What Covid has taught the world about ethics | NEJM

The Covid pandemic has posed considerable challenges to societies and health systems around the world. Many of these challenges have been technical, such as the development of effective vaccines and therapies. The challenges that have proven most frustrating and controversial, however, are determining the “right” course of action on a number of critical issues: how to allocate scarce vaccines, whether to introduce mask mandates and whether to restrict travel, and whether to intentionally infect research participants in order to test vaccines, to name a few. The “right” decision in these cases is neither a technical question nor resolved by additional evidence; rather, it requires value judgments and, therefore, ethics (see Table 1).

Many policy makers and political leaders around the world have recognized the central role of ethics in addressing these challenges, calling, for example, for a “fair and equitable” allocation of Covid vaccines. Yet this recognition has rarely led to ethically desirable outcomes. Some of the most important lessons of the pandemic therefore relate to ethics and its effective integration into global health decision-making.

Although world leaders frequently invoked “solidarity”, “equity” and “justice” during the pandemic, they seemed unable to elucidate these ethical standards, including how they should be concretely implemented. For example, many calls for a “fair and equitable” distribution of Covid vaccines between countries have failed to characterize what distribution would constitute fair or equitable distribution; while these calls indicated that more vaccines should be provided to low- and middle-income countries, they did not specify how much more would be fair or what sacrifices on the part of high-income countries would be ethically justified to achieve these goals . Ethics provides the moral requirements driven by these standards and helps to navigate disagreements in their interpretation.

Although Covid is new, the ethical issues it raises are not and they do not need to be resolved From the beginning. There is a wealth of knowledge about appropriate values ​​and principles to guide policy during global health emergencies.^1-3 Indeed, well-developed frameworks articulate ethical values ​​to address health resource allocation, mandates, challenge studies, and other issues. These approaches have been informed by previous events considered public health emergencies of international concern, such as the outbreaks of Zika, Ebola in West Africa, and H1N1 influenza. Ethical guidance can sensitize policy makers to this knowledge and help them navigate trade-offs between ethical values ​​and implement ethical principles in future health emergencies.

For example, Covid vaccines are not the first scarce health resource to be allocated. Penicillin during World War II, dialysis in the 1960s, and antiretroviral therapies for HIV/AIDS in the 1990s all required prioritization in the context of resource constraints. These challenges have forced the critical examination of practices, the identification of unethical allocation patterns, and the elucidation and critical evaluation of ethical frameworks and policies for the allocation of scarce health resources. .⁴

Table 2. Table 2. Core values ​​affecting the allocation of scarce medical resources.

Analysis of our pre-existing knowledge, on the one hand, and established priorities for resource allocation during Covid, on the other hand, reveals agreement between the two on the importance of five core values ​​in resource allocation. resources: maximizing benefits and preventing harm, mitigating disadvantages, reciprocity, instrumental value and equal moral concern (see Table 2). Explicit acknowledgment of these values ​​helps elucidate key ethical considerations, but additional information is needed to determine which values ​​should take priority in particular circumstances.

We would argue that maximizing benefits and preventing harm should be viewed as a presumed priority, as any benefit that generates more death or serious illness should be viewed with suspicion. But this value should not be given absolute priority; it must be balanced and shaped by the other four values, which help to clarify, for example, the weight to be given to the distribution of advantages and disadvantages between different populations. These values ​​also impose constraints on the maximization of benefits in accordance with ethical commitments to social justice. For example, already disadvantaged groups should not be further disadvantaged by the allocation of resources in emergencies. Therefore, prevention of harm in less advantaged populations is particularly important. Similarly, in public health emergencies, medical personnel are often given priority for resources not because they are more worthy but because of their instrumental value: their work can save the lives of many other people, thereby maximizing benefits and preventing harm.

Other frequently invoked ethical principles, including transparency, engagement and responsiveness to evidence, are procedural in nature. Unlike substantial values, they do not determine the allocation of resources, although they can make those allocations more equitable. Indeed, ethical decision-making processes go beyond the articulation of values ​​and principles. Allocation schemes must also be translated into fair policies which are then implemented with fidelity. In the case of allocation, these policies take the form of population priority levels. Procedural principles shape and constrain the process of translating values ​​into priority levels and their implementation in the world.

While it is naive to expect unanimity on the allocation of resources, mandates or health challenge studies, we do not have to revert to the debate on core values ​​when they are already clear. Continuing with this multi-value framework and pre-existing ethical knowledge may not “solve” these questions, but it may facilitate faster policy formulation and enable decision makers to publicly communicate the ethical rationale for policies. Such communication should help build awareness, trust and compliance.

Ethical values, however, cannot apply or resolve conflicts between them. Positioning ethics to meaningfully inform decisions requires changing the policy-making process. Ethics must be considered at the start of any response to a health emergency. Government policies should be expected to be not only evidence-based, but also explicitly grounded in ethics. During an emergency, decision-makers call on epidemiologists and others to contribute their expertise and experience to policy formulation; they should also appeal to ethicists to inform a coherent ethical response.

How to operationalize this approach? First, like epidemiology and vaccine development, ethics cannot simply be activated in an emergency. Institutional capacity and memory cannot be built or restored ad hoc. Agencies responsible for responding to public health emergencies should have trained ethicists on staff, regularly involved in scenario planning and advice.

Second, this function cannot be fulfilled by a single token ethicist. As Covid has proven, the many ethical issues require a competent team with complementary capabilities and skills, able to fully consider the complex global, regional and local impact of emergency planning and decision-making. pandemic. We need to build capacity to expand expertise in public health ethics.

Third, before an emergency occurs, personnel ethicists can draw on pre-existing knowledge to anticipate common issues, such as allocation of scarce resources, mandates, isolation protocols, and research studies. challenge. Then they can elucidate approved frameworks that incorporate well-accepted ethical values. Using these frameworks, they can develop potential policies for implementation. Ethicists could also translate these frameworks into checklists that can be used by policy makers to ensure they take into account relevant ethical considerations when responding to an emergency.⁵ Staff ethicists can seek feedback on their proposals from experienced ethicists and the public (including disenfranchised populations) to refine a working ethical framework and an initial set of policy considerations.

Finally, ethics must be integrated into emergency decision-making. Ethicists should be at the table when policy is being formulated, rather than simply serving as external critics.

The world has not yet had time to fully elucidate the lessons of Covid and apply them to preparations for future emergencies. But policymakers should heed the lessons of the pandemic by appreciating the ethical, not just technical, dimensions of all the challenges encountered during emergencies; starting from existing knowledge on the right values ​​and principles to guide policies; and ensuring that ethics expertise is present before an emergency response is designed and is effectively incorporated into decision-making. Achieving these goals will require a sustained and focused effort to build the ethical capacity of key global, national and local public health organizations, academic institutions and government agencies.