________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ 1 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Letter to editor Volume 13 (Suppl.) Number 24 December 2020 Copyright © 2020 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. COVID-19 pandemic and the ethical challenges in patient care Ali Sahebi1, Siamak Moayedi2, Mohamad Golitaleb3* 1.PhD Candidate in Health in Emergencies and Disasters, Department of Health in Emergencies and Disasters, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2.Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA. 3.Instructor, Department of Nursing, School of Nursing, Arak University of Medical Sciences, Arak, Iran. The COVID-19 disease is a recent human infectious disease caused by the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). This virus has affected almost all world's countries, and hence challenged the global healthcare system (1). Healthcare providers should comprehend ethical aspects of providing care services during the COVID-19 pandemic, and the following factors highlight the need for providing ethical care services: (i) ongoing advances in diagnosis and treatment of COVID-19, (ii) discovery of new pharmaceuticals, and (iii) disparities in accessing to healthcare among the pandemic- affected (2). The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have proposed healthcare guidelines for standard precautions while caring for the COVID-19 patients and observing quarantine principles (3). Social distancing and quarantining can lead to neglect of vulnerable patients, discrimination against them, as well as limiting their access to health services, educational and social programs. The consequences of social distancing and quarantining can become risk factors in violating patient rights. Physicians and nurses have a moral duty to fulfill patients’ rights (2, 4), and failure to adhere to professional ethics leads to the challenges reducing care quality (2). *Corresponding Author Mohamad Golitaleb Basij Sq., Sardasht Region, Arak, Iran. Postal Code : 6941738481 Tel : (+98) 86 34 17 35 24 Email: m.golitaleb@arakmu.ac.ir Received: 8 Oct 2020 Accepted: 1 Dec 2020 Published: 19 Dec 2020 Citation to this article: Sahebi A, Moayedi S, Golitaleb M. COVID-19 pandemic and the ethical challenges in patient care. J Med Ethics Hist Med. 2020; 13(Suppl.): 24. mailto:m.golitaleb@arakmu.ac.ir COVID-19 pandemic and the ethical challenges in patient care 2 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 (Suppl.) Number 24 December 2020 Patient rights established by WHO include the followings: (i) receiving high-quality care and treatment, (ii) equitable access to healthcare services and information, (iii) confidentiality of information, (iv) informed consent, (v) self- determination and independence, (vi) access to health education, and (vii) the right to complain and demand compensation (2). Social stigma and discrimination due to fear and misinformation can promote significant violations of these basic rights (2, 5) . Violating rights, such as receiving information, education, and care, compromises individuals’ basic rights (e.g., medical care and social services) during pandemics such as COVID- 19, thereby making individuals more vulnerable. To reduce vulnerabilities, individuals and communities should be empowered not only to make effective choices but also to manage what threatens their health. Moreover, consequences of not adhering to ethics reduce both patients’ satisfaction and healthcare providers' service quality. Considering the importance of ethics in providing healthcare services during the pandemic, this article aimed at addressing eight ethical challenges in providing such services to the COVID-19 patients (2, 6). Challenge of allocating limited resources A key ethical issue in the COVID-19 pandemic is fair allocation of the limited available resources among patients. During this pandemic, involved 218 world countries, due to the virus’s highly-contagious nature, maximum capacity of most hospitals has been consummated, and their need for medical and life-saving equipment (e.g., mechanical ventilation, Extra-Corporeal Membrane Oxygenation (ECMO) device) has been high and increasing. Hence, resource triage is a difficult challenge for healthcare staff, and these limited resources should be appropriately allocated. Almost always, high priority is given to young patients who may have higher survival chance. The COVID-19 disease often presents itself with Acute Respiratory Distress Syndrome (ARDS), and allocating a ventilator, currently being rationed among patients, has been one of the most difficult decisions to make. During this pandemic, repetition triage or reallocation has been necessary. For example, with a shortage in ventilators, nurses and other healthcare staff need to constantly monitor the effects of invasive ventilation on specific patients and reallocate the ventilator to a patient with higher recovery chance (4). Medical and healthcare staff are not unlimited resources, and the virus has seriously affected them during this pandemic as well as inflicted them with severe burnout. Therefore, in caring for the COVID-19 patients, in addition to limitations in medical equipment and Personal Protective Equipment (PPE), a shortage in human resources is another important challenge that should be managed by hiring new staff or employing trained volunteers. Ethical challenges in researches Ethical challenges in researches are among the most important issues during the COVID-19 pandemic. As of November 8, more than 10 months after the advent of COVID-19 and the time of writing this article, no definitive treatment or vaccine is publicly available. Due Sahebi A., et al. 3 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 (Suppl.) Number 24 December 2020 to high prevalence and mortality of COVID-19, pharmaceutical and vaccine companies around the world are rigorously competing, and several companies have claimed to produce medication or vaccine so far. In addition, to acquire more profits and to introduce their products earlier, these companies may disregard research ethics in respective interventional studies and clinical trials (7). Hence, observing protocols according to the guidelines of research ethics committees and the principles of the Helsinki Declaration is critical to respect human dignity in all circumstances. Safety of medical and healthcare staff In the fight against COVID-19, the safety of nurses as well as other medical and healthcare staff at the forefront is a significant ethical issue, given that their high-risk work situation threatens their health. Although COVID-19 is not as mortal as Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) or Swine- Origin Influenza (H1N1), medical and healthcare staff confront high risk and unknown conditions due to limited knowledge regarding the virus (e.g., pathophysiology, transmission routes, vulnerability, and contagious rate) and lack of adequate PPE supplies. Inadequate protection of medical staff in hospitals and healthcare centers raises an ethical concern about the extent to which they have a professional patient-care duty since the pandemic disrupted their routine tasks and increased their workload. In addition, the conflict between civil duty and self-interest makes nurses more vulnerable and confused in their fight against COVID-19. Therefore, they make best effort to balance their personal interests and duties to be able to care for patients, as well as to compensate for shortcomings in healthcare systems. Therefore, they try to make such efforts in a way that is compatible with their duties and rights to protect themselves and their families. Politicians and authorities should realize the risks associated with the nursing profession as well as related emotional burden and consequences. Healthcare staff’s concern about PPE are not only because of their own protection, but also due to their fear of transmitting the infection to their family members, especially those with underlying diseases and higher vulnerability. Additionally, a nurse can be the only and primary caregiver at home for their children or older family members (e.g. parents). Both healthcare organizations and healthcare and medical staff have a responsibility to utilize all their resources for providing care (4, 8). Regardless of the presence or absence of PPEs, organizational leaders should appropriately guide and support nurses and other medical and healthcare staff. Moreover, they should endeavor to provide PPEs, encourage proper use of them, and manage shortage or lack of them. Respecting patient’s independence As a key component in providing ethical care, all medical and healthcare providers need to guarantee and respect patient's independence. Patient’s independence is referred to patient’s ability to make informed or rational decisions, COVID-19 pandemic and the ethical challenges in patient care 4 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 (Suppl.) Number 24 December 2020 requiring adequate information from medical and healthcare team (2, 5, 9). In addition to promoting trust, respecting patients’ independence enhances their mental and physical comfort, as well as increases adherence to treatment. However, in caring for the COVID-19 patients, adhering to this principle may present challenges, as the patients ' refusal to accept treatment or quarantine endangers not only their personal health but also community’s general health. Given these dangers, relying on paternalism, along with the traditional patient care approaches while noticing medical and healthcare team's decisions, is a predominant and practical care approach during this pandemic. Educating patients about the risk of death and disease transmission can improve the situation, and with patients’ participation, right decisions can be made to continue treatment (6, 8). Healthcare providers may have high medical experience and knowledge; however, patients prefer participatory decision-making. Such decision-making requires patients to have adequate information and appropriate education that must be offered by medical and healthcare team as well as healthcare organizations and providers. Ethics in quarantine Quarantine, as a mandatory isolation, restricts physical contact of a person exposed to an infectious disease to prevent its spread. Since quarantine restricts freedom, patient's rights and independence may be endangered. Although maintaining public health takes precedence over the individual’s independence and interests, public health interventions should be conducted with appropriate ethical justification and efforts should be made to minimize violations of patient independence. Quarantine can also impose economic and social consequences, thereby raising many other ethical concerns. In implementing quarantine policies, a balance should be struck between public health benefits and human rights violations. Adherence to ethics enhances trust of the quarantined individuals, boosts their cooperation, and ensures the success of the treatment and management processes (2, 6). Several parameters increase the trust and cooperation of the quarantined individuals (6, 8): (i) participation of the quarantined in decision-making, (ii) ability to perform necessary tasks if the required facilities are provided, (iii) convincing individuals about the benefits of processes, approaches, or restrictions, (iv) fair distribution of health resources among individuals, (v) officials’ timely response, (vi) determination in implementing guidelines, (vii) authorities’ adherence to transparency principle such that they fully explain the background reasons for implementing restrictions, (viii) psychological support, and (ix) financial and insurance supports as the quarantined may be day laborers or lose their jobs during the pandemic. Duty of care During this pandemic, traditional caregivers (e.g., friends and family members) were asked to maintain social and physical distance from their patients as well as were not allowed to visit their hospitalized patients. These traditional caregivers often, acting as their patient advocate, raise concerns with medical Sahebi A., et al. 5 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 (Suppl.) Number 24 December 2020 providers and make requests from them (10). During this pandemic, however, medical professionals should be ethically required to act as advocates for the COIVD-19 patients. Because the community as well as friends and family may leave the COVID-19 patient alone, medical and healthcare staff should provide care to the COVID-19 patients despite the risks imposed on their health. The high morbidity and mortality of COVID-19 has increased the fear and panic in medical and health staff because in case of close and frequent contact with such patients, the risk of contracting this disease increases (8, 9). However, due to their professional ethics and commitment as the patients’ sole advocate, medical and healthcare staff need to perform their duty while observing safety measures and standard precautions. Reciprocity principle The duty of care can endanger medical and healthcare staff’s health; for example, 50% of those who died during Severe Acute Respiratory Syndrome (SARS) were medical and healthcare staff (2). Likewise, a considerable mortality rate has been reported among healthcare staff during the COVID-19 pandemic. In Italy, 10% of healthcare staff contracted the disease, and 3% of them died of the disease (8). According to the reciprocity principle, hospitals have reciprocal responsibilities regarding their staff. Healthcare organizations should implement appropriate measures and create infrastructures to support their staff (2), including the followings: (i) effective communication, (ii) appropriate interventions to control disease spread, (iii) motivating staff to perform their duties, (iv) providing adequate resources including PPEs, (v) providing training required to create a safe environment, (vi) providing psychological and medical care to the afflicted staff, and (vii) giving priority for vaccination to the staff. Responsibility and accountability of governments in caring for COVID-19 patients Governments should provide opportunities for individuals to achieve their maximum possible rights. Control and management of pandemics are among the most difficult duties of healthcare systems, and fulfilling such duties requires the country’s executive organizations and institutions to become involved in decision- making and implementation processes as well as requires financial resources, trained staff, facilities, and stable infrastructure (2). Undertakings to ensure the health and well- being of individuals in this pandemic should be fulfilled under ethically-approved conditions. To this end, undertakings need to be clearly defined as well as their effectiveness need to be evaluated. Interventions should be performed justly and free of discrimination (including ethnic, race, gender and economic status), as well as based on scientific evidences. Transparency in decision-makings is crucial in convincing the public about the benefits of difficult policies. Consistency and flexibility in the implementation of the decisions, along with the assessment of their outcomes, promote the success of adopted policies. The COVID-19 patients are only guided toward understanding and fulfilling their rights, including the right to COVID-19 pandemic and the ethical challenges in patient care 6 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 (Suppl.) Number 24 December 2020 receive healthcare, when necessary requirements are provided for them (2, 6, 8). To do so, the policies and programs should be designed to develop social support and services to families and communities. Conclusion This study’s findings highlight the necessity of considering ethical principles in caring for the COVID-19 patients. Hence, healthcare providers need to be educated regarding professional ethics and ethical decision- making. Moreover, practical solutions should be provided to prevent ethical challenges, support patients’ rights, and present quality healthcare to patients during the pandemic. For this purpose, governments and health policymakers should resolve these challenges and support healthcare providers in various aspects including the followings: (i) safety and personal protection, (ii) mental and psychological health, (iii) financial issues, (iv) providing medical equipment, and (v) hiring new staff. Informed and ethical decision- makings are necessary for optimal management and increasing healthcare staff’s satisfaction, leading to enhancing patients’ contentment and health. Conflict of Interests Authors declare no conflict of interests. Sahebi A., et al. 7 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 (Suppl.) Number 24 December 2020 References 1. Vardanjani AE, Ronco C, Rafiei H, Golitaleb M, Pishvaei MH, Mohammadi M. 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