Coronavirus: Explanations and Ethical Issues

The SARS-CoV-2 virus that causes COVID-19 has spread throughout the world with the number of cases increasing daily, both due to spread and to extended testing. We have provided links to the Centers for Disease Control and Prevention’s websites that give up-to-date numbers and guidelines as the virus spreads.

Overview of the Virus

Let’s take a look at viruses in general and SARS-CoV-2 in particular. First, bacterial infections are different from viral infections. Antibiotics can be used against bacterial infections, such as bacterial pneumonia. Unfortunately, there is not an equivalent combatant to viral infections. Antiviral drugs are only available for certain viral infections—for example Tamiflu for the flu—but most antiviral drugs must be taken soon after a person is infected. The other way to combat viral infections is vaccines.

Things get confusing when viral infections cause bacterial infections, as can be the case with respiratory viruses like the influenza virus. Influenza can cause pneumonia. Pneumonia itself can be either viral or bacterial. Recent studies indicate that while the strain that caused the 1918 flu pandemic was particularly deadly, many of the victims probably died of bacterial pneumonia. Another contributing factor to the high mortality rate was World War I. Soldiers were living in sometimes crowded, squalid conditions with poor sanitation.[1] This is the opposite of the CDC’s recommendations for curbing the spread of COVID-19: social distancing and hand washing. Additionally, COVID-19 appears to cause viral pneumonia in some people.[2]

So what about the SARS-CoV-2, or the coronavirus? Scientists and news outlets call this a “novel” virus, which is true, but the virus itself is part of a family of viruses known as “coronaviruses.” Corona is Latin for “crown,” and is also the name of the diffuse plasma layer that surrounds stars, including the sun. The coronavirus has spike-like protrusions, like a crown, coming out of it. SARS-CoV and MERS-CoV are examples of viruses in the coronavirus family (Influenza is not a coronavirus).

The coronavirus family, like all viruses, has a strand of RNA housed within a membrane casing. The casing has proteins on its surface (the corona part on coronaviruses) that attach to receptors on the cell surface. Once the virus attaches to the cell, it enters the cell and commandeers the cell’s machinery to replicate the virus’s RNA and viral proteins. The new virus is released from the cell and moves on to infect the next cell in the body. As the virus continues to infect cells, the human body’s immune system mounts an attack against the virus. This leads to symptoms, such as a fever. Children seem to get mild symptoms, and people with other underlying conditions seem to get more severe symptoms. Scientists are still trying to figure out why COVID-19 causes some people to have more severe symptoms while others do not.

The virus’s RNA can undergo many mutations even within a single host. In places like Seattle, for example, epidemiologists have tried to trace the spread of COVID-19 by looking at differences in point mutations in different individuals who have contracted the virus. However, this is a time-consuming process that may or may not show the exact path of the virus.

Ethical Issues

From a bioethics standpoint, there are several issues. Of most importance is the responsibility we have to protect the vulnerable, which includes not over-taxing our medical system so people can get the support care that they need.

Another issue that was seen in Wuhan and now Italy is allocation of scarce medical resources. Disaster ethics deals with situations in which a crisis has led to a large number of people needing medical help. In the case of disasters, decisions must be made on who should receive medical care until more can arrive.

Related to scarce medical supplies is protecting medical workers so they are not infected. This involves providing the needed protection to ensure they are not infected, as well as reinforcements so medical workers can rest.

The CDC has websites with case numbers, how to prevent the spread of the virus, and additional guidelines for those that may be sick. The CDC continues to update their websites as they get new information.

More Information

Below are links to several common questions regarding COVID-19 and answers from the CDC website:

1. Up-to-date information on Coronavirus Disease 2019 (COVID-19)
2. Symptoms of the COVID-19
3. What to do if you are sick
4. Information regarding testing
5. Number of cases and updates
6. Travel guidelines
7. Recommendations for schools, workplaces, and community locations
8. Frequently Asked Questions

Relevant Books and Chapters

• John Kilner, Criteria for the Allocation of Limited Healthcare Resources: The Timeless Challenge of the Coronavirus (COVID-19) Crisis. Updated and adapted from chapter 11, “Determining Who Lives” in Life on the Line: Ethics, Aging, Ending Patients' Lives, and Allocating Vital Resources.
• In this newly updated piece, Dr. Kilner addresses the current pandemic, laying out several criteria for making ethical decisions regarding the allocation of scarce medical resources. He begins with criteria based on medical benefit and patient desire for treatment. If these are met, he argues that priority should be given to those who are at imminent risk of death, who need a small or temporary amount of a resource (if doing so will lead to greater life-saving ability), and to those on whom others’ lives depend (i.e., treating a doctor first so that he or she can, in turn, save others). Finally, he asserts that any resources still available should be distributed through a random allocation or lottery system to ensure impartiality and justice.
• Donal P. O’Mathúna, Vilius Dranseika, and Bert Gordijn, eds., Disasters: Core Concepts and Ethical Theories. This open access book is the first to examine disasters from a multidisciplinary perspective. Justification of actions in the face of disasters requires recourse both to conceptual analysis and ethical traditions. Part 1 of the book contains chapters on how disasters are conceptualized in different academic disciplines relevant to disasters. Part 2 has chapters on how ethical issues that arise in relation to disasters can be addressed from a number of fundamental normative approaches in moral and political philosophy. Providing analysis of core concepts, and with real-world relevance, this book should be of interest to disaster scholars and researchers, those working in ethics and political philosophy, as well as policy makers, humanitarian actors and intergovernmental organizations. -Adapted from the publisher
• Donal P. O’Mathúna, Bert Gordijn, and Mike Clarke, eds., Disaster Bioethics: Normative Issues when Nothing Is Normal. With the growing awareness of the need for evidence to guide disaster preparedness and response, more research is being conducted in disasters. Any research involving humans raises ethical questions and requires appropriate regulation and oversight. The authors explore how disaster research can take account of survivors? vulnerability, informed consent, the sudden onset of disasters, and other ethical issues. Both parts examine ethical challenges where seeking to do good, harm can be done. Faced with overwhelming needs and scarce resources, no good solution may be apparent. But choosing the less wrong option can have a high price. In addition, what might seem right at home may not be seen to be right elsewhere. This book provides in-depth and practical reflection on these and other challenging ethical questions arising during disasters. -Adapted from the publisher
• Paul Ramsey, The Patient as Person: Exploration in Medical Ethics. See especially chapter 7, “Choosing How to Choose: Patients and Sparse Medical Resources.” In chapter 7, “Choosing How to Choose: Patients and Sparse Medical Resources,” Ramsey deals with the realities of resource scarcity and how we are to make decisions regarding who lives and who dies as informed by our medical and social priorities. Rejecting social evaluations of those seeking limited medical treatments (i.e., basing decisions on comparisons of age, marital status, dependents, income, community service, etc.), Ramsey argues that only a random lottery or a first-come, first-served system are well suited for allocating scarce medical resources. He does make certain exceptions, however, stating that triaging care is acceptable in very specific instances and given very specific limits (i.e., caring for a doctor first after a natural disaster so that he or she in turn can care for more patients).
• Allen Verhey, Reading the Bible in the Strange World of Medicine. See especially chapter 10, “The Good Samaritan and Scarce Medical Resources.” In chapter 10, “The Good Samaritan and Scarce Medical Resources,” Verhey seeks to answer the question “Can we still be Good Samaritans . . . in the midst of tragic choices imposed by scarcity?” He answers, “yes,” but nuances what it means to be good. A truly “good” Samaritan recognizes the realities of scarcity as well as the sanctity of every human life while also acknowledging there is a tension between the two. Regarding the scarcity of specific therapies, decisions should be made based on therapeutic benefit (without social valuations); if there is not enough to go around, random selection is the most fitting way to determine who will receive treatment.
• Maxwell Smith and Ross Upshur, "Pandemic Disease, Public Health, and Ethics," in The Oxford Handbook of Public Health Ethics, eds., Anna C. Mastroianni, Jeffrey P. Kahn, and Nancy E. Kass (Oxford, 2019). Open Access Infectious disease pandemics raise significant and novel ethical challenges to the organization and practice of public health. This chapter provides an overview of the salient ethical issues involved in preparing for and responding to pandemic disease, including those arising from deploying restrictive public health measures to contain and curb the spread of disease (e.g., isolation and quarantine), setting priorities for the allocation of scarce resources, health care workers’ duty to care in the face of heightened risk of infection, conducting research during pandemics, and the global governance of preventing and responding to pandemic disease. It also outlines ethical guidance from prominent ethical frameworks that have been developed to address these ethical issues and concludes by discussing some pressing challenges that must be addressed if ethical reflection is to make a meaningful difference in pandemic preparedness and response.

Encouragement for those on the Front Lines of Medicine (from Friends of CBHD)

The Impossible Ethics of Pandemic Triage
April 3, 2020, The New Atlantis
Aaron Kheriaty, MD, University of California Irvine School of Medicine

This is a very helpful and readable introduction to and overview of some of the most difficult questions, truly life and death decisions, that may come to face healthcare clinicians over the next few weeks. Dr. Kheriaty describes the complexity involved in various scenarios and provides words of comfort and encouragement to those who may face them.

Exhortation to My Former Students (Video)
March 26, 2020, YouTube
Jeffrey P. Bishop, MD, PhD, St. Louis University

Dr. Bishop encourages those practicing medicine to rely on the training they’ve received and the experience they gained to guide them through this time of pandemic.

Respirators, Our Rights, Right and Wrong: Medical Ethics in an Age of Coronavirus
March 22, 2020, New York Daily News
Daniel Sulmasy, MD, PhD, Kennedy Institute of Ethics

A helpful and encouraging overview of the pandemic and the ethical implications it brings to bear on those in healthcare and government as well as on those of us in the general public.

Battlefield Promotions
March 18, 2020, The New Atlantis
Aaron Kheriaty, MD, University of California Irvine School of Medicine

Dr. Kheriaty addresses third- and fourth-year medical students who are entering the field of medicine in the midst of a situation not seen unprecedented in the history of modern medicine.

Resources from Organizations Working from a Judeo-Christian Perspective

Triage and Resource Allocation Statement - Executive Summary
April 2, 2020, Christian Medical and Dental Associations

Health care systems and health care professionals (HCPs) should be prepared for public health emergencies (e.g., mass casualty, local epidemics, and pandemics) as have occurred throughout history and will certainly occur in the future. During a major health emergency, HCPs have an ethical duty to provide compassionate and competent care, including making life-and-death decisions as rationally and transparently as possible. This requires advance planning, such as designing decision-making tools and disseminating contingency protocols to alleviate uncertainty and moral distress.

Executive Summary, Duties of Christian Health Care Professionals in Pandemic Infection
April 2, 2020, Christian Medical and Dental Associations

Throughout the ages, Christians, in obedience to Jesus Christ, have cared for the sick, even at risk to themselves. Christians’ refusal to abandon the sick in times of terrible pandemics was an inspiring witness to God’s love that transformed the ancient world. Christians today inherit this high calling. For the Christian health care professional, placing the interests of patients above our own is a matter of conscience.

Points to Consider: Triage in the Perspective of Catholic Bioethics
March 25, 2020, National Catholic Bioethics Center

This page explores triage and rationing and draws on the Catholic moral tradition to assist both individuals and organizations in developing protocols relevant to the current pandemic.

New Articles on Ethics and COVID-19

In the midst of the current pandemic, a number of scholarly articles are being developed and published on a wide range of topics related to coronavirus, COVID-19, SARS-CoV-2. In an effort to stay abreast of the literature, CBHD staff are attempting to compile something of an annotated bibliography of new articles that discuss ethical issues that may or will arise.

If you know of new articles that may be applicable, please forward them to research@cbhd.org.

High Tech, High Risk: Tech Ethics Lessons for the COVID-19 Pandemic Response
October 9, 2020, Patterns
Emanuel Moss and Jacob Metcalf

The COVID-19 pandemic has, in a matter of a few short months, drastically reshaped society around the world. Because of the growing perception of machine learning as a technology capable of addressing large problems at scale, machine learning applications have been seen as desirable interventions in mitigating the risks of the pandemic disease. However, machine learning, like many tools of technocratic governance, is deeply implicated in the social production and distribution of risk and the role of machine learning in the production of risk must be considered as engineers and other technologists develop tools for the current crisis. This paper describes the coupling of machine learning and the social production of risk, generally, and in pandemic responses specifically. It goes on to describe the role of risk management in the effort to institutionalize ethics in the technology industry and how such efforts can benefit from a deeper understanding of the social production of risk through machine learning.

Rationing of Civilian Covid-19 Vaccines While Supplies Are Limited
September 7, 2020, The Journal of Infectious Diseases
Richard K Zimmerman, MD, MPH, MA (Bioethics); Jeannette E South-Paul, MD, DHL (Hon); Gregory A Poland, MD, FIDSA, MACP, FRCP (London)

Allocation of the initial doses of COVID-19 vaccines should account for epidemiology, vaccinology, bioethics, and racial disparities. Our priority tiers for vaccination are critical infrastructure, those at highest medical benefit, and those chosen by a weighted Area-Deprivation Index lottery.

Ethics of Digital Contact Tracing and Covid-19: Who Is (Not) Free to Go?
August 24, 2020, Ethics and Information Technology
Michael Klenk and Hein Duijf

Digital tracing technologies are heralded as an effective way of containing SARS-CoV-2 faster than it is spreading, thereby allowing the possibility of easing draconic measures of population-wide quarantine. But existing technological proposals risk addressing the wrong problem. The proper objective is not solely to maximise the ratio of people freed from quarantine but to also ensure that the composition of the freed group is fair. We identify several factors that pose a risk for fair group composition along with an analysis of general lessons for a philosophy of technology. Policymakers, epidemiologists, and developers can use these risk factors to benchmark proposal technologies, curb the pandemic, and keep public trust.

Emerging Pandemic Diseases: How We Got To COVID-19

August 15, 2020, Cell

David M.Morens, MD and Anthony S.Fauci, MD

Infectious diseases prevalent in humans and animals are caused by pathogens that once emerged from other animal hosts. In addition to these established infections, new infectious diseases periodically emerge. In extreme cases they may cause pandemics such as COVID-19; in other cases, dead end infections or smaller epidemics result. Established diseases may also re-emerge, for example by extending geographically or by becoming more transmissible or more pathogenic. Disease emergence reflects dynamic balances and imbalances, within complex globally-distributed ecosystems comprised of humans, animals, pathogens, and the environment. Understanding these variables is a necessary step in controlling future devastating disease emergences.

Ethics of controlled human infection to study COVID-19
May 7, 2020, Science
Seema K. Shah et al.

Given the extraordinary nature of the pandemic, our framework and analysis support laying the groundwork for SARS-CoV-2 controlled human infection studies (CHIs)—for example, by developing a challenge strain, drafting consensus protocols that address ethical concerns, and engaging stakeholders to enhance their social value, minimize risks, and build public trust.

End-of-life Decisions and Care in the midst of a Global Coronavirus Pandemic
April 2, 2020, Intensive and Critical Care Nursing
Editorial

This essay addresses the question, "how do health professionals prepare for providing large scale end-of-life care in critical care in a pandemic?" The authors highlight several resources from the literature on H5N1 and H1N1 as well as “The COVID 19: Rapid Guidance for Critical Care” and others. They also emphasize the need to address the longer-term effects the current crisis situation will have on healthcare providers once the acute phase of the pandemic has passed. Notably, the article asserts in its introductory remarks that the key tension in the ethics of resource allocation in pandemic involves tradeoffs between autonomy and utilitarianism. It may well be worth considering whether framing the ethical questions differently might help to address at least some of the concerns this article raises.

Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line
March 18, 2020, New England Journal of Medicine
Lisa Rosenbaum, M.D.

Based on interviews with physicians practicing in Italy, the article describes the realities of caring for far more patients than hospitals, clinicians, and other caregivers are equipped to handle, which leads to excruciating decisions regarding limited resources such as ventilators.

Fair Allocation of Scarce Medical Resources in the Time of Covid-19
March 23, 2020, New England Journal of Medicine
Ezekiel J. Emanuel, M.D., Ph.D., Govind Persad, J.D., Ph.D., Ross Upshur, M.D., Beatriz Thome, M.D., M.P.H., Ph.D., Michael Parker, Ph.D., Aaron Glickman, B.A., Cathy Zhang, B.A., Connor Boyle, B.A., Maxwell Smith, Ph.D., and James P. Phillips, M.D.

Examines the allocation of various kinds of resources such as personal protective equipment (PPE), hospital beds, ICU beds, pharmaceuticals, ventilators, etc. in the current pandemic. The authors emphasize four values, “maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off,” and make six recommendations: “maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients.” Recommends the use of triage officers or committees to lessen burdens on front-line personnel.

Allocating Medical Resources in the Time of Covid-19
April 28, 2020, New England Journal of Medicine
Various Authors

Responses to "Fair Allocation of Scarce Medical Resources in the Time of Covid-19," NEJM, March 23, 2020.

The Toughest Triage — Allocating Ventilators in a Pandemic
March 23, 2020, New England Journal of Medicine
Robert D. Truog, M.D., Christine Mitchell, R.N., and George Q. Daley, M.D., Ph.D.

Recommends the use of triage committees for decisions regarding mechanical ventilation in this time of pandemic.

Ethics of rooming-in with COVID-19 patients: Mitigating loneliness at the end of life

October 31, 2021, Journal of Critical Care

Eline M.Bunnik, ShahlaSiddiqui, Rozemarijn L. van Bruchem-Visser

The COVID-19 pandemic is taking many lives around the world. When patients infected with SARS-CoV-2 become critically ill or are dying in hospitals, they must often make do without the physical presence of family members. Family visitation is commonly restricted based on safety concerns. Although spread of the SARS-CoV-2 virus should be prevented, and imposing limits on family visitation in hospitals may be instrumental to this end, separation of family members from critically ill patients is not humane. The moral costs of not being able to be together at the end of life may not outweigh the benefits of reducing risk of infection with SARS-CoV-2. Relaxation of family visitation policies in hospitals is therefore of paramount importance to patients critically ill with COVID-19 and their family members.

References

[1] Richard Gunderman, “Ten Myths about the 1918 Flu Pandemic,” Smithsonian Magazine, March 17, 2020, https://www.smithsonianmag.com/history/ten-myths-about-1918-flu-pandemic-180967810/.

[2] Cynthia Liu et. al., "Research and Development on Therapeutic Agents and Vaccines for COVID-19 and Related Human Coronavirus Diseases," ACS Central Science (March 12, 2020):  https://pubs.acs.org/doi/10.1021/acscentsci.0c00272.

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