Ethics-based decision-making in a COVID-19 pandemic crisis

COVID-19 pandemic has presented us with an unprecedented health crisis that has tested our ability to make appropriate choices and health decisions. These decisions are not limited to an individual but have an all-encompassing influence on the broader population. Therefore, these health decisions have to be moral and ethics based. This article provides an overview of ethics- based decision-making during a COVID-19 pandemic crisis.

Seven ethical principles guide decision-making in a pandemic crisis. They are

1. Minimizing harm: All attempts should be made to minimize physical, social, psychological, and economic harm of the population faced with the pandemic crisis. The measures taken to minimize harm should be rational, reasonable, and open for review. The exercise of harm minimization should always weigh the benefit and negative outcomes of action. The measures that cause minimal damage to an individual and greater good for the society should be the ethical principle of decision-making. In the majority of the hospitals, elective cancer surgeries were cancelled during the lockdown period to avoid COVID risk to cancer patients and to ration health-care resources for COVID patients. However, the benefit of these cancellations should be weighed against the possible risk of cancer progression and the harm caused due to cancer progression

2. Proportionality: The steps that are taken or the decisions made should be proportional to the threat and sufficiently adequate for protecting the public from harm. However, overzealous extreme restrictive measures that are disproportionate to the danger can be counterproductive and could lead to resentment and bitter experiences. Being circumspect, communicating the actions, education, and compassionate approach often yields better outcomes than coercive or restrictive measures. During the initial stages of a pandemic, many hospitals decided to completely stop or restrict their non-COVID work. Care of patients with non-COVID illnesses was significantly compromised due to these disproportionate measures

3. Solidarity: Pandemic crisis demands solidarity where the society gears up to the challenges beyond self-interest and territoriality. Individuals, institutions, and administration have to work together for the collective good. People should be ready to be redeployed to situations beyond their expertise, and the system should exhibit readiness and responsive behavior. Health-care professionals without an intensive care focus in their routine work may have to receive rapid training to make themselves available for COVID work. Moreover, both the public and private hospitals have to work in unison across the territorial boundaries to ensure solidarity in a pandemic crisis

4. Fairness: Fair allocation of scarce resources effectively for maximizing benefit is an important ethical consideration. It is pertinent to recognize moral equality while making resource allocation decisions. Moreover, resource allocation should be based on sound reasoning and evidence. Intensive care resources are often scarce in a pandemic situation. These scarce intensive care resources should be allocated appropriately considering the age, comorbidities, and other factors. A patient with older age with end-stage organ impairment or advanced cancer with serious COVID illness has a lesser likelihood of benefit from intensive care measures compared to a younger person with no comorbid illness

5. Duty to provide: All health care workers are ethically bound with an obligation to provide their services during a pandemic crisis. The health care workers may have to accommodate a contradictory role and continue to work despite risks. Even in the presence of a competing personal and family obligations, pandemic crisis calls for a commitment. Majority of health-care professionals in India live with their families that include elderly parents and young children. There is a heightened risk of contracting the illness and transmitting it to the families. However, acknowledging these risks, the health-care providers have a duty to provide care with maximum precautions to avoid any collateral damage

6. Reciprocity: It is the responsibility of the administration and the government to empower health-care providers to meet the demand of their role. Both the professional and personal needs of the health-care providers have to be met on priority. They should be empowered by providing them adequate guidance, protection, and resources to care for themselves and their families. There were instances where the health-care providers were barred from their housing complexes due to perceived risk by the neighbors about them to be the carriers of infection. It puts undue stress on the health- care providers who are already working in a distressful situation. It is imperative for the society to be reciprocal to the needs of the frontline health-care providers battling COVID-19 on behalf of society

7. Privacy: There has to be a balance between protecting a person’s right versus safeguarding public interests. Privacy of an individual should be adequately protected to prevent discrimination, stigmatization, and criminalization of illness. The level of access to disease demographics data and its public disclosure should be limited to protecting public interests without compromising the confidentiality of the individuals. There were many instances during the pandemic situation where private information of an individual affected with COVID was available for public consumption in the websites and social media. It only compromises individual liberty and safety with no added benefit to the public.

Along with the ethical principles, five procedural values guide ethics-based decision-making in a pandemic crisis.

1. Reasonableness: The decisions made should be (a) based on the best available evidence, (b) proportionate to the threat, (c) made by credible people having expertise and experience in the field, and (d) should have a reasonable chance of being successful

2. Openness: The decisions should be made openly and transparently. It should be accessible to scrutiny and audit. Moreover, the public should be able to avail this information through appropriate communication and media portals

3. Inclusiveness: The decision-making process should be inclusive and should involve all the relevant stakeholders. The voices of all the stakeholders should be taken into account while making a decision

4. Responsiveness: The decisions made must be continually revisited and revised based on new information. There has to be a redressal system to address disputes and disagreements in decision-making

5. Accountability: A multilevel network of accountability relationship is required to facilitate accountable decision-making. There has to be clear documentation of the trail of decisions made with justification, which is open for future audit.

In the future, history will judge our responsiveness and our ability to navigate the pandemic crisis. It will solely depend on timely and appropriate decisions made. Ethics-based decision-making should underpin our moral purposes to place us on the right side of history.

(The structure for this article was adapted from the ethical framework for decision-making in a pandemic, published by the Department of Health, Government of Ireland).