Coronavirus outbreak raises ethical dilemmas for governments and health-care systems

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From the restriction of fundamental liberties to the rationing of scarce medical resources, the spread of COVID-19 is expected to raise extraordinary ethical dilemmas for leaders in government and the health-care system.

Experts say Canada will likely consider restrictions on movement and large gatherings, as in China and Italy, to slow the progress of the disease. Such measures have rarely been considered in this country.

Canada may also have to consider how to allocate scarce medical resources, such as ventilators and intensive-care beds. How will it ensure that health-care workers, among the hardest hit in these outbreaks, can stay on the job?

Here are some of the key ethical categories identified by the pandemic influenza working group of the University of Toronto Joint Centre for Bioethics.

Health care workers:

As COVID-19 spreads in Canada, doctors and nurses may worry about the risk to themselves and their families. In the SARS outbreak, 43 per cent of patients in Canada were health-care workers. Afterward, a report concluded the government failed to protect medical professionals.

"We want to be able to protect them, both because they’ve done a service treating the public, but also because if we protect them they’re able to continue treating patients,” said Lorian Hardcastle, a professor in the faculties of law and medicine at the University of Calgary.

It’s critical that health-care workers stay on the job and trust that they’re being looked after, Prof. Hardcastle said.

“The current ethical guidelines are not overly helpful. ...They don’t provide a lot of concrete guidance about when health-care workers can ethically refuse to work versus when they have an ethical duty to treat patients,” Prof. Hardcastle said.

Most doctors and nurses, though, accept the risks in their work and are trained to protect themselves.

“Most of us who went into the health-care system did so because we score high on wanting to help others,” said John Conly, an epidemiologist and professor of medicine at the University of Calgary.

“There will be stresses on the system, but I think the health-care profession will pull through.”

Sally Bean, director of ethics and policy at Sunnybrook Hospital in Toronto, said hospitals are discussing how to assign staff. They may decide that those who are pregnant, for example, or elderly, or have underlying health conditions, should be deployed elsewhere.

“The key thing is providing personal protective equipment or environmental settings so that we minimize the risk of potential harm to our health care providers,” Ms. Bean said.

Restricting Liberty:

It appears that social distancing and restriction of movement have proved effective in some countries at slowing the spread of COVID-19. Canada has not yet instituted such polices, but it may be only a matter of time.

Prof. Hardcastle says it’s a delicate balancing act for governments.

“Whenever the government restricts rights, we expect them to do so in a way that’s evidence-based and justifiable and transparent,” she said.

“It’s partly a public a public support and public trust issue. If the public perceives what the government’s doing to be evidence-based and necessary and rational, then they’re more likely to comply,” she said.

Quarantine often sounds reasonable so long as the person in quarantine is not you, Prof. Hardcastle added. It can also create real hardship for those who are disabled or don’t have the support of friends or family in the community to help provide food and medicine.

Maintaining the willing support of the public is crucial because the government doesn’t have the capacity to compel compliance.

Rationing medical care:

An influx of coronavirus patients could force a strained health system to confront difficult questions. Should coronavirus patients take precedence over those with other conditions? Should the elderly or those with underlying conditions take precedence over younger and healthier patients? In the event of a shortage, who gets a ventilator?

“I think these conversations are starting to happen in the abstract but I don’t think they’re far enough along and I don’t think they’re concrete enough,” Prof. Hardcastle said.

“We don’t want to be making these decisions on the fly. ...Those questions need to be dealt with now, because that’s not an appropriate kind of pressure to put on health-care professionals."

Ms. Bean said Ontario is developing guidelines for allocating resources based on a framework devised for the drug supply shortages of 2012. The guidelines have three parts: describing the allocation criteria, identifying the values that guide decision making and outlining the processes that guarantee fairness.

“I think [the spread of COVID-19] poses really acute ethical considerations because they’re urgent. We don’t know what this is or what the scope will look like when it when it arrives. That unknown dimension brings the ethical considerations into sharp focus,” Prof. Hardcastle said.

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