Health Ethics during the Pandemic

The pandemic has given rise to complex issues in various fields, including ethics. During the Covid-19 pandemic, conflicts involving ethics become widespread.

Conflicts often occur between one ethicist and another regarding different issues of the Covid-19 pandemic.

At the beginning of the pandemic, Russia allowed a Covid-19 vaccine to be administered to a group of its population, while in fact the vaccine had not yet passed its phase 2 clinical trial. Some ethicists deemed the case unethical for violating the ethics of vaccine study. However, other ethicists justified the program. Their reason was that Russia wanted to provide immediate protection for its people.

Here there was an ethical conflict, between the intention to save the people as early as possible and the necessity to fulfill vaccine trial requirements.

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In another setting, at the end of 2020 several advanced countries were racing to buy up Covid-19 vaccines that were going to be produced. They ordered in large quantities, even three times as big as their populations. Some ethicists saw this action as unethical because they reduced the chance of other countries to secure their allotments. Other ethicists regarded it as appropriate because they were trying to protect their peoples to the maximum.

In another case, today a number of countries tend to “force” vaccination programs. Although they don’t use the term “mandatory vaccination”, they impose activity and social restrictions on unvaccinated people. No vaccine, no mall and travel. Some ethicists describe this “coercion” as a violation of individual ethics. Others can accept it because “mandatory vaccination” is seen as the only way of getting free from the pandemic.

Ethics in normal conditions

Every individual has inborn moral values that should be respected and considered in any health program. These must not be breached. The values are beneficence, non-maleficence, autonomy and justice.

Beneficence means that every health program should have clear benefits for individuals, rather than benefits for the government or other groups.

Non-maleficence refers to the absence of danger affecting individuals as a result of a program. A program can offer great benefits but at the same time produce serious side effects. Such a program is unacceptable.

Autonomy warns that individuals have their own rights, including the right to determine the treatment they receive. Individuals can reject a measure even though it is considered the best one for them.

Meanwhile, justice concerns the right of individuals to receive just and equal service regardless of social standing, race and religion. A health program is seen as ethical if the moral values are not violated.

In normal conditions, every health program should give maximum consideration to the four moral values. There must not be significant reduction. For instance, before being administered to the public, vaccines are required to pass all clinical trial phases and standard procedures. None of the phases must be skipped. It’s because this serves to fulfill the principles of beneficence and non-maleficence for individuals.

The purchase of vaccines should be proportional to their demand. No group is justified to buy up vaccines unreasonably because this is opposed to the principle of justice for individuals. In a normal situation, forcing vaccination is not justified. Individuals have the right to accept or reject the vaccines offered. This is part of the autonomy right.

Ethics in crisis

The pandemic is a crisis. In a crisis, the service standard applied is not a normal standard of care. It means that normative standards cannot be maximally applied, including the moral values of individuals. The crisis condition triggers conflicts of individual values versus public good. Consequently, there is a shift in the ethical standard. Things considered unethical in a normal condition can be ethical during the pandemic. The opposite is also true.

In a normal situation, Russia’s utilization of a vaccine not yet having passed its phase 2 trial would certainly have been unethical. It was opposed to the principles of non-maleficence and autonomy. But when this was done during the raging pandemic, some ethicists could accept the measure. They argued that the action was taken when Covid-19 cases and deaths were peaking and no drugs were yet available.

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It means there was urgency for Russia to promptly save its people and this was regarded as meeting the principles of beneficence, non-maleficence and justice.

A number of advanced countries ordered vaccines in huge quantities at the start of the pandemic. Actually, vaccine production was not yet finished at the time. For some ethicists, it was unethical. But this move was not without justification. Covid-19 vaccines were then not yet produced. There was no information yet about their effectiveness, doses and efficacy. So, for the other ethicists, the buying-up action was acceptable. By so doing, those countries wanted to provide effective and sufficient vaccines for their populations. Their move was considered in line with the principles of beneficence, non-maleficence and justice for their peoples.

So far, no countries have yet obligated their peoples to receive Covid-19 vaccination. Nonetheless, some countries restrict the activity access of unvaccinated groups. Some ethicists see this as breaching autonomy. Others can accept it.

The reason is that so far there have been no effective drugs yet against the virus and vaccines are believed to be the only modality that can reduce morbidity and mortality. The effect produced is not only individual protection but also community protection. It is thus proper if vaccination is “half-coerced”. This program is deemed in fulfilment of the principles of beneficence, non-maleficence and justice.

Ethical principle trade-off

In a crisis, there is indeed a trade-off between various moral values. Individual moral values have to be adjusted to those of public interests. Even when conflicts occur, public values have to be prioritized.

How far should individual moral values be given second importance for the sake of public good? Should individual values be totally negated? In this regard, ethicists have divided views. Some adopt the extreme path and maintain that individual values should be ignored for the sake of public health interests.

Their reason is that the pandemic poses a very dangerous risk to society. Therefore, public safety should come first and other values be ignored. In the US, the state has the “police power” to “coerce” a public health program if the safety of society is in danger. In the legal concept it is known as the principle of salus populi suprema lex (public welfare and interests should be the supreme law).

By applying this principle, one can easily agree that Covid-19 vaccines can be given to people despite their incomplete clinical trials. The reason is that it is a crisis condition and the public needs immediate treatment. One is also apt to agree if a country buys up vaccines because that country wishes to protect its population. It’s also for this reason that the public can readily accept the mandatory vaccine program because it has to do with the safety of the majority. There should be no rejection and bargaining.

It’s not easy to claim an ethical decision to be correct or not. There are many determinants.

Other ethicists opine that even in a crisis state the rights of individuals should be given attention and respected. No absolute abandonment is allowed. So, even if public interests are prioritized, individual moral values should remain accommodated. This principle is followed by various world organizations such as the WHO, Hasting Centers and the European Bioethical Council.

By referring to this principle, a public health program can be accepted as long as individual values are accommodated. For example, the mandatory vaccination program can be carried out but its target is not the entire public. It is sufficiently limited to the groups of high-risk people like healthcare workers, the police and public officers. It should also be wisely implemented. Individuals need to be given informed consent and description of the vaccine types to be administered, their benefits and side effects. Comorbidities should also be identified and the aspect of contraindication making individuals unfit for vaccination be explained. It is thus not just giving direct jabs and ignoring individual moral values.

ARSIP PRIBADI

Iqbal Mochtar

The prevailing pandemic will continue to cause the emergence of various ethical conflicts. People will more frequently debate about whether a health program is ethical or not, good or bad, acceptable or not. It’s not easy to claim an ethical decision to be correct or not. There are many determinants. Moreover, ethical values in fact are not rigid. They can change according to the change of space and time. For that reason, what can be done is to adopt the wisest and most balanced attitude when considering the existing moral values in line with the current space, time and condition.

Iqbal Mochtar, Physician and Doctor of Medicine and Health. Chairman of the Indonesian Medical Association of the Middle East

This article was translated by Aris Prawira.