COVID-19 & the Ethical Concerns: The Four Main Principles

Dianne Montano
Dr. Sonsoles de Lacalle
HLTH 307- Sec 002
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The COVID-19 pandemic has impacted over 11 million people’s lives, resulting in over
200 thousand deaths in the United States alone. There have been many strategies and policies put
into place to combat the pandemic, many without lasting results. Tufecki’s (2020) article brings
forward ethical concerns when it comes to the policies that were put into action to combat the
COVID-19 pandemic. The four main principles of bioethics are placed under a microscope and
applied in particular situations to determine what is the right thing to do. This is done while
taking into account the rules and consequences that may occur with the decisions policymakers
and doctors choose to make. When applying the principles from an ethical perspective, an
essential component of the reasoning process is weighing and balancing the potential risks and
benefits. This is additionally difficult while addressing the COVID-19 pandemic. The two main
topics that were covered in the article were overdispersion and tests. I chose this article because
it prompts policymakers to rethink the current policies once they are framed in a different ethical
perspective. Along with that, doctors are faced with difficult decisions in how they offer care
while keeping in mind the shortage of supplies.
The concept of overdispersion was one of the main reasons for the high positive case
rates due to “super-spreading” events such as weddings, parties, gatherings at gyms, and other
events where people congregate. The goal of most countries has been to keep the outbreak within
expanded critical care capacity. However, many countries are reopening despite ongoing
community transmission. Each state has its policymakers who are implementing social
distancing actions such as the stay-at-home order. Some states have lifted these restrictions such
as Alabama and Colorado, unlike California where the stay-at-home order is still applied
statewide. The ethical issue that is taken into consideration is the principle for the respect of
autonomy, as the autonomous person may freely choose values, loyalties, or systems of religious
belief that limit other freedoms of that person. Restricting people’s access to certain events, and
ordering them to stay at home are common arguments for the respect of autonomy. However, is
it ethically permissible to allow people to attend these ‘super-spreading’ events, even if they are
more likely to contract the virus, placing themselves and others at greater risk? The principle of
nonmaleficence is also correlated with this question. The principle of nonmaleficence focuses on
not intentionally creating harm or injury to the individual. The challenge between the two
principles is due to the conflicting nature of each of the principles. Below, I will address the four
main principles of ethics along with relevant issues that may appear.
I. Principle of Respect for Autonomy
The principle of respect for autonomy is defined as implying that the patient can act
intentionally without controlling influences that would mitigate against a free and voluntary act.
The principle of respect for autonomy takes into consideration the individual and their right to
make decisions about their health based on the information given to them. However, what
happens when the right to their autonomy places others at risk? It is morally wrong placing
others in intentional harm, yet many who attend these ‘super-spreading’ events decide they have
the right to their autonomy and are knowingly putting themselves at risk. The likelihood of
attending indoor events such as weddings, gathering at gyms or bars, and attending church
services increase the chances of contracting COVID-19. It is found that potentially 80% of
transmissions are caused by 10% of infected individuals (Endo et al., 2020), meaning that a small
portion of individuals are responsible for a large portion of transmissions. For example, take a
hypothetical situation at a bar attended by a person infected with COVID-19. If this bar is also
poorly ventilated and loud, necessitating a general increase in speaking volume at close range,
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almost everyone in the room could potentially be infected. The close range, poor ventilation, and
accumulation of COVID-19 in the air all contribute to the factors of ‘super-spreading’ events.
The argument for the respect of autonomy directly violates the principles of
nonmaleficence because there is evidence that the virus has the potential to spread. Though each
principle is important in ethical reasoning, the principle of nonmaleficence outweighs respect for
autonomy. That does not mean there is a complete disregard for respect for autonomy. In the
context of the pandemic, the respect for autonomy does not take precedence over the principle of
nonmaleficence.
II. Principle of Nonmaleficence
The principle of nonmaleficence is defined as not intentionally creating harm or injury to
the patient either through acts of commission or omission. However, those who choose to attend
these events are ignoring the studies and evidence that demonstrate how detrimental the results
can be. Predominantly indoor settings are the main clusters where ​COVID-19 transmission
events occur, especially in religious venues (​Leclerc et al., 2020). While administrating removal
of lockdown restrictions, policymakers have the tough decision to maintain prolonged closure of
places of public gathering that present a greater risk of public infection. However, in terms of
nonmaleficence, these administrators and policymakers are doing their duty in closing potential
risk sites, thus avoiding further damage to the public. An individual has the right to their
autonomy, but once that violates the dignity of others, then justice allows their freedom to be
limited to protect them and others (Kirchhoffer, 2020). It is not morally legitimate to protect
individuals' autonomy that may cause harm to others. Policymakers have to keep in mind the
rights and freedom of individuals, while also keeping in mind the protection of the overall
public.
Even though all the principles of ethics are non-hierarchical, some principles take
precedence over the others due to balancing the demands of the principles. This can be done by
determining which carries more weight in a particular case. In the case of respect for autonomy
during a pandemic, it can be argued that the principle of nonmaleficence is more important.
There are fewer risks and chances of transmitting the virus if public events are closed. This
ensures fewer people are in groups, are in poorly ventilated areas, and are adhering to social
distance restrictions. In difficult times such as the pandemic, it is important to focus on the big
picture, rather than focusing on smaller parts. Autonomy is important to adhere to from a
medical and ethical perspective, but it can be limited when an individual is objectively morally
wrong. When a choice violates inherent dignity, it would make the clinical team morally
complicit, and they would thereby undermine their realization of dignity as self-worth
(Kirchhoffer, 2020). Policymakers do not have to fulfill an individual’s need to attend these
events and instead focus on policies that enforce social distancing. They have to prioritize the
health of the public, not that of individuals, as doing so could lead to catastrophe. It would also
increase (rather than alleviate) moral distress for decision-makers and clinical teams if they
comply with individual autonomy decisions that are morally corrupt.
III. Principle of Justice
The other main issue highlighted in the article was the issues with the types of testing
methods along with the tracing methods that are used. The ethical concern with the principle of
justice was with the distribution of resources and services. The pandemic has caused a shortage
of supplies and services which brings the difficult situation of allocating resources accordingly.
The principle of justice in a healthcare system is defined as a form of fairness and implies the fair
distribution of goods in society. The ethical question that the principle of justice addresses is
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which populations should get tested, and with which tests? It is important to keep in mind that
resources are limited and that policymakers are keeping in mind the principle of distributive
justice.
The results from the tests are then used to determine who is more likely to contract the
virus through a method called forward contact-tracing. However, studies have shown that
backward contact-tracing is providing better results in predicting who is likely to be infected.
The principle of beneficence is also taken into consideration as the change in the tracing method
can benefit individuals and the public. It brings the ethical question: is changing the method
beneficial towards the greater public? Other health issues aside from COVID-19 have impacted
the public. Policymakers and doctors have to keep in mind the health impacts and how to address
them due to the lack of resources and services. Some ethical concerns that might arise are when
do doctors opt for less care, and who benefits from the lockdown policies?
The principle of justice is a form of fairness in the medical field, and COVID-19 has
brought into question distributive justice due to some goods and services being in short supply,
there is not enough to go around. This means of allocating scarce resources must be determined
by going through a set of factors as criteria. There are two tests currently being used to test for
the virus: PCR and antigen tests. The PCR tests can be used to determine the presence of the
virus’s genetic material which is generally highly accurate. It is the use of a fluid sample that is
collected by inserting a long swab into the nostril and taking fluid from the back of the nose.
However, it can take days to over a week to get the results of a PCR test. The antigen tests detect
specific proteins on the surface of the coronavirus. Sometimes they are referred to as rapid
diagnostic tests because it can take less than an hour to get the test results and maybe more
practical to use for large numbers of people. However, not everyone can be tested with PCR tests
as it is an expensive and slow process. Along with that, not everyone can get rapid testing either
as it is nearly impossible to test over 300 million people in the United States as resources are
limited. The CDC does not insist on everyone getting tested as it would not provide accurate data
and a waste of testing kits for those who have not been in contact with someone who has the
virus. Instead, the CDC asks for people who have symptoms, may have been in contact with an
infected person, or were referred by their health care provider. At the beginning of the
pandemic, tests were often restricted to specific groups of populations, such as healthcare
workers, individuals with known SARS- CoV-2 exposure, COVID-19 symptoms, or with risk
factors for severe disease.
One reason for limited testing is due to the shortage of PCR testing reagents, and that it
may procure false-negative results. This can be due to improper handling of the sample. Another
factor that may infringe on the results is the time the sample was taken. The day of exposure may
not be enough time for the virus to develop, and the PCR test will not yield accurate results.
Policymakers should opt for multi-stage group testing for large-scale testing, such as testing
those who may have attended ‘super-spreading’ events. The high efficiency of multi-stage group
testing allows for large scale testing of the population. The study focused on group testing which
divided the population into small groups called a ‘pool’.Pooled sample testing is most helpful in
areas where most samples are expected to be negative. According to Eberhardt et al. (2020), the
data showed that group testing is more efficient than individual testing for prevalence rates under
30%. In using multi-stage group testing, groups of negative samples can be eliminated with a
single test, avoiding the need for individual testing and achieving considerable savings of
resources.
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Policymakers should consider this method as supplies are limited, and it allows for
larger-scale testing. This would provide data that is beneficial for not only individuals but
doctors as well. The doctors would be able to treat those who are infected earlier. In terms of
distributive justice, it is both the responsibility of policymakers and the public to help even the
playing field by providing resources to help overcome the disadvantaged situation. Not everyone
can get PCR testing due to its slow process and shortage of testing kits, so it would be better to
use group testing for larger populations. It allows for testing about five times as many individuals
with the same number of tests (Eberhart et al., 2020). It provides a better distribution of
resources as it yields better results for positive cases. Morally acceptable scarce resource
allocation may not benefit individuals equally but instead tries to adjust care for the needs of the
entire population.
There are issues with the principle of justice itself as it has to benefit the individual and
the entire population but also work systemically with the laws and policies. There needs to be
consideration of the moral rightness of withholding or withdrawing treatment due to resources
being limited. This topic focuses on individuals who have health problems that are not correlated
with COVID-19. Certain circumstances can leave those threatened by illness due to limited
resources, and alternative treatments that are not as effective. A significant number of treatments
with proven benefit might be unavailable to patients while those alternatives that are available
are not usually considered best practice and might be inferior. There is an absence of strong
policies that accommodate the needs of populations with disabilities who are unable to protect
themselves from COVID-19. According to Sabatello et al. (2020), 20% of children and 26% of
adults are highly marginalized. This is attributed to factors such as less education, high insecurity
with food, housing, and employment. They also ranked health care providers/health systems 15
% as the most important source of information about COVID-19. Ethically, adequate information
about treatments is essential for the patient to enable them to weigh up options and decide which
treatments they wish to undertake. However, current healthcare systems are poorly informing
those with disabilities about COVID-19 and other treatment alternatives. There is little respect
for autonomy in this case, as the patient does not have access to all information. It is being
withheld from them.
There needs to be an increasing awareness raised for the injustice concerns as the
pandemic and our public health response expose disadvantaged groups that are at risk. There are
concerns between justice and balancing considerations that should play a role in critical care
triage policy. Reid’s (2020) article focuses on discrimination and fundamental egalitarian and
social justice concerns. Racialized minorities and/or immigrant groups are exposed to a greater
risk of contracting COVID-19 for the very reasons that they are at greater risk of chronic health
conditions. The injustices of the social determinants of health have negative implications for the
equity of racialized groups, especially when seeking care. This violates the principle of justice as
it does not comply with the fair distribution of goods and services. Reid (2020) proposes to
refuse outcome-maximizing criteria that further structural inequalities and focus on neutralizing
the distribution among categories relevant to justice, such as socioeconomic status, gender, and
racialized groups. This pandemic has required and will continue to require an enormously
disruptive societal response with substantially inequitable effects. It is up to doctors to make the
ethical decision on whether to provide care for those in disadvantaged groups. Radicalized
minorities are more likely to have chronic health conditions that affect how they receive care for
COVID-19. This is because they are less likely to survive, factoring in other determinants as
well. In comparison to a healthy individual who has a higher life expectancy, a non-minority
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patient is likely to receive better care for the virus because they have a higher chance of living.
Those with disabilities have also received less care due to the pandemic. According to Sabatello
(2020), the rationing of medical care has placed those with disabilities with fewer priorities.
Washington State, for example, excluded patients with “loss of reserves in energy, physical
ability, cognition and general health” which alienates many with disabilities. This is not only
unjust, as it is not fair to those with disabilities, but also violates the principle of nonmaleficence.
Some policies intentionally omit care to those with disabilities while the hospitals prioritize
COVID-19 cases.
IV: Principle of Beneficence
The principle of beneficence emphasizes ​health care providers having a duty to be of
benefit to the patient, as well as the necessity to take positive steps towards preventing and
removing harm from the patient. The United States currently focuses on forwarding contact
tracing of an infected person involving testing everyone they were in touch with since getting
infected. Unlike forward contact tracing, backward contact tracing identifies the source of newly
detected cases. It has the potential to identify a large portion of infections and this approach is
particularly valuable when there is high individual-level variation in the number of secondary
transmissions known as overdispersion (Endo et al., 2020). Backward tracing is found to increase
the maximum number of traceable individuals by a factor of 2–3 (Endo et al., 2020) which would
lead to better benefits for individuals. Since it is better at predicting individuals who are more
susceptible to being infected with COVID-19, they can target the right individuals to self-isolate.
This stands in comparison to forward tracing methods where possible uninfected individuals
have to practice self-isolation while waiting for test results. The forward tracing method would
lead unknowingly healthy people into self-isolation which can lead to detrimental results in their
health. There is a need for accurate data on prevalence to better inform political and public health
decision making and to broadly identify infected individuals. This data can be used to benefit
patients by not only giving them accurate care but also allowing non-infected individuals to
continue living their life normally.
There are physical and mental health impacts resulting from the prevailing COVID-19
policies that need to be addressed. Current lockdown policies have affected the short and
long-term public health, as visible when considering lower childhood vaccination rates,
worsening cardiovascular disease outcomes, fewer cancer screenings, and deteriorating mental
health. Unnecessary self-isolation, especially long-term can lead to other health effects aside
from COVID-19. The Great Barrington Declaration recommends an approach called Focused
Protection which focuses on balancing the risks and benefits of reaching herd immunity. This
allows those who are at minimal risk of death to live their lives normally while building up
immunity to the virus through natural infection. The principle of beneficence is the ​desire to
"benefit" the patient, and in this case, those who are less susceptible to the virus should continue
to live freely. Remaining indoors under the lockdown policies may cause greater risks in the long
run. Most youth groups have experienced extreme mental health problems during the pandemic.
There is an increasing need for local governments to take appropriate mental health interventions
based on the characteristics of youth groups. According to Liang et al. (2020), approximately
40.4% of the youths that were interviewed reported having psychological problems. Along with
that 14.4% of youth groups were reported as having PTSD symptoms. Policymakers should
focus on policies that allow the youth to continue living a normal life as they are less at risk. It
can help them in the long run and benefit them as a whole. In a medical sense, there needs to be
more active action from doctors in treating the mental health of the population, especially in
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youths. Other issues that have come to light are the lack of access of some people with
disabilities to personal care assistants (Sabatello et al., 2020) which places them at risk because
they are unable to get direct support. Policymakers are not currently benefiting those with
disabilities in the pandemic. It violates the principle of justice and beneficence as it deliberately
fails to involve the needs of disabled persons.
The COVID-19 pandemic is far from over, and if certain policies stay in place it will
continue. There needs to be a change in how policymakers and healthcare systems address the
pandemic. The argument of respect for autonomy is overruled by the principle of
nonmaleficence. Though it is important to respect the individual’s wishes and desires, it is not
morally right to place others at risk intentionally. It violates the principle of nonmaleficence and
it is negligent if one imposes a careless or unreasonable risk of harm upon another. The
allocation of resources for tests has made it hard to determine which populations are more
inclined to care. The principle of justice is used to rationalize the allocation of tests, resources,
and health care services. The change from forward contact tracing to backward contact tracing
would lead to better benefits. The principle of beneficence can support the results, and it is
ethically important to use methods that would create more medical benefits for the public.
Policymakers and doctors are faced with difficult decisions during this pandemic. Therefore it is
important to obtain relevant and accurate facts as this evidence is an essential component of
decision making. They should keep in mind all the principles and balance their demands by
determining which carries more weight in any particular case. In the rapidly changing climate
about the knowledge-landscape and situational status of COVID-19, there is an emphasis on the
importance of recognizing the limitations of each principle. It is essential if we are going to
continue to make decisions with an act of sincerity and a clear moral conscience.
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Eberhardt, J. N., Breuckmann, N. P., & Eberhardt, C. S. (2020). Multi-Stage Group
Testing Improves Efficiency of Large-Scale COVID-19 Screening. ​Journal of Clinical Virology​,
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Endo, A., Leclerc, Q.J., Knight, G. M., Medley, G. F., Atkins, K. E., Funk, S., &
Kucharski, A. J. (2020). Implication of backward contact tracing in the presence of
overdispersed transmission in COVID-19 outbreaks. ​Wellcome open research, 5(​ 239).
https://doi.org/10.12688/wellcomeopenres.16344.1
Great Barrington Declaration and Petition. (2020, November 12). Retrieved November
17, 2020, from ​https://gbdeclaration.org/
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https://doi.org/10.1007/s11673-020-09998-3
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settings have been linked to SARS-CoV-2 transmission clusters?. ​Wellcome Open Research,
5​(83). ​https://doi.org/10.12688/wellcomeopenres.15889.2
Liang, L., Cao, R., Hu, Y., Qin, Z., Li, C., & Mei, S. (2020). The Effect of COVID-19 on
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Sabatello, M., Burke, T. B., McDonald, K. E., & Appelbaum, P. S. (2020, October).
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