization (NACI). 2021.
10 pages (approx).
( VF au : https://www.canada.ca/fr/sante-publique/services/immunisation/comite-consultatif-national-immunisation-ccni/recommandations-utilisation-vaccins-covid-19.html#annc )
This document, part of ongoing work by the National Advisory Committee on Immunization (NACI) on vaccine allocation in Canada, describes how the ethics equity feasibility and acceptability (EEFA) framework (see below for the framework) was used to inform deliberations about how to deploy second doses of available Covid-19 vaccines. The principal question is whether to reserve second doses to ensure the recommended two-dose completion for fewer people, or to use them all up as first doses to get partial immunization for more people. The committee produced an analysis based on the first three of the framework’s five steps: (1) identify issue and context; (2) identify ethical considerations (in light of respect for persons and communities, beneficence and non-maleficence, proportionality, effectiveness, precaution, reciprocity, justice, and trust); (3) identify and assess options; (4) select best course of action and implement; and (5) evaluate. They recommend that provinces and territories consult this analysis to ethically inform their decisions about how to proceed through steps (4) decide and implement and (5) evaluate.
Avis préliminaire sur les groupes prioritaires pour la vaccination contre la COVID-19 au Québec [Preliminary guidance on priority groups for Covid-19 vaccination in Québec]
Comité sur l’immunisation du Québec. Institut national de santé publique du Québec. (2020).
https://www.inspq.qc.ca/sites/default/files/publications/3085-groupes-prioritaires-vaccination-covid19.pdf (in French).
The authors identify five values to justify the choice of main objectives of a Covid-19 immunization program and the priorities for distribution in the context of scarcity: beneficence, equity, justice, reciprocity, and non-maleficence. The overarching objective is to reduce serious illness and death. The criteria for establishing priority groups are based on risks relative to i) age, ii) comorbidities, iii) work environment, and iv) living environment. They propose prioritizing access to Covid-19 vaccination in this order: 1) long-term care home residents; 2) health care/care workers in contact with persons at risk; 3) residents in private elder care homes; 4) those in remote communities with high proportions of chronic diseases and crowded living environments; 5) persons 80 years of age and older; 6) persons 70-79 years of age; 7) persons 60-69 years of age; 8) those under 60 years of age with a chronic condition or at higher risk; 9) those under 60 years of age who provide services for or who come into contact with persons at higher risk; 10) the rest of the adult population; (the two remaining groups are to be considered based on vaccine safety) 11) children; and 12) pregnant women. This preliminary prioritization is subject to revision.
Constructing an ethical framework for priority allocation of pandemic vaccines
Fielding, J., Sullivan, S. G., Beard, F., Macartney, K., Williams, J., […] & McVernon, J. (2021).
In producing this document, the authors reviewed the literature on vaccine allocation guidance and pandemic plans, interviewed key informants regarding past experience, current guidance and emerging strategies, and modelled differing vaccine strategies. They presented the available evidence to a national panel for deliberation in order to produce a framework for vaccine priorities. Based on this work, the authors identified three key goals for a vaccine allocation framework: (1) creating and maintaining trust, a constant background requirement; (2) promoting equity; and (3) focusing on outcomes. Both (2) and (3) call for careful interpretation of unfolding evidence in context. The authors note the importance of articulating pandemic response goals and how these relate to priority groups in advance of an emergency. They identify priority groups for the Australian context in two levels of priority, with the highest level including care workers and people who self-identify as First Nations.
COVID-19 and mandatory vaccination: Ethical considerations and caveats. Policy brief 13 April 2021
World Health Organization Ethics and COVID-19 Working Group. (2021).
In this document, the authors identify the ethical considerations and caveats that governments and policy makers should discuss when considering mandatory vaccination. The considerations and caveats include i) necessity and proportionality; ii) sufficient evidence of vaccine safety; iii) sufficient evidence of vaccine efficacy and effectiveness; iv) sufficient supply; v) public trust; and vi) the ethical process of decision making. After outlining these considerations, the authors then apply them to three specific contexts to consider how mandatory vaccination measures might affect the general public, children in school settings, and health care workers. They conclude by noting that governments should make efforts to achieve herd immunity through voluntary vaccination among the population and to consider applying vaccination mandates only if less restrictive means fail.
Covid-19 vaccination certificates: Prospects and problems
Kofler, N. & Baylis, F. (2021).
4 pages (approx.).
In this short article advising caution with respect to vaccine passports/certificates, the authors, who had previously argued that such passports are potentially problematic in terms of privacy, potential for discrimination and for increasing social inequities, raise additional concerns in light of more recent developments. The caution that policies i) should be evidence-informed (e.g., take into account evidence about level and duration of transmissibility among the immunized); ii) should not further entrench inequity (e.g., enabling international travel to places where vaccines are not yet available); iii) should not exacerbate mistrust (e.g., among those marginalized populations who may be mistrustful of authorities and therefore vaccine-hesitant); and iv) must be aligned with public health objectives (i.e., to reduce viral transmission) and not simply to jump-start the economy or to return to ‘normal’.
Ethical allocation of future Covid-19 vaccines
Gupta, R. & Morain, S. R. (2020).
In this article, the authors frame their approach to ethical vaccine allocation around three overarching ethical goals: (1) to reduce morbidity and mortality; (2) to minimize economic and social burdens due to the pandemic; and (3) to reduce unjust inequalities. With these goals in mind, they review five approaches to vaccine prioritization, assess their success at advancing each of the three goals and consider variables that may affect their outcomes. Among the five prioritization approaches (i.e., targeting (i) those most vulnerable to morbidity and mortality; (ii) by life cycle to maximize chances of living through all life stages; (iii) by instrumentality or usefulness to society, such as care and essential workers; (iv) by focusing on equal access for all; and (v) strategically targeting the reduction of spread of Covid-19, by focusing on group settings etc. and those most likely to transmit the virus) none was seen to advance all three goals. The authors recommend a balanced approach that focuses on vulnerability, life-cycle and instrumentality, with those at intersections of these groups receiving first access.
Good reasons to vaccinate: Mandatory or payment for risk?
Savulescu, J. (2021).
In this article, the author argues that mandatory vaccination can be justified if four conditions can be met: i) the threat to public health is serious; ii) the vaccine is both safe and effective; iii) the vaccine is better than the alternatives; and iv) the amount of coercion is proportionate. In instances where it is judged that coercive measures would be disproportionate given higher, perceived, or uncertain risks associated with vaccination, he proposes that incentives can be increased by paying people to accept the risks that accepting to be vaccinated entails, as is done to compensate workers in dangerous construction jobs, for example. The author argues that this may be a morally superior way of increasing vaccination rates in those circumstances as compared to more coercive approaches.
Guidance on the prioritization of initial doses of COVID-19 vaccine(s)
Government of Canada. National Advisory Committee on Immunization (NACI). (2020).
10 pages (approx.)
In this document (webpage consulted December 8, 2020), informed by the Preliminary guidance on key populations for early COVID-19 immunization (just above), the authors provide recommendations for the planning of efficient and equitable prioritization when vaccine supply is limited. These recommendations are based on recent information about vaccine characteristics, trial results and the number of available doses. Recommendations may be updated as the evidence evolves. The populations identified for early Covid-19 immunization include: (Stage 1) “Residents and staff of congregate living settings that provide care for seniors; Adults 70 years of age and older, beginning with adults 80 years of age and older, then decreasing the age limit by 5-year increments to age 70 years as supply becomes available; Health care workers (including all those who work in health care settings and personal support workers whose work involves direct contact with patients); Adults in Indigenous communities where infection can have disproportionate consequences;” (Stage 2) “Health care workers not included in the initial rollout; Residents and staff of all other congregate settings (e.g., quarters for migrant workers, correctional facilities, homeless shelters); Essential workers.”
Instead of vaccine passports, let’s push for global justice in vaccine access
Arguedas-Ramirez, G. (2021).
2 pages (approx.).
The author of this short article challenges the desirability of vaccine passports, arguing that the advantages would accrue to wealthy countries or to the more well-off within countries who are able to access vaccines while others cannot. With such global inequities in vaccine access as we see today, the author asks, “why would a bioethicist or health professional consider vaccine certificates ethical? Covid-19 vaccine production and distribution have been devastatingly unfair” (p. 2). Citing examples of inequitable access, the author concludes that “the decolonized ethical position is to reject Covid-19 vaccine certificates and, most importantly, to put all efforts–political, intellectual, and social–to the task of scaling up global vaccine production as soon as possible and allocating vaccines globally” (p. 2).
Mandatory vaccination for health care workers: An analysis of law and policy
Flood, C. M., Thomas, B., & Wilson, K. (2021).
The authors of this analysis set out to respond to the question of whether governments, health care organizations and private long-term care home companies should consider making Covid-19 vaccinations mandatory for care workers. While the authors consider law and policy precedents and recommend that provincial governments (and not individual employers) are best situated to successfully implement mandatory vaccination for care workers, they also take a normative ethical stance in declaring that provincial authorities should do so. After reviewing a range of labour law and Canadian Charter of Rights and Freedoms challenges that could be mounted by dissenters, the authors argue that in the present context with Covid-19, a vaccination mandate can be justified, for the moment at least, on the grounds that we need to maximize the health care workforce available to treat patients.
Multivalue ethical framework for fair global allocation of a Covid-19 vaccine
Liu, Y., Salwi, S., & Drolet, B. (2020).
The authors observe that fair international allocation of a vaccine will be unlikely in the absence of an ethical framework, and that the barriers to access faced by low-income countries are exacerbated during a pandemic. They analyze the priority claims of four allocation paradigms: (1) ability to pay – access is based on a nation’s ability to produce or purchase it; (2) reciprocity – developing countries that contribute to vaccine development should also benefit; (3) ability to implement – a vaccine’s benefits will be maximized by allocating it to countries with the most developed delivery infrastructure; and (4) distributive justice for developing countries – priority goes to those with higher disease burden, risk of transmission and lack of access to care. To mitigate international and local disparities, the authors propose a multivalue ethical framework comprising three principles and a point system for prioritizing countries’ access to vaccines: ability to provide care (where a lack of capacity scores high), ability to implement (where high capacity scores high), and reciprocity (where participation in development and testing scores high).
Persuasion not coercion or incentivisation, is the best means of promoting COVID-19 vaccination
Pennings, S. & Symons, X. (2021).
In this response to Savulescu’s article Good reasons to vaccinate: Mandatory or payment for risk?, (also summarized in this section) the authors agree with Savulescu that governments have a strong obligation to reduce the spread of Covid-19, and that it is unlikely that a sufficient percentage of the population will choose to be vaccinated to achieve herd immunity. However, contra Savulescu, the authors argue against compulsory vaccination, and against monetary or other incentives. Instead, they argue for (re)building social trust, an approach which, although lengthy and complex, is less risky than incentive or coercion-based approaches. This calls for efforts in communications, transparency, social outreach, and taking the time to address the expressed concerns of vaccine-hesitant communities.
Preliminary guidance on key populations for early COVID-19 immunization
Government of Canada. National Advisory Committee on Immunization (NACI). (2020).
59 pages (approx.).
This preliminary document (November 2020) by the NACI provides guidance for the “efficient, effective, and equitable” allocation of approved Covid-19 vaccines when supply is limited and some populations are to be prioritized before others, with an overarching goal of minimizing serious illness, deaths, and societal disruption. The process was informed by a review of the current Covid-19 vaccine landscape, a rapid review of risk factors for severe Covid-19, a survey of expert stakeholders, and an assessment of ethics, equity, feasibility and acceptability considerations (following the framework of Ismail et al. DOI: 10.1016/j.vaccine.2020.05.051 ). The process considered a number of factors, including risk-benefit analyses, vaccine characteristics, vaccine supply, and evolving epidemic conditions. Key populations for prioritization include those at high risk of illness or death due to Covid-19; those most likely to transmit it to others at high-risk; workers essential to Covid-19 response; those providing essential services for societal function; and those in conditions of elevated infection risk and who would face potentially disproportionate consequences.
The Advisory Committee on Immunization Practices’ ethical principles for allocating initial supplies of Covid-19 vaccine – United States 2020
McLung, N., Chamberland, M., Kinlaw, K., Matthew, D. B., Wallace, M., […] & Dooling, K. (2020).
The US Advisory Committee on Immunization Practices outlined principles to guide the development of recommendations for allocating vaccines when supply is limited. The four principles are: (1) maximize benefits and minimize harms, (2) promote justice, (3) mitigate health inequities, and (4) promote transparency. For each principle, the authors propose several questions to help ensure that the principle is being observed when considering allocation scenarios. They then apply the principles, considering some of the implications of each across four candidate groups for initial vaccine allocation: health care workers, essential workers, adults with high-risk medical conditions, and those aged 65 years or over.
The Coronavirus vaccines are here. Now what?
Goldenberg, M. (2020).
3 pages (approx.)
In this article, the author stresses that the message is not an anti-vaccine one, but rather a call for a comprehensive response to Covid-19 that includes questioning and acting upon the social arrangements and institutions that did not adequately respond to the Covid stress-test. Covid-19 vaccines are not a panacea and should not allow us to neglect other crucial demands of a pandemic response, notably more robust public health infrastructure at home and abroad. The author concludes by saying that the “pandemic has highlighted the need for better strategies for managing ourselves in relation to the environment, to animals, and to other people through more just political and economic systems.”
The COVID-19 vaccines rush: Participatory community engagement matters more than ever
Burgess, R. A., Osborne, R. H., Yongabi, K. A., Greenhalgh, T., Gurdasani, D., […] & McKee, M. (2021).
In this article, the authors identify a number of pitfalls and contextual considerations, many connected to inequalities, that can affect implementation and uptake of Covid-19 vaccinations. Reflecting on the potential for mistakes increasing and solidifying some communities’ mistrust of authorities, the authors present a series of recommendations for “achieving meaningful engagement with diverse communities in preparation for the Covid-19 vaccines roll-out” (p. 10). Their recommendations, in tabular form, set out a pathway for enabling community engagement, considering key aims, actors, responsibilities and delivery mechanisms at local, regional, and national levels. The authors make a case for participatory community engagement, from the ground up, to produce better results, increase uptake, and save resources.
With first dibs on vaccines, rich countries have ‘cleared the shelves’
Twohey, M., Collins, K., & Thomas, K. (2020).
8 pages (approx.)
Based on data on vaccine contracts obtained by the New York Times, this article outlines some of the issues relating to wealthy countries securing enough doses to immunize their populations many times over, hedging on different companies’ offerings by pre-purchasing multiple vaccine candidates, while less wealthy countries may not be able to fully immunize their populations until as late as 2024. Some less-wealthy nations are using their domestic drug-manufacturing strengths or other means to overcome these gaps, but not all nations are able. In addition, there is competition among wealthier countries to secure priority for earlier delivery dates as orders exceed supply capacity.
Priority-setting/allocation of resources
A framework for rationing ventilators and critical care beds during the Covid 19 pandemic
White, D. B. & Lo, B. (2020).
This article addresses the following question: under the present circumstances, when clinicians’ priorities shift from concern for individual patients to concern for many in need, when there is greater demand for ventilators than supply, by what criteria should rationing decisions be made? The authors reject the categorical exclusion of any group, whether due to comorbidities or any other traits; thus there is no discrimination against anyone as “not worth saving.” They exclude likelihood of survival as a sole criterion for triage, instead arguing that other criteria are ethically relevant, including expected life-years (prioritizing youth), access to the range of life-stages (prioritizing youth), and instrumental value (prioritizing healthcare workers). The authors explicitly exclude other criteria as morally irrelevant (“sex, race, religion, intellectual disability, insurance status, wealth, social status, or social connections”). They propose a framework that deploys a scoring system for likelihood of survival and likelihood of achieving longer-term survival, adjusting scores to favour healthcare workers; in the event of equal scores between patients, youth is a tiebreaker. Finally, the authors treat ventilator withdrawal and reallocation separately, focusing on time-limited but not-too-brief allocations, conferring decisions onto triage officers or teams, and attending to the importance of palliative care.
An ethics framework for making resource allocation decisions within clinical care: Responding to Covid 19
Sydney Health Ethics. (2020).
The authors propose an ethics framework for allocation of scarce resources that is consistent with four clinical aims: appropriate care relative to need, continuity and sustainability in health and public health systems, maintenance of trust in the health system, and research and innovation to improve care. They propose planning ahead, defining processes, designating triage committees, and three key conditions: equal value of all; getting the most out of resources; and giving priority to those in need. The authors propose that decision making proceed by: (1) defining the tipping point (for conditions of scarcity); (2) determining ICU eligibility (i.e., excluding those who refuse, who do not need it, or who are terminally ill); (3) prioritizing the eligible candidates from high to low (highly likely to recover vs may recover); (4) prioritizing among high priority candidates (to be discussed and justified but may include care workers, home caregivers, Indigenous persons, etc.); and (5) regularly reviewing patients’ status and resources to change course as needed. They do not see a valid distinction between Covid and non-Covid patients for prioritizing resources. The authors address the obligations of organizations and clinicians, and the importance of conducting ongoing research.
Contextualizing ethics: Ventilators, H1N1 and vulnerable populations
Silva, D., Nie, J. X., Rossiter, K., Sahni, S., & Upshur, R. E. G. (2010).
This 2010 article contemplates rationing criteria for ventilator shortages in the context of the H1N1 crisis. The discussion is relevant to today’s concerns. The authors critique the criteria that they had seen proposed to date, as they were predominantly based on the principles of utility and efficiency, i.e., maximizing the greatest good for the greatest number. They note that such an approach would be at the expense of marginalized populations, groups that are already at greatest risk, thereby magnifying existing inequalities. For example, Indigenous persons were disproportionately affected by H1N1, and may not be well-served by the bare application of utility and efficiency as criteria. To correct this, the authors recommend adding other principles to the discussion, including equity (“distributing resources on the basis of trying to rectify social inequalities”) and need (“prioritizing those persons who are in the worst conditions”) (p. 34), and engaging in consultation with those who would be disproportionately affected in order to inform decision makers.
Disablism in a time of pandemic: Some things don’t change
Scully, J. L. (2020).
4 pages (approx.).
In this blog article, the author addresses the ethics of triage (moral guidance for what to do if ICU beds and ventilators do not meet need, and how to justify difficult choices) claiming that there is a worrying degree of disablism (prejudice against disabled people) in recently-published resources. In response to these, the author analyzes disablist assumptions and norms at play and proposes recommendations for producing better clinical guidelines. Assumptions are made about disabled people’s diminished health status, quality of life and social utility, suggesting that they are harder-to-save, have less valuable lives, etc. Unexamined norms relating to human form, function and behaviour shape the published guidance in a way that can exclude people with disabilities from consideration for critical care. Recommendations include: triage guidance should explain its reasoning; disability status should not be used to represent health status; critical care decisions should be based on the individual’s health, not just on medical records or assumptions; critical care decisions should exclude broad social utility criteria; and triage guidance should explicitly state that disabled persons are equally valuable and worthy of care.
Fair allocation of scarce medical resources in the time of Covid 19
Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020).
The authors observe that this pandemic will most likely exceed hospitals’ ICU, ventilator, personal protective equipment (PPE) and staffing capacities. Given inevitable shortages, it is therefore important to set consistent and ethical limits on resources and not make ad hoc decisions in the heat of the moment. Past analyses have focused on four fundamental values as criteria for rationing: maximizing benefits (life-years saved), treating people equally (lottery), promoting instrumental value (care workers first), and favouring the worst off (either the sickest, or youth – who have more to lose). Based on these four, the authors propose six recommendations, in order of priority: (1) maximize benefits in terms of saving lives and saving life years; (2) prioritize care workers; (3) other things being equal, equality demands a lottery rather than first-come first-served as a criterion; (4) evidence, context, and prognosis should inform prioritization guidelines; (5) participants in Covid-19 clinical research should receive some prioritization for interventions; and (6) there should be no difference in resource allocation “between patients with Covid-19 and those with other medical conditions” (p. 6). The authors propose triage officers or committees to relieve clinicians of this burden.
ICU triage in an impending crisis: Uncertainty, pre-emption and preparation
Wilkinson, D. (2020).
The author argues that in a pandemic triage situation that ICUs may face due to Covid 19, “at a basic level the key values are those of benefit and fairness” (p. 1), where benefit focuses on maximizing outcomes while fairness focuses on equity. When ICU capacity is not overtaxed, it is possible to focus on fairness. When resources become scarce, the value balance must shift to benefit. This means prioritizing patients with the highest chance of surviving and with the shortest duration of ICU stay. The author considers the uncertainty faced during an approaching pandemic surge and offers three suggestions: plan to revise triage decisions as the situation evolves; determine how to support ICU clinicians in their decision making; and accept that during a crunch it may be reasonable to withdraw treatment depending on how a patient’s progress changes.
Not who, but what professional bioethicists should prioritize when responding to the Covid-19 pandemic?
Stramondo, J. (2020).
3 pages (approx.).
In this short article, the author relies on the work of Shelley Tremain to argue that it is very difficult to overcome ableist biases in triage protocols. While there is a great deal of work being done to refine protocols to make them more equitable, it may not be something that can be overcome. Meanwhile, this attention to protocols distracts us from advancing a more important conversation: reducing the need to make these triage choices at all. Needing to make triage choices is not inevitable; it will be determined by economic, social and political choices beforehand. Given these observations, the author argues that bioethicists should focus on reducing the need for triage rather than on perfecting protocols, and offers two specific recommendations for how to do so. First, bioethicists can help to keep stay at home orders in place and advocate for a safety net so that citizens can shelter in place without undue hardship. Second, bioethicists can use their influence to push for a massive scale-up of the production of personal protective equipment. Both of these will add to society’s ability to avoid triage in the first place and help to reduce systemic injustices.
Pandemic palliative care: Beyond ventilators and saving lives
Arya, A., Buchman, S., Gagnon, B., & Downar, J. (2020).
The authors take a different angle on triage questions by reviewing the challenges related to providing palliative care, arguing that a failure to provide high-quality palliative care to patients who are not provided access to a ventilator would compound the tragedy of the pandemic. Palliative care focuses on three main dimensions: managing symptoms, discussing patients’ wishes, expectations and values, and supporting families. The article presents the main considerations for Covid-19 palliative care in Canada as follows: services will be needed in many care settings including ICUs, wards, emergency departments and long-term care (where resources are particularly limited); patients’ autonomy to choose life-prolonging measures or the place of their death may be limited, and some may be isolated; much has been written on how to triage in emergencies, but there is little guidance on how to manage patients for whom life-sustaining measures are not offered; authorities should plan for palliative care needs by preparing stuff, staff, spaces, systems, means for family connections, communications plans, and ensuring a focus on equity. These can serve as a guide to ensure that Canada provides effective palliative care during this crisis.
Structural racism, white fragility and ventilator rationing policies
Galarneau, C. (2020).
2 pages (approx).
In this short article, the author argues that many leaders in health care turn themselves in knots denying that their policies differentially affect people of colour, saying that disability, race, ethnicity, etc. have no bearing on care decisions. This she views as an instance of white fragility, a term coined by Robin DiAngelo. “This avoidance of dealing with race and racism stems in part, [DiAngelo] says, from whites not understanding themselves as raced, not owning up to being the dominant racial group […] and to having racial privilege” (p.1). The way forward consists in white people, the dominant racial group, accepting the reality that they are the beneficiaries of a hierarchy that has hurt others; recognizing that structural racism is present in health institutions; and trusting that those most affected by racism have knowledge that is crucial to ending it.
The toughest triage: Allocating ventilators in a pandemic
Truog, R. D., Mitchell, C., & Daley, G. Q. (2020).
This short article in the New England Journal of Medicine begins with the observation that the US will soon face a never-before seen shortage of critical supplies at this scale; among these, ventilator shortages will lead to the most problematic type of rationing. In a time of extreme shortage, we can envision situations where mechanical ventilation is either withheld or withdrawn when its use would be non-futile and would save a life. The moral distress involved in making such decisions is extreme, and the authors propose that physicians should be buffered from these tragic choices. In their place, decision making should be done by triage committees acting with prior written guidance. They cite several advantages to this approach: physicians and nurses can maintain their fiduciary roles as advocates for their patients, the moral burden of the choice is spread over a committee and not one individual, physicians can be relieved of the role of communicating to families the decision to withdraw life-saving ventilation, as well as the task of withdrawing the ventilation itself. In short, “Creation and use of triage committees … can help mitigate the enormous emotional, spiritual, and existential burden to which caregivers may be exposed” (p. 2).
The way we ration ventilators is biased
Schmidt, H. (2020).
3 pages (approx.).
The author of this article agrees that rationing may be necessary, and that on first glance the model guidance for saving the most lives possible seems fair. However, he argues that there are biases baked into the “saving most lives” formula that disadvantages groups facing worse health due to historical and structural reasons. Baseline health is much worse among some groups, including low-income, disabled, uninsured, and some racial and ethnic groups, for reasons that are overwhelmingly structural and historical, whether due to environment, social status, etc. These produce disadvantages in health and those must be acknowledged in triage decisions. The author proposes that fairness be built into a weighting system to recognize historic disadvantage as a factor in triage decision making, going beyond measures that rely on simple physiology and life expectancy.
Unblinded: Systematic racism, institutional oppression, and colorblindness
Sederstrom, N. O. (2020).
3 pages (approx.).
In this article, the author conducts two theoretical ventilator triage scenarios using two different processes to respond to the question: “Is the ‘most lives saved’ standard equitable given the reality of structural racism?” In the scenarios, two patients are in need of a ventilator. One is a black woman, Covid-19 positive with comorbidities and the other is a white man, Covid-19 positive without comorbidities. The author critiques efforts to include considerations of equity in crisis standards of care through incorporating retrospective review into processes, and argues for “unblinding” and placing race and equity in the foreground.
Communicating risk in public health emergencies: A WHO guideline for emergency risk communication (ERC) policy and practice
World Health Organization. (2017).
This guidance document sets out to address the risk-communication challenges that emerged during recent public health emergencies. Some key issues include rapid change in communications technology, the prevalence of cellular communications, the use and influence of digital media (at the expense of traditional sources), changes in the means of accessing and the degree of trust in health information, and the contextual factors that influence people’s risk analyses and behaviours, among others. The document provides three main sets of recommendations, under building trust and engaging with affected populations, integrating emergency risk communications into health and emergency response systems, and emergency risk communications practice. Recommendations within each of these categories are given a relative strength and a rating for the quality of evidence supporting the recommendation.
Ethical issues in Covid-19 communication to mitigate the pandemic: Dilemmas and practical implications
Guttman, N. & Lev, E. (2020).
In this article, the authors outline the types and complexity of the ethical challenges relating to communication in a pandemic. The types of ethical issues are discussed in four sections: (1) ethical issues when disseminating risk information (including communicating uncertainty, communicating gravity, the risks of using scare tactics and using war frames); (2) sociocultural and medical unintended consequences (including communication and inequities, stigma, ageism and delay of care for other medical conditions); (3) communicating about specific mitigation practices (including contact tracing, hygiene, face masks and distancing); and (4) appealing to social values of responsibility, compassion and solidarity. They argue that attending to these concerns will enhance trust, cohere with best practices, and improve the effectiveness and equitability of communications efforts.
Guilt, fear, stigma and knowledge gaps: Ethical issues in public health communication interventions
Guttman, N. & Salmon, C. T. (2004).
For access to a one-page adapted summary, click here: http://www.ncchpp.ca/docs/2017_eth_frame_guttman_salmon_En.pdf
In this paper, the authors focus on eight themes that can help to illuminate the ethical issues that arise in public health communication initiatives. The themes are: the targets of the intervention, informed consent, persuasion tactics, responsibility and culpability, harm reduction, labelling and stigmatization, social and health equity, and the promotion of health as a value. This article is not pandemic or emergency specific, but may serve as a helpful reference document.
Producing fear for the greater good? The ethics of truth and public safety during the Covid-19 pandemic
Williams, K. & Stroud, S. R. (2020).
In this case study/discussion paper published in May 2020, drawing from experiences in the early weeks and months of the Covid-19 pandemic, the authors consider the ethics of using fear (i.e., publicly communicating that 40% of patients requiring hospitalization were under 55) to motivate younger adults to observe precautions to limit the spread of the virus. The authors suggest that while numbers for the 20-54 years of age cohort as a percentage of overall hospitalization rates that were used in public messaging may have been overestimated due to asymptomatic cases and low testing numbers, there are benefits and risks to using “not-entirely-baseless but nonetheless misleading statistics” (p. 2) to motivate certain behaviours. They conclude with questions for discussion relating to truthfulness, contextualization, persuasion, prioritization of health over other values, and how to achieve the ends of health without compromising other values.
We need to change our thinking and communication, urgently, to beat Covid-19
Carter, S., Braunack-Mayer, A., & Degeling, C. (2020).
4 pages (approx.).
The authors of this blog article set out to highlight that we are all connected; a pandemic shows us this. They propose the adoption of public values of solidarity, reciprocity and common good as being the most suitable values for addressing ethical issues in a pandemic. By contrast, they indicate that two individualistic, rather than collective, responses tend to hold sway in the sphere of communications: the Crocodile Dundee (“no worries, mate,” shrugging off risks and ignoring public orders) response, and the fearful preparation (hoarding, over-preparing and producing shortages) response. These both reflect selfish individualism and the authors claim that they are exacerbated by media during the pandemic, as the messaging focuses on risks to individuals, tending to separate “us” from “them.” They call for reframing media communications around solidarity, reciprocity and common good, concepts that Australians know well and can attach to if encouraged.
Global health, global justice
Covid 19 in humanitarian settings and lessons learned from past epidemics
Lau, L. S., Samari, G., Moresky, R. T., Casey, S. E., Kachur, S. P., Roberts, L. F., & Zard, M. (2020).
Covid 19 has reached 79 refugee-hosting countries and transmission will inevitably spread to highly-vulnerable displaced populations. Based on lessons learned from their experience with past pandemics and epidemics, the authors present three broad recommendations. First, essential health services must be maintained to reduce additional deaths from Covid 19, as the indirect health effects of epidemics (due to disruptions and diversions of health resources) can exceed the death tolls from the disease, especially with respect to chronic diseases. Second, access to infection prevention, control, testing and treatment for refugees is essential, as these measures that are known to protect communities are just as important in crowded, poorly-resourced camps, high-density urban areas, detention facilities, etc. Third, controlling a pandemic depends upon community engagement and trust, as detection, communications and containment efforts all depend upon public cooperation. To conclude, the authors observe that “protecting the most vulnerable among us is not just a moral imperative but an urgent public health objective: the health of one is the health of all” (p. 2.).
World’s most vulnerable in “third wave” for Covid-19 support, experts warn
Ahmed, K. (2020).
2 pages (approx.).
This short article claims that we face an upcoming disaster: the world’s most vulnerable people will be last in line for support to deal with Covid 19. In particular, countries facing refugee crises and humanitarian situations will lack the resources for dealing with the pandemic when it arrives. Wealthier countries are already struggling to cope, but less-resourced countries that have relatively few cases at present, those with weakened health systems, have not yet been hit. This calls for a more global approach to strengthening health systems and for coordination between humanitarian organizations and governments.
Coronavirus: The effects on human rights
Amnesty International UK. (2020).
4 pages (approx.).
This document focuses on the UK context but it makes broad claims about the role and responsibilities of governments with respect to human rights and Covid 19, claiming that Covid 19 responses must be framed by a human rights focus. Human rights protect citizens from the power of the state and oblige governments use their power to protect health and well-being. The authors demand that governments ensure human rights are “at the centre of all prevention, preparedness, containment and treatment efforts, in order to best protect public health, welfare, and support the groups and individuals most at risk.” Government should support people economically, attending first to the most vulnerable and least protected. Emergency powers must be temporary, proportionate, in accord with international rights laws and subject to scrutiny. The document identifies groups subject to greater risk and makes the link between vulnerability and exclusion from the health care system, calling for, above all, support and respect for the most vulnerable.
Physical (or social) distancing: balancing benefits and harms
Cohesion in distancing
Shen, M. (2020).
We recommend that you click on the link for this, as it is a visual art piece. The artist is Dr. Michael Shen, a physician in New York City. In his commentary, he observes that as we are now required to distance ourselves from one another, contrary to our human needs and norms, this evokes a dramatic tension between separation and togetherness. By distancing ourselves, we show our cohesion, we manifest our solidarity.
Individual rights vs the common good in the age of Covid 19
Will, M. (2020).
6 pages (approx.).
In this article from a suburban Denver newspaper, the author interviews local experts to discuss issues relating to whether (US) behavioural norms and political orientations are incompatible with the demands of the Covid 19 crisis. In particular, they reflect on the area’s (as of late March 2020) half-hearted response to social isolation in order to flatten the curve. While on the one hand the crisis calls for coordinated efforts, including a robust, collective effort to practice distancing, this is less compatible with the individual-liberty focused or libertarian leanings of many citizens. What’s more, distancing does harm, and while it may be justifiable early on in the pandemic, as time passes it is likely to become more difficult to justify and to enforce.
Markets vs lives
Gonsalves, G. & Kapczynski, A. (2020).
8 pages (approx.).
In this (US) article, the authors accept that physical/social distancing is necessary for minimizing the transmission of Covid 19, for protecting the vulnerable, and for flattening the curve to reduce catastrophic outcomes. Their objective is to take on a backlash against distancing that pits efforts to stop Covid 19 against the economy. These arguments might be summed up as saying “the cure is worse than the disease” due to damage to the economy. The authors note that distancing has taken much of the workforce out of the economy in the name of a social and common good, and that this unpaid work does not show up in GDP, in the economy. This crisis calls for us to protect people from disease, to support them through this emergency, and to not treat anyone as expendable in the name of economic stability. To do so, the authors propose several priorities: coordinate to end the shortages of protective gear and medical equipment; dramatically increase testing; massively support clinics and hospitals with personnel, resources and support; do everything possible to develop vaccines; provide stable and appropriate income support for people; and attend to the needs of those who are vulnerable, whether incarcerated, homeless, elderly, or otherwise at risk.
Issues relating to shutting down and reopening
A harm reduction approach to the ethical management of the Covid-19 pandemic
Weinstock, D. (2020).
In this paper, the author notes that the most complex policy aspects of the Covid-19 pandemic occur in the middle phase (between the confinement measures of the flattening the curve phase and the pandemic’s end phase, when it is no longer a threat), as this involves emerging from confinement while keeping risk to acceptable levels. After enumerating the various types of harm that arise due to confinement, he draws from those costs a set of four principles, consistent with a harm-reduction approach, to guide policy measures during the middle phase. These include: (1) attending to the secondary harms that arise from combating the primary harm; (2) recognizing that the disadvantaged suffer more from the primary harms and the secondary harms due to existing injustices; (3) recognizing the sociality of people by limiting coercive distancing measures; and (4) recognizing that informed, willing compliance is preferable to enforcement. After applying the principles to an analysis of immunity passports, the author concludes with a consideration of how we might rethink space and time in our work, play and cultural spaces in order to adapt.
An ethics framework for the Covid-19 reopening process
Bernstein, J., Hutler, B., Rieder, T., Faden, R., Han, H., & Barnhill, A. (2020).
This is a framework for ethically evaluating the “cascade of policy decisions” that define the reopening process and navigating the trade-offs between science, economics, well-being, liberty, justice and other values. Setting out, the authors identify the importance of public participation, expert input, clear communications and responsiveness to new information. The framework is organized in seven steps. Step (1) involves selecting potential policies and considering their feasibility. Steps (2) to (5) are about evaluating the policies through the values of (2) well-being; (3) liberty; (4) justice; and (5) legitimacy. Step (6) is about evaluating how to mitigate harms implied by the policy options to make them more acceptable. Step (7) is an overall assessment to decide if the option(s) is(are) ethically acceptable based on steps (1) to (6). Each step includes a series of questions and considerations, and some include grids for identifying policy effects or distributions of benefits and burdens by group.
Enjeux éthiques de la pandémie de Covid-19 Précaution et déconfinement
Désy, M., Bernier, N., St-Pierre, J., Leclerc, B., Couture-Ménard, M-È., & Maclure, J. (2020).
28 pages (in French).
In this reflection document, to be considered alongside the ethics framework (see Désy et al., 2020, in the “Frameworks and guidance” section above) the authors outline some of the ethical issues relating to shutting down and reopening (confinement, déconfinement) and identify the main values and principles to consider in complex social, economic, scientific and policy contexts during the pandemic through the overarching perspective of the precautionary principle to help clarify decision making in times of uncertainty. Some of principal considerations include the role of science in policy making, the quality of evidence during an emergency, recognizing the social context, the confidence of the population, and the precautionary principle. The authors analyze three case studies to discuss the ethical dimensions of reopening, identifying issues and key ethical values in each: (1) reopening schools, (2) reopening parks and sporting venues, and (3) wearing a mask. The document concludes with a discussion of communication with the public.
Failure to combat Covid-19 can have economic consequences too
Smith, M. (2020).
3 pages (approx.)
In this short article, the author argues that discourses that pit Covid-19 control measures against the economy produce a false dilemma, and that the economy and the public’s well-being are interconnected. By keeping businesses open amid surging case numbers, the economic consequences may be worse than those due to shutting down. Instead, he argues that governments should take measures to “mitigate the potential economic and social harms that may result from restrictive public health measures used to prevent deaths and serious illness (such as closures or lockdowns)” since it is possible for governments to reciprocally help individuals and business withstand shorter-term economic hardship, but death is irreversible.
Duties of society/professionals/citizens (and expectations of reciprocal support)
Covid-19 ethics analysis: What is the ethical duty of health care workers to provide care during Covid-19 pandemic?
BC Centre for Disease Control & BC Ministry of Health. (2021). (updated version published January 2021)
In this document, the authors examine the duty to care, which demands that patients’ well-being should come first, and relates this to tensions and competing duties that can arise for healthcare workers in the context of Covid-19. They identify three features underlying the duty to care: (i) greater ability to care creates an obligation to provide care; (ii) choosing the profession implies accepting risks; (iii) society provides legitimacy to healthcare workers through an agreement that they will step up in an emergency. The authors turn to what is known about Covid-19 to contextualize risks for workers and consider potential limits to the duty to care, through an ethical analysis based on BC’s Covid-19 Ethical Decision-Making Framework (summarized in the section Ethics frameworks and guidance for pandemics and public health emergencies, above). This analysis proceeds through a consideration of the ethical principles of reciprocity, respect, the harm principle, duty to care, fairness, proportionality, least coercive or restrictive means, working together, and procedural justice, considering each in the context of Covid-19. The article concludes with 14 specific recommendations for healthcare workers, organizational (hospital) leaders, and system-level (health authority and government) leaders.
What are the rights and responsibilities of healthcare providers in a pandemic? What can they expect from their employers, governments and us?
Gruben, V. & Czarnowski, A. (2020).
In this article, the authors set out to define our reciprocal duties towards one another, the duty to care of healthcare workers, the responsibilities of governments and employers and the responsibilities of the public. The duty to care obliges healthcare workers to act in the interests of their patients, but this duty has limits. Redeploying workers into higher risk settings or out of their fields of expertise is more problematic than expecting workers to continue in their chosen settings. Increasing personal risk to the worker under conditions of low benefit to the patient also diminishes the obligation to care. Obligations to families and loved ones can also justify stepping back. Governments have obligations to protect healthcare workers with protective equipment, testing, up-to-date information, systemic measures to reduce the burden on the system, counselling and other supports. The public also has responsibilities, including physical distancing, self-isolating if returning from abroad, etc., affirming that the duties of healthcare providers are not one-directional and there are corresponding societal duties towards them.