The Perfect Moral Storm: Diverse Ethical Considerations in the COVID-19 Pandemic

A scoping review of ethics review processes during public health emergencies in Africa

BACKGROUND

The COVID-19 pandemic forced governments, multilateral public health organisations and research institutions to undertake research quickly to inform their responses to the pandemic. Most COVID-19-related studies required swift approval, creating ethical and practical challenges for regulatory authorities and researchers. In this paper, we examine the landscape of ethics review processes in Africa during public health emergencies (PHEs).

METHODS

We searched four electronic databases (Web of Science, PUBMED, MEDLINE Complete, and CINAHL) to identify articles describing ethics review processes during public health emergencies and/or pandemics. We selected and reviewed those articles that were focused on Africa. We charted the data from the retrieved articles including the authors and year of publication, title, country and disease(s) reference, broad areas of (ethical) consideration, paper type, and approach.

RESULTS

Of an initial 4536 records retrieved, we screened the titles and abstracts of 1491 articles, and identified 72 articles for full review. Nine articles were selected for inclusion. Of these nine articles, five referenced West African countries including Liberia, Guinea and Sierra Leone, and experiences linked to the Ebola virus disease. Two articles focused on South Africa and Kenya, while the other two articles discussed more general experiences and pitfalls of ethics review during PHEs in Africa more broadly. We found no articles published on ethics review processes in Africa before the 2014 Ebola outbreak, and only a few before the COVID-19 outbreak. Although guidelines on protocol review and approval processes for PHEs were more frequently discussed after the 2014 Ebola outbreak, these did not focus on Africa specifically.

CONCLUSIONS

There is a gap in the literature about ethics review processes and preparedness within Africa during PHEs. This paper underscores the importance of these processes to inform practices that facilitate timely, context-relevant research that adequately recognises and reinforces human dignity within the quest to advance scientific knowledge about diseases. This is important to improve fast responses to PHEs, reduce mortality and morbidity, and enhance the quality of care before, during, and after pandemics.

Public opinion on global COVID-19 vaccine procurement and distribution policies: A nationally representative survey in Aotearoa New Zealand 2022

The World Health Organisation and many health experts have regarded vaccine nationalism, a "my country first" approach to vaccines procurement, as a critical pandemic response failure. However, few studies have considered public opinion in this regard. This study gauged public support for vaccine nationalism and vaccine internationalism in a representative survey in New Zealand (N = 1,135). Support for vaccine internationalism (M (mean rating) = 3.64 on 5-point scales) was significantly stronger than for vaccine nationalism (M = 3.24). Additionally, support for openly sharing COVID-19 vaccine manufacturing knowledge and technology (M = 4.17 on 5-point scales) was significantly stronger than support for safeguarding vaccine manufacturers' intellectual property (M = 2.66). The public also supported a utilitarian approach that would see distributions based on need (M = 3.76 on 5-point scales) over an equal proportional international distribution (M = 3.16). Akin to the few preceding studies, the present observations suggest that the public is likely to be more supportive of pandemic responses that are globally equitable and long-term orientated. Our findings have substantial implications for pandemic preparedness as the congruence or lack thereof of public vaccine-related values with government policies can affect public trust, which, in turn, can affect public cooperation. It may pay for governments to invest in proactive public engagement efforts before and during a pandemic to discuss critical ethical issues and inequities in global vaccine procurement and distributions.

Is It Possible to Allocate Life? Triage, Ageism, and Narrative Identity

Triage protocols can exclude older patients for the sake of effectiveness and this may be defended as the older have already had their fair share of life, which can mean fair amounts or complete lives. Nevertheless, if life is considered as a narrative, mentioning amounts might be nonsensical. Narratives have a quality of unity; so, life events are fragments whose meanings are dependent on the meaning of the whole. Thus, time units do not represent a reliable measure of the content of life. In addition, people's experience is different from the external flow of time, making its significance relative. Moreover, to compare the completeness of lives qualitatively, it is necessary to have a common cultural understanding, which is improbable to agree on in a modern society. Therefore, basic assumptions of the accounts that refer to fair shares of lives are mistaken, and these accounts do not support age-based rationing.

Ethical uncertainty and COVID-19: exploring the lived experiences of senior physicians at a major medical centre

Given the wide-reaching and detrimental impact of COVID-19, its strain on healthcare resources, and the urgent need for-sometimes forced-public health interventions, thorough examination of the ethical issues brought to light by the pandemic is especially warranted. This paper aims to identify some of the complex moral dilemmas faced by senior physicians at a major medical centre in Saudi Arabia, in an effort to gain a better understanding of how they navigated ethical uncertainty during a time of crisis. This qualitative study uses a semistructured interview approach and reports the findings of 16 interviews. The study finds that participants were motivated by a profession-based moral obligation to provide care during the toughest and most uncertain times of the pandemic. Although participants described significant moral dilemmas during their practice, very few identified challenges as ethical in nature, and in turn, none sought formal ethics support. Rather, participants took on the burden of resolving ethical challenges themselves-whenever possible-rationalising oft fraught decisions by likening their experiences to wartime action or by minimising attention to the moral. In capturing these accounts, this paper ultimately contemplates what moral lessons can, and must be, learnt from this experience.

Trusting the Government to Do the Right Thing: Data Ethics in Australia's Pandemic Response

After a brief overview of ethical issues in an Australian context catalyzed by the current pandemic, this article focuses on data protection in the light of recent debates about COVID-19 data tracking in Australia and globally. This article looks at the issue of trust as a fundamental principle of effective and ethical COVID-safe measures undertaken by the government. Key to ensuring such trust are Habermasian participatory dialogs, which assume trust as a condition of authentic illocution, and an emphasis on short-term data capture.

Ethics and Moral Agency for a Postpandemic Era: Beyond the Storm

Laura Lee (Dolly) Swisher, PT, MDiv, PhD, FAPTA, the 53rd Mary McMillan Lecturer, is professor emerita and former director of the school of physical therapy and rehabilitation sciences at the University of South Florida in the USF Health Morsani College of Medicine. Dr Swisher received a bachelor of arts degree from Wilson College and is a 1986 physical therapy graduate of the University of Tennessee Health Science Center, Memphis. She received the M.Div. from Andover Newton Theological School and a doctoral degree in public administration from Tennessee State University. Dr Swisher is a highly regarded expert on professionalism, ethics, and interprofessional education and has been a featured speaker at local, state, and national conferences. She is the coauthor of Rehabilitation Ethics for Professional Practice, Professionalism in Physical Therapy and Legal and Ethical Issues in Physical Therapy and is a lead author or coauthor of multiple peer reviewed articles and individual book chapters. She served as a member and chair of the Commission on Accreditation for Physical Therapy Education, was former chair and member of the APTA Ethics and Judicial Committee, and served as co-chair of the Task Force to Revise the Core Ethics Documents. Dr Swisher served on the Editorial Board of the Journal of Physical Therapy Education and is a member of the Editorial Board of the Journal of Humanities in Rehabilitation. She is the recipient of APTA's Lucy Blair Service Award and the Polly Cerasoli Lecture Award and is a Catherine Worthingham Fellow of the APTA.

Public acceptability of COVID-19 control measures in Singapore, Hong Kong, and Malaysia: A cross-sectional survey

Background

Several countries have implemented control measures to limit SARS-CoV-2 spread, including digital contact tracing, digital monitoring of quarantined individuals, and testing of travelers. These raise ethical issues around privacy, personal freedoms, and equity. However, little is known regarding public acceptability of these measures.

Methods

In December 2020, we conducted a survey among 3635 respondents in Singapore, Hong Kong, and Malaysia to understand public perceptions on the acceptability of COVID-19 control measures.

Findings

Hong Kong respondents were much less supportive of digital contact tracing and monitoring devices than those in Malaysia and Singapore. Around three-quarters of Hong Kong respondents perceived digital contact tracing as an unreasonable restriction of individual freedom; <20% trusted that there were adequate local provisions preventing these data being used for other purposes. This was the opposite in Singapore, where nearly 3/4 of respondents agreed that there were adequate data protection rules locally. In contrast, only a minority of Hong Kong respondents viewed mandatory testing and vaccination for travelers as unreasonable infringements of privacy or freedom. Less than 2/3 of respondents in all territories were willing to be vaccinated against COVID-19, with a quarter of respondents undecided. However, support for differential travel restrictions for vaccinated and unvaccinated individuals was high in all settings.

Interpretation

Our findings highlight the importance of sociopolitical context in public perception of public health measures and emphasize the need to continually monitor public attitudes toward such measures to inform implementation and communication strategies.

Companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19: a mixed-methods analysis of national and organisational responses and perspectives

OBJECTIVES

To explore stakeholders' and national organisational perspectives on companionship for women/birthing people using antenatal and intrapartum care in England during COVID-19, as part of the Achieving Safe and Personalised maternity care In Response to Epidemics (ASPIRE) COVID-19 UK study.

SETTING

Maternity care provision in England.

PARTICIPANTS

Interviews were held with 26 national governmental, professional and service-user organisation leads (July-December 2020). Other data included public-facing outputs logged from 25 maternity Trusts (September/October 2020) and data extracted from 78 documents from eight key governmental, professional and service-user organisations that informed national maternity care guidance and policy (February-December 2020).

RESULTS

Six themes emerged: 'Postcode lottery of care' highlights variations in companionship and visiting practices between trusts/locations, 'Confusion and stress around 'rules'' relates to a lack of and variable information concerning companionship/visiting, 'Unintended consequences' concerns the negative impacts of restricted companionship or visiting on women/birthing people and staff, 'Need for flexibility' highlights concerns about applying companionship and visiting policies irrespective of need, ''Acceptable' time for support' highlights variations in when and if companionship was 'allowed' antenatally and intrapartum and 'Loss of human rights for gain in infection control' emphasises how a predominant focus on infection control was at a cost to psychological safety and human rights.

CONCLUSIONS

Policies concerning companionship and visiting have been inconsistently applied within English maternity services during the COVID-19 pandemic. In some cases, policies were not justified by the level of risk, and were applied indiscriminately regardless of need. There is an urgent need to determine how to sensitively and flexibly balance risks and benefits and optimise outcomes during the current and future crisis situations.

Religious Perspectives on Precision Medicine in Singapore

Precision medicine (PM) aims to revolutionise healthcare, but little is known about the role religion and spirituality might play in the ethical discourse about PM. This Perspective reports the outcomes of a knowledge exchange fora with religious authorities in Singapore about data sharing for PM. While the exchange did not identify any foundational religious objections to PM, ethical concerns were raised about the possibility for private industry to profiteer from social resources and the potential for genetic discrimination by private health insurers. According to religious authorities in Singapore, sharing PM data with private industry will require a clear public benefit and robust data governance that incorporates principles of transparency, accountability and oversight.

[COVID-19 vaccination: the reality after clinical trials]

After the start of vaccination against SARS-CoV-2, enough clinical experience is already accumulating, in the real world and outside clinical trials, to resolve some of the questions that are still pending about this problem. The Scientific Committee on COVID-19 of the Madrid College of Physicians has discussed and reviewed some of these issues with a multidisciplinary approach. The following document is an attempt to answer some of these questions with the information available so far. This document is structured in questions on different aspects of the indications, efficacy and tolerance of anti-COVID-19 vaccination.

Mastering the scientific peer review process: tips for young authors from a young senior editor

Are you a student at a higher institution or an early-career researcher who is striving to understand and master the peer review process so to increase the odds of getting a paper published in the Journal of Forestry Research or another reputable, peer-reviewed, scientific journal? In this paper, a young, senior editor provides a handbook of the peer review process based on his decadal experience in scientific publishing. He covers major information you need to know during the entire process, from selecting journals to completing the proofing of your accepted paper. He introduces key points for consideration, such as avoidance of predatory journals, dubious research practices and ethics, interaction with peers, reviewers, and editors, and the pursuit of aretê. Finally, he points out some common statistical errors and misconceptions, such as P hacking and incorrect effect size inference. He hopes that this paper will enhance your understanding and knowledge of the peer-review process.

Should nurses take a COVID-19 vaccine?

The issue as to whether health care professionals have a moral obligation to take a vaccine for a communicable disease is not new. Nonetheless, this issue takes on a fresh urgency within nursing practice in the context of the present COVID-19 pandemic, i.e., is there an ethical requirement for nurses to take a COVID-19 vaccine? This paper approaches the issue by using a hypothetical example of Nurse X who has inadvertently infected Patient Y. French's (1984a) Principle of Responsive Adjustment is adapted to claim that there would be a moral expectation that Nurse X takes a COVID-19 vaccine (unless there are justifiable reasons not to). The proposition is also made that, should Nurse X not take a COVID-19 vaccine, they could be morally associated with originally infecting Patient Y.

COVID-19 age-dependent immunology and clinical outcomes: implications for vaccines

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leading to acute respiratory distress syndrome (ARDS). Understanding the evolution of the virus, and immune-pathogenic processes are critical for designing future therapeutic interventions. In this review, we collate information on the structure, genome, viral life cycle, and adult and pediatric host immune responses in response to SARS-CoV-2. The immunological responses are a prototype of the developmental origins of health and disease (DOHaD) hypothesis to explain the socio-geographic differences impacting the severity and mortality rates in SARS-CoV-2 infections. The DOHaD hypothesis identifies the relevance of trained innate immunity, age groups, and geography for effective vaccinations. As COVID-19 vaccines are being rolled out, it may be pertinent to assess population-based immunological responses to understand the effectiveness and safety across different populations and age groups.

Educating Social Workers in the Midst of COVID-19: The Value of a Principles-led Approach to Designing Educational Experiences during the Pandemic

Social work education in Australia in the midst of Corona Virus Disease 2019 (COVID-19) would not have been possible under our pre-pandemic accreditation standards due to assumptions about best practice in higher education that were not possible to enact during the pandemic. Rather than immediately arguing for a new set of standards, as Heads of Social Work programmes the authors of this paper promoted a principles-led approach to inform 'the right' way-in an ethical sense-of ensuring social work education could continue in Australia during the pandemic. This meant conceptualising the challenges of delivering social work education in a pandemic as being not only practical but also ethical in their nature. Using examples of how this approach guided the design of adaptive online teaching and field education placements at our universities, we consider the future possibilities for ethical and rules-based governance approaches to social work education. How students learn is changing and what they are learning will help them respond to the immediate and future needs arising from the pandemic. As such, rather than having their education compromised by COVID-19, social work students at the time of the pandemic and into the future may in fact benefit from the changes that have emerged during this period.

An interrupted time series analysis of the lockdown policies in India: a national-level analysis of COVID-19 incidence

India implemented a national mandatory lockdown policy (Lockdown 1.0) on 24 March 2020 in response to Coronavirus Disease 2019 (COVID-19). The policy was revised in three subsequent stages (Lockdown 2.0–4.0 between 15 April to 18 May 2020), and restrictions were lifted (Unlockdown 1.0) on 1 June 2020. This study evaluated the effect of lockdown policy on the COVID-19 incidence rate at the national level to inform policy response for this and future pandemics. We conducted an interrupted time series analysis with a segmented regression model using publicly available data on daily reported new COVID-19 cases between 2 March 2020 and 1 September 2020. National-level data from Google Community Mobility Reports during this timeframe were also used in model development and robustness checks. Results showed an 8% [95% confidence interval (CI) = 6–9%] reduction in the change in incidence rate per day after Lockdown 1.0 compared to prior to the Lockdown order, with an additional reduction of 3% (95% CI = 2–3%) after Lockdown 4.0, suggesting an 11% (95% CI = 9–12%) reduction in the change in COVID-19 incidence after Lockdown 4.0 compared to the period before Lockdown 1.0. Uptake of the lockdown policy is indicated by decreased mobility and attenuation of the increasing incidence of COVID-19. The increasing rate of incident case reports in India was attenuated after the lockdown policy was implemented compared to before, and this reduction was maintained after the restrictions were eased, suggesting that the policy helped to ‘flatten the curve’ and buy additional time for pandemic preparedness, response and recovery.

Open science saves lives: lessons from the COVID-19 pandemic

In the last decade Open Science principles have been successfully advocated for and are being slowly adopted in different research communities. In response to the COVID-19 pandemic many publishers and researchers have sped up their adoption of Open Science practices, sometimes embracing them fully and sometimes partially or in a sub-optimal manner. In this article, we express concerns about the violation of some of the Open Science principles and its potential impact on the quality of research output. We provide evidence of the misuses of these principles at different stages of the scientific process. We call for a wider adoption of Open Science practices in the hope that this work will encourage a broader endorsement of Open Science principles and serve as a reminder that science should always be a rigorous process, reliable and transparent, especially in the context of a pandemic where research findings are being translated into practice even more rapidly. We provide all data and scripts at https://osf.io/renxy/ .

Health indicators on adolescents reveal disparity and inequality on regional and national levels

BACKGROUND

Health status in adolescents is difficult to evaluate and compare horizontally, vertically and longitudinally among different regions and nations of the world.

METHODS

With repeated surveys conducted with relatively uniformed standards, the UNICEF Data warehouse compiles and publishes a wide spectrum of health indicators, of which data analysis and visualization would reveal the underlying statuses and trends on global, regional and national levels.

RESULTS

Apparent geographic disparity is present in that sub-Saharan African countries lag far behind their counterparts in other regions with regard to most health indicators on adolescents. Education attendance rates sequentially drop from primary to secondary school levels, and display correlation with youth literacy. Harmful practices of early marriage, early childbearing and female genital mutilation have decreased but the presences of peer violence and sexual violence are worthy of attentions. Although incidence and mortality rates of HIV/AIDS have dropped (most notably in sub-Saharan Africa), adolescents' HIV/AIDS awareness remains suboptimal in selected countries. Cumulative COVID-19 cases and deaths in the adolescents are comparable to the children but relatively lower than the adult and senior groups.

CONCLUSIONS

Findings on the health indicators of adolescents until 2019 reveal the most recent status quo for reference right before the hit of ongoing COVID-19 pandemic. Progresses made on the various health indicators as well as the associated disparity and inequality underlie the remaining gaps to fill for the achievement of the Sustainable Development Goals by 2030.

The effect of Covid-19 on ethical sensitivity

BACKGROUND

In the midst of the Covid-19 pandemic, healthcare workers increasingly encounter serious ethical issues that negatively affect their professionalism.

PURPOSE

The study aims to examine the ethical sensitivity levels of physicians and nurses working in surgical units during the Covid-19 pandemic and the associating factors.

METHOD

The sample of this cross-sectional online questionnaire-based study consists of 161 healthcare workers working at the surgical units in Turkish hospitals. The data were collected using the "Nurse Descriptive Information Form" developed by the researchers and the "Ethical Sensitivity Questionnaire."

ETHICAL CONSIDERATIONS

Approval was granted by the ethics committee. Verbal and written consent was received from the healthcare workers.

RESULTS

Ethical sensitivity in the dimension of conflict was found to be higher in healthcare workers who had ethical issues during the Covid-19 pandemic, who were married, who were nurses, who worked more than 45 h, and who had a work experience of 7-10 years (p < 0.05). Healthcare workers with a family member diagnosed with Covid-19 had high ethical sensitivity in the dimension of conflict (p = 0.008), while those who reported being fully competent and ready (p = 0.038) about Covid-19 were found to have low ethical sensitivity. Besides, those who experienced inadequate supplies (p = 0.045), long working hours (p = 0.038), and problems in asepsis-sterilization (p = 0.046) during the Covid-19 pandemic were found to have low sensitivity in the holistic approach dimension.

CONCLUSION

The study revealed that ethical issues during the Covid-19 pandemic, sociodemographic characteristics, knowledge-skills about Covid-19, and the problems encountered in the work environment during the pandemic affect the ethical sensitivity of healthcare workers in the dimensions of conflict and holistic approach. Therefore, it is recommended that governments and all healthcare workers, and stakeholders in the health system in our country and other countries take action to promote ethical sensitivity in response to the rapidly increasing epidemic by considering the factors that adversely affect ethical sensitivity.

Adherence to behavioral Covid-19 mitigation measures strongly predicts mortality

In the absence of vaccines or causal therapies, behavioral measures such as wearing face masks and maintaining social distance are central to fighting Covid-19. Yet, their benefits are often questioned by the population and the level of adherence to the measures is variable. We examined in representative samples across eight countries (N = 7,568) whether adherence reported around June 1, 2020 predicted the increase in Covid-19 mortality by August 31, 2020. Mortality increased 81.3% in low adherence countries (United States, Sweden, Poland, Russia), 8.4% in high adherence countries (Germany, France, Spain, United Kingdom). Across countries adherence and subsequent mortality increases correlated with r = -0.91. No African or South American countries were included in the present study, which limits the generalizability of the findings. While reported Covid-19 mortality is likely to be influenced by other factors, the almost tenfold difference in additional mortality is significant, and may inform decisions when choosing whether to prioritize individual liberty rights or health-protective measures.

The Effects of COVID-19 on Early Childhood Education and Care: Research and Resources for Children, Families, Teachers, and Teacher Educators

The COVID-19 world health crisis has profound implications for the care and education of young children in homes and schools, the lives of preservice and inservice teachers, and the work of college/university faculty. This article begins by discussing the implications of a world health pandemic for education and the challenges of conducting a literature review on such a rapidly evolving topic. The next four sections categorize the COVID-19 literature into themes: (1) threats to quality of life (QoL) and wellness, (2) pressure on families and intensification of inequities, (3) changes in teaching methods and reliance on technology, and (4) restructuring of higher education and scholarship interrupted. Each of the four themes is introduced with a narrative that highlights the current context, followed by the literature review. Next is a compilation of high-quality, online resources developed by leading professional organizations to support children, families, and educators dealing with the COVID crisis. The article concludes with changes that hold the greatest potential to advance the field of early childhood education and care.

Effective Contact Tracing for COVID-19 Using Mobile Phones: An Ethical Analysis of the Mandatory Use of the Aarogya Setu Application in India

Several digital contact tracing smartphone applications have been developed worldwide in the effort to combat COVID-19 that warn users of potential exposure to infectious patients and generate big data that helps in early identification of hotspots, complementing the manual tracing operations. In most democracies, concerns over a breach in data privacy have resulted in severe opposition toward their mandatory adoption. This paper examines India as a noticeable exception, where the compulsory installation of such a government-backed application, the “Aarogya Setu” has been deemed mandatory in certain situations. We argue that the mandatory app requirement constitutes a legitimate public health intervention during a public health emergency.