Applying the code of medical ethics in the context of a pandemic: COVID-19 in Sri Lanka

When thinking of something that would kill millions of people, a pandemic is the greatest risk. The outbreaks hit much harder to the lower-income nations, given the lack of access to basic health services, health infrastructure, and effective infection control mechanisms. In this context, ethical aspects related to equity in resource allocation, selective vaccination, clinical trials involving human subjects, limitation of personal freedom such as quarantine regulations, and so forth need to be addressed by the healthcare professionals. Therefore, a recognized clinical ethics scheme is imperative to balance individual and population rights during the response to an outbreak.


Introduction
A pandemic is something that would surpass the death poll of past gigantic wars, devastate the world economy, and cause mass destruction to humanity. It brings out panic around the globe, but for a brief period. People forget easily: the leaders allocate more budget on the military than health care. However, the experts in the infectious disease field remain alert. In 2005, the WHO, who lead the global response to the pandemic, released the pandemic response blueprint (1). Similarly All the health care decisions are a balance between the basic principles; beneficence, non-maleficence, respect for autonomy, and justice. During a pandemic, it is of no difference. However, the way these principles are prioritized and balanced against each other ought to be adjusted so that some principles, which would be less relevant in ordinary days, are now highlighted (3). Moreover, medical professionals should weigh up their obligation towards patients, community, fellow professionals, and undeniably self.

Responsibility towards the Patient-Resource allocation
In a well-resourced health care system of a developed country, the principle of justice/ fairness appears to have little influence on day-to-day care. All the patients are offered the best possible care they need since the resources are adequate.  (3,4). Therefore, it is beneficial to have a formal criterion or a scoring system and be prepared while ensuring moral integrity.

Responsibility towards community
Clinical ethics also promotes empowering the health professionals' responsibilities towards the broader community. In the pre-pandemic context, the professionals' goal is to optimize the individual care of their patients. In contrast, now the clinical decisions aim at benefiting the whole community rather than one patient or currently identified patients (4). By the strategic use of justice, not only individual autonomy and beneficence but also nonmaleficence must be practiced across the whole population (3). For instance, although the clinicians are committed to patient-centered care, barring the visitors to a Covid-19 positive patient, which has a cost for the patient's well-being, is ethically justified concerning minimizing the spread of the virus to the community.

Responsibility towards the other professionals and self
The very next thought a healthcare professional struggles with is up to which extent he must risk the well-being of himself and his family to dispense his role-based responsibility to patient care. This is guided by two perspectives. One is the healthcare professionals' role-based obligation to expose themselves to a degree of risk and inconvenience to ensure optimal patient care (3). This is based on beneficence and non-maleficence, considering the patients' interests first. In usual circumstances, the system has the knowledge and resources to fulfill this commitment while protecting the staff. Health professionals would be using universal precautions with preventive protocols such as vaccination and prophylaxis. This is not the same as a pandemic.
Hence, comes the second perspective, which is the society's responsibility to protect and compensate for the people who furnish their healthcare need (3).
The healthcare providers are also human beings: their well-being matters as everyone else's does.

Moral distress
Another rarely discussed aspect of pandemic clinical ethics is moral distress. There is an intellectual difficulty for health professionals in making decisions as there are no distinct data or predictions about the disease dissimilar to a usual clinical scenario. Secondly, the value trade-offs that affect the people they care brings emotional difficulty. Subsequently, they feel that they are forced to take courses of action, which they feel are not right. The ideal way to overcome this situation is to first self-analyze the information considering the ethical fundamentals and discuss with colleagues to formulate a considered view. In this pandemic, clinicians are not to be left to make ethical decisions alone (3,4).
The race does not end here. There are around 1.5million viruses in wildlife that could leap to humans at any point. Human behavior as new mining, farming, and expanding into wildlife areas make pandemics inevitable. When it happens, there are no vaccines or counter-drugs, a global health emergency looms large. Therefore, humanity should be prepared and well-equipped with a legal, transparent, and educational basis to mitigate the effects of a pandemic in an ethically and morally justified approach.