ePub ahead of print, 10 November, 2020.

The Journal of Bioethical Inquiry is pleased to share the second set of articles from its symposium on social and ethical implications of the COVID-19 pandemic. Together with the papers from part 1, the complete symposium presents 65 articles from 133 authors across the globe. The symposium editors write that: The number and quality of the submissions was striking, and their diversity was extraordinary—in terms both of the rich variety of substantive issues with which they dealt and the range of their theoretical, cultural, and geographical origins. …they present a picture of the complexity of the experiences formed in the crucible of the pandemic emergency, of the diverse effects on cultures, societies, and lifeworlds in transition, and of shared concerns, hopes, and fears.

We invite you to read the editors’ lead essay and the symposium articles listed below—all #Free2Read. We also invite you to listen to the editors discuss the symposium—including their suggestions of where to start reading—in the JBI Dialogues podcast (transcript available).

I. Overviews and Provocations

• The Left Reflects on the Global Pandemic and Speaks to Transform!, Gayatri Chakravorty Spivak Abstract
  The structure of this intervention is deliberately schizo-analytic: “and then—,” and “then—.” They are preparatory notes for a webinar by Transform! Europe on the COVID, arranged before the global explosion of Black Lives Matter. I question the top-down philanthropy of the bourgeois Left. I take the Rohingyas as bottom-line victims. I speak from two hometowns—Calcutta and New York. I ask the bourgeois Euro-U.S. Left not to monolithize the Global South. Many examples of how “India” is constructed are given. From New York, the United States is declared a failed state. Trump’s delinquencies are mentioned. It is argued that the only remedy at present is human behaviour and the typical U.S. character is not ready to practice this. This empirical fact shows the failure of the Kantian Sublime and reminds us that Kant thinks that the human moral will comes in to protect us from a hugely frightening natural phenomenon only by “subreption,” the same impulse that says that following steps provided by institutional religion will absolve us. Class and caste are taken into consideration throughout. I mention that as a coronavirus convalescent, I am donating plasma regularly.
• Interview: Mourning Is a Political Act Amid the Pandemic and Its Disparities (Republication), Judith Butler & George Yancy Abstract
  This conversation between a feminist and a critical whiteness scholar addresses the politics of vulnerability to COVID-19 and the questions of what it means to mobilize and learn from private grief and mass mourning and the role of academia and intellectuals in the current crisis.
• Engaged Ethics in the Time of COVID: Caring for All or Excluding Some from the Lifeboat?, Paul James Abstract
  If good ethics is the process of ongoing dialogical deliberation on basic normative questions for the purpose of instituting principles for action, then the COVID crisis, or any crisis, is not a good time for developing ethical precepts on the run. Given dominant ethical trends, such reactive ethics tends to lead to either individualized struggles over the right way to act or hasty sets of guidelines that leave out contextualizing questions concerning regimes of care. Good people will find themselves suggesting strange things, from setting up lifeboat scenarios to supporting structural racism. This essay argues against both these paths—crisis-ridden agonism or algorithmic resource-allocation—and turns instead to a form of ethics of care which takes its departure from older forms of ethics, while recognizing that modern and postmodern challenges no longer allow their grounding in animated relations, natural rights, or cosmological truths.

II. Society and the Lifeworld

• The Way We Live Now, John Wiltshire Abstract
  This is a personal account of one man’s experience of the months during which COVID-19 spread in Australia. Though personal, it aims to also be representative, so that readers will find in it reflections of their own experiences. Various social incidents are described, some in which social distancing is involved. The altering states of the author’s mind as time passes are carefully described in sequence, and the impact of continued anxiety and isolation on his mental well-being is presented as a form of madness, in one dramatic incident.

III. Global Perspectives

• A Global Ecological Ethic for Human Health Resources, Lisa A. Eckenwiler Abstract
  COVID-19 has highlighted with lethal force the need to re-imagine and redesign the provisioning of human resources for health, starting from the reality of our radical interdependence and concern for global health and justice. Starting from the structured health injustice suffered by migrant workers during the pandemic and its impact on the health of others in both destination and source countries, I argue here for re-structuring the system for educating and distributing care workers around what I call a global ecological ethic. Rather than rely on a system that privileges nationalism, that is unjust, and that sustains and even worsens injustice, including health injustice, and that has profound consequences for global health, a global ecological ethic would have us see health as interdependent and aim at “ethical place-making” across health ecosystems to enable people everywhere to have the capability to be healthy.
• Risk Communication Should be Explicit About Values. A Perspective on Early Communication During COVID-19, Claire Hooker & Julie Leask Abstract
  This article explores the consequences of failure to communicate early, as recommended in risk communication scholarship, during the first stage of the COVID-19 pandemic in Australia and the United Kingdom. We begin by observing that the principles of risk communication are regarded as basic best practices rather than as moral rules. We argue firstly, that they nonetheless encapsulate value commitments, and secondly, that these values should more explicitly underpin communication practices in a pandemic. Our focus is to explore the values associated with the principle of communicating early and often and how use of this principle can signal respect for people’s selfdetermination whilst also conveying other values relevant to the circumstances. We suggest that doing this requires communication that explicitly acknowledges and addresses with empathy those who will be most directly impacted by any disease-control measures. We suggest further that communication in a pandemic should be more explicit about how values are expressed in response strategies and that doing so may improve the appraisal of new information as it becomes available.

IV. Voices from Different Places

• Ethical Considerations for Restrictive and Physical Distancing Measures in Brazil During COVID-19: Facilitators and Barriers, Beatriz C. Thomé, Gustavo C. Matta & Sérgio T.A. Rego Abstract
  COVID-19 was recognized as a pandemic on March 11, 2020. Nine days later in Brazil, community transmission was deemed ongoing, and following what was already being put in place in various affected countries, restrictive and physical distancing measures that varied in severity across the different states were adopted. Adherence to restrictive and physical distancing measures depends on the general acceptance of public health measures as well as communities’ financial leverage. This article aims to explore and discuss ethical facilitators and barriers to the implementation of physical distancing measures within three dimensions: political, socio-economic, and scientific. Furthermore, we would like to discuss ways to ethically promote restrictive and physical distancing measures in a large and unequal country like Brazil. There is an urgent need for transparent, consistent, and inclusive communication with the public, respecting the most vulnerable populations and attempting to minimize the disproportionate burden on them.
• COVID-19 from Wellington New Zealand, Ben Gray Abstract
  This paper examines the role of bioethics in the successful control of COVID-19 in New Zealand. After the severe acute respiratory syndrome (SARS) coronavirus episode in Toronto researchers developed a framework of values and principles to articulate values that were already commonly accepted “in the community of its intended users,” to be used to inform decision-making. New Zealand subsequently developed its own framework that was embedded in its Pandemic Influenza Plan. These formed the basis of the New Zealand response to COVID-19. This paper illustrates the ways in which the bioethical framework was reflected in the decisions and actions made by the government.
• Venenum, Virus, Fear, and Politics, Zvi Bekerman Abstract
  This article presents a short reflection on the confluence between politics and pandemics as they are reflected in Israel in March and April 2020.
• It Didn’t Have to be This Way: Reflections on the Ethical Justification of the Running Ban in Northern Italy in Response to the 2020 COVID-19 Outbreak, Silvia Camporesi Abstract
  In this paper I discuss the ethical justifiability of the limitation of freedom of movement, in particular of the ban on running outdoors, enforced in Italy as a response to the COVID-19 outbreak in the spring of 2020. I argue that through the lens of public health ethics literature, the ban on running falls short of the criterion of proportionality that public health ethics scholars and international guidelines for the ethical management of infectious disease outbreak recommend for any measure that restricts essential individual freedoms, such as the freedom of movement. The public health ethics framework, however, falls short of explaining the widespread public support that the running ban has had in Italy. I discuss possible factors which could explain the public support for the ban in Italy. Finally, I raise the question of what societal implications the abandonment of the public health ethics framework based on proportionality might have. I conclude that if it is the case, as the history of pandemics teaches us, we will experience further waves of COVID-19 outbreaks, it becomes very important to raise these questions now, with an eye towards informing public health policies for the management of future COVID-19 outbreaks. This discussion should not become politicized along the lines of liberal pro-lockdown/conservative anti-lockdown. Instead, we should reflect on the trade-offs of lockdown policies according to a pluralist framework, in which COVID-19 related deaths are not the only possible value to pursue.
• Synergistic Disparities and Public Health Mitigation of COVID-19 in the Rural United States, Kata L. Chillag & Lisa M. Lee Abstract
  Public health emergencies expose social injustice and health disparities, resulting in calls to address their structural causes once the acute crisis has passed. The COVID-19 pandemic is highlighting and exacerbating global, national, and regional disparities in relation to the benefits and burdens of undertaking critical basic public health mitigation measures such as physical distancing. In the United States, attempts to address the COVID-19 pandemic are complicated by striking racial, economic, and geographic inequities. These synergistic inequities exist in both urban and rural areas but take on a particular character and impact in areas of rural poverty. Rural areas face a diverse set of structural challenges, including inadequate public health, clinical, and other infrastructure and economic precarity, hampering the ability of communities and individuals to implement mitigation measures. Public health ethics demands that personnel address both the tactical, real-time adjustment of typical mitigation tools to improve their effectiveness among the rural poor as well as the strategic, longer-term structural causes of health and social injustice that continue to disadvantage this population.
• Heralding the Digitalization of Life in Post-Pandemic East Asian Societies, Calvin Wai-Loon Ho, Karel Caals & Haihong Zhang Abstract
  Following the outbreak of what would become the COVID-19 pandemic, social distancing measures were quickly introduced across East Asia—including drastic shelter-in-place orders in some cities—drawing on experience with the outbreak of severe acute respiratory syndrome (SARS) almost two decades ago. “Smart City” technologies and other digital tools were quickly deployed for infection control purposes, ranging from conventional thermal scanning cameras to digital tracing in the surveillance of at-risk individuals. Chatbots endowed with artificial intelligence have also been deployed to shift part of healthcare provision away from hospitals and to support a number of programmes for self-management of chronic disease in the community. With the closure of schools and adults working from home, digital technologies have also sustained many aspects of both professional and social life at a pace and scale not considered to be practicable before the outbreak. This paper considers how these new experiences with digital technologies in public health surveillance are spurring digitalization in East Asian societies beyond the conventional public health context. It also considers some of the concerns and challenges that are likely to arise with rapid digitalization, particularly in healthcare.
• COVID 19 and Australian Prisons: Human Rights, Risks, and Responses, Cameron Stewart, George F. Tomossy, Scott Lamont & Scott Brunero Abstract
  Australian prisons are overpopulated with people suffering from numerous health problems. COVID-19 presents a significant threat to prisoner health. This article examines the current regulatory responses from Australian state and territory governments to COVID-19 and a recent case which tested the human rights of prisoners during a pandemic.
• Social Justice for Public Health: The COVID-19 Response in Portugal, Luís Cordeiro-Rodrigues Abstract
  The COVID-19 pandemic requires emergency policies to be put in place in order to avoid a global health catastrophe. At the same time, there has been an increasing preoccupation that argues urgent policies for public health neglect social justice. By looking at Portugal’s successful confinement case during the pandemic, I argue that ethically driven social justice policies are not just compatible but also an instrumentally important element in addressing this pandemic in an effective way. The Portuguese case study suggests that enhancing social justice towards socio-economically vulnerable groups correlates with the prevention of the spread of COVID-19; these benefits to public health can be explained by the fact that those policies create social distancing and less exposure to the COVID-19 virus and other contagious diseases and also remove disincentives to the use of healthcare services.
• What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France, Kristina Orfali Abstract
  In today’s pandemic, many countries have experienced shortages of medical resources and many healthcare providers have often been faced with dramatic decisions about how to allocate beds, intensive care, or ventilators. Despite recognizing the need for triage, responses are not the same everywhere, and opinions and practices differ around what guidelines should be used, how they should be implemented, and who should ultimately decide. To some extent, triage issues reflect community values, revealing a given society’s moral standards and ideals. Our goal is to study two countries which share many common features—Italy and France—as they deal with the pandemic, revealing the moral organization of medicine and healthcare, the power structures, and the nature of the disruptions in each context.
• Preserving Bodily Integrity of Deceased Patients From the Novel SARS-CoV-2 Pandemic in West Africa, Peter F. Omonzejele Abstract
  The outbreak of the novel coronavirus pandemic, otherwise known as COVID-19 brought about the use of new terminologies—new lexical items such as social distancing, self-isolation, and lockdown. In developed countries, basic social amenities to support these are taken for granted; this is not the case in West African countries. Instead, those suggested safeguards against contracting COVID-19 have exposed the infrastructural deficit in West African countries. In addition, and more profoundly, these safeguards against the disease have distorted the traditional community-individuality balance. The enforcement of social distancing, self-isolation, and lockdown has made it impossible for West Africans to drift to their ancestral homes and villages, as is usually the case in times of crisis, with attendant consequences for communal life and traditional burial rites. This could be one of the reasons why some COVID-19 patients are escaping from isolation centres, since to die in such centres violates their bodily integrity at an ontological level.

V. Bioethical Debates

• Ethical Challenges in Clinical Research During the COVID-19 Pandemic, B.E. Bierer & S.A. White & J.M. Barnes & L. Gelinas Abstract
  The sudden emergence of the COVID-19 pandemic brought global disruption to every aspect of society, including healthcare, supply chain, the economy, and social interaction. Among the many emergent considerations were the safety and public health of individuals including patients, essential workers, and healthcare professionals. In certain locations, clinical research was halted—or terminated—in deference to the immediate needs of patient care, and clinical trials focusing on the treatment and prevention of coronavirus infection were prioritized over studies focusing on other diseases. Difficult decisions were made rapidly; flexibility and reconsideration were necessary, however, not only because the intensity and severity of infection varied over time and by locale but also because knowledge of the disease and understanding of its treatment (and prevention) grew. Here we discuss the ethical challenges in decision-making and competing ethical tensions during the pandemic in an effort to advance future preparedness.
• Beyond Duty: Medical “Heroes” and the COVID-19 Pandemic, Wendy Lipworth Abstract
  When infectious disease outbreaks strike, health facilities acquire labels such as “war zones” and “battlefields” and healthcare professionals become “heroes” on the “front line.” But unlike soldiers, healthcare professionals often take on these dangerous roles without any prior intention or explicit expectation that their work will place them in grave personal danger. This inevitably raises questions about their role-related obligations and whether they should be free to choose not to endanger themselves. In this article, I argue that it is helpful to view this situation not only through the lens of “professional duty” but also through the lens of “role-related conflicts.” Doing so has the advantage of avoiding exceptionalism and allowing us to draw lessons not only from previous epidemics but also from a wide range of far more common role-related dilemmas in healthcare.
• We Need to Talk About Rationing: The Need to Normalize Discussion About Healthcare Rationing in a Post COVID-19 Era, Neera Bhatia Abstract
  The global COVID-19 pandemic has brought the issue of rationing finite healthcare resources to the fore. There has been much academic debate, media attention, and conversation in the homes of everyday individuals about the allocation of medical resources, diagnostic testing kits, ventilators, and personal protective equipment. Yet decisions to prioritize treatment for some individuals over others occur implicitly and explicitly in everyday practices. The pandemic has propelled the socially taboo and unavoidably prickly issue of healthcare rationing into the public spotlight—and as such, healthcare rationing demands ongoing public attention and transparent discussion. This article concludes that in the aftermath of COVID-19, policymakers should work towards normalizing rationing discussions by engaging in transparent and honest debate in the wider community and public domain. Further, injecting greater openness and objectivity into rationing decisions might go some way towards dismantling the societal taboo surrounding rationing in healthcare.
• Justice, Wellbeing, and Civic Duty in the Age of a Pandemic: Why We All Need to do Our Bit, Johan C. Bester Abstract
  This article presents an argument related to justice obligations during a pandemic and explores implications of the argument. A just society responds to a serious threat to the well-being of its people such as a viral pandemic to mitigate the impact of the pandemic on the well-being of its members. This creates identifiable societal obligations which are discharged by the institutions and individuals within society that are situated to do so. There are therefore identifiable obligations resting on various societal institutions, such as government, churches, schools, and corporate institutions, as well as obligations resting on individuals. Should an institution or individual fail to act in ways consistent with these social obligations, they perpetrate an injustice on society and its members.
• Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research, N. Straiton, A. McKenzie, J. Bowden, A. Nichol, R. Murphy, T. Snelling, J. Zalcberg, J. Clements, J. Stubbs, A. Economides, D. Kent, J. Ansell & T. Symons Abstract
  Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

VI. Clinical Implications

• Imagining and Preparing for the Aftermath of the COVID-19 Pandemic: A Justification for Taking Caring Responsibilities into Consideration when Allocating Scarce Resources, Christopher F.C. Jordens Abstract
  Various models have been used to “emplot” our collective experience of the COVID-19 pandemic, including the epidemiological curve, threshold models, and narrative. Drawing on a threshold model that was designed to frame resource-allocation decisions in clinical care, I offer an ethical justification for taking caring responsibilities into consideration in such decisions during pandemics. My basic argument is that we should prioritize the survival of patients with caring responsibilities for similar reasons we should prioritize the survival of healthcare professionals. More generally, the pandemic reveals the fundamental importance of informal care and affords an opportunity to raise questions of justice relating to it.
• COVID-19, Moral Conflict, Distress, and Dying Alone, Lisa K. Anderson-Shaw & Fred A. Zar Abstract
  COVID-19 has truly affected most of the world over the past many months, perhaps more than any other event in recent history. In the wake of this pandemic are patients, family members, and various types of care providers, all of whom share different levels of moral distress. Moral conflict occurs in disputes when individuals or groups have differences over, or are unable to translate to each other, deeply held beliefs, knowledge, and values. Such conflicts can seriously affect healthcare providers and cause distress during disastrous situations such as pandemics when medical and human resources are stretched to the point of exhaustion. In the current pandemic, most hospitals and healthcare institutions in the United States have not allowed visitors to come to the hospitals to see their family or loved ones, even when the patient is dying. The moral conflict and moral distress (being constrained from doing what you think is right) among care providers when they see their patients dying alone can be unbearable and lead to ongoing grief and sadness. This paper will explore the concepts of moral distress and conflict among hospitalstaff and how a system-wide provider wellness programme can make a difference in healing and health.
• Ought Conscientious Refusals to Implement Reverse Triage Decisions be Accommodated?, Nathan Emmerich Abstract
  Although one can argue that they do not represent a radical departure from existing practices, protocols for reverse triage certainly step beyond what is ordinarily done in medicine and healthcare. Nevertheless, there seems to be some degree of moral concern regarding the ethical legitimacy of practicing reverse triage in the context of a pandemic. Such concern can be taken as a reflection of the moral antipathy some exhibit towards current practices of withdrawing treatment—that is, when withdrawal of treatment is arguably in the best interests of patients—and a rejection of the purported normative insignificance of withholding and withdrawing. Given that the relevance of the psychological attitudes of some healthcare professionals to the moral assessment of withdrawing and withholding treatment continues to be debated, it would seem that some thought should be given to the introduction and implementation of reverse triage decisions in response to a pandemic. This brief paper will consider if provision should be made for healthcare professionals to conscientiously refuse to participate in reverse triage.
• Healthcare Professional Standards in Pandemic Conditions: The Duty to Obtain Consent to Treatment, Sarah Devaney, Jose Miola, Emma Cave, Craig Purshouse & Rob Heywood Abstract
  In the United Kingdom, the question of how much information is required to be given to patients about the benefits and risks of proposed treatment remains extant. Issues about whether healthcare resources can accommodate extended shared decision-making processes are yet to be resolved. COVID-19 has now stepped into this arena of uncertainty, adding more complexity. U.K. public health responses to the pandemic raise important questions about professional standards regarding how the obtaining and recording of consent might change or be maintained in such emergency conditions, particularly in settings where equipment, medicines, and appropriately trained or specialized staff are in short supply. Such conditions have important implications for the professional capacity and knowledge available to discuss the risks and benefits of and alternatives to proposed treatment with patients. The government’s drive to expedite the recruitment to wards of medical students nearing the end of their studies, as well as inviting retired practitioners back into practice, raises questions about the ability of such healthcare providers to engage fully in shared decision-making. This article explores whether the legal duty on healthcare practitioners to disclose the material risks of a proposed medical treatment to a patient should be upheld during pandemic conditions or whether the pre-eminence of patient autonomy should be partly sacrificed in such exceptional circumstances. We argue that measures to protect public health and to respect autonomous decision-making are not mutually exclusive and that there are good reasons to maintain professional standards in obtaining consent to treatment even during acute pressures on public health systems.
• What Matters? Palliative Care, Ethics, and the COVID-19 Pandemic, Linda Sheahan & Frank Brennan Abstract
  As is often the case in clinical ethics, the discourse in COVID-19 has focused primarily on difficult and controversial decision-making junctures such as how to decide who gets access to intensive care resources if demand outstrips supply. However, the lived experience of COVID-19 raises less controversial but arguably more profound moral questions around what it means to look after each other through the course of the pandemic and how this translates in care for the dying. This piece explores the interface between the pandemic, ethics, and the role of palliative care. We argue that the ethical discourse should be broader, and that the principles that underly the discipline of palliative care provide a solid ethical foundation for the care of all patients through the coronavirus pandemic.
• Telling the Truth to Child Cancer Patients in COVID-19 Times, Lynn Gillam, Merle Spriggs, Clare Delany, Rachael Conyers & Maria McCarthy Abstract
  A notable feature of the COVID-19 pandemic is that children are less at risk of becoming infected or, if infected, less likely to become seriously unwell, so ethical discussions have consequently focused on the adult healthcare setting. However, despite a lower risk of children becoming acutely ill with COVID-19, there nevertheless may be significant and potentially sustained effects of COVID-19 on the physical, psychological, and emotional health and wellbeing of children. Focusing on the context of children’s cancer care, and specifically bone marrow transplant (BMT), we describe some of these effects and then address one specific ethical challenge that arises. That is the question of what and how much to tell children whose cancer treatment has been changed because of COVID-19. Drawing on our previous work on the ethical reasons for telling the truth to younger children (aged 5-12) we link different ethical reasons to the different types of information that could be given to children in this context. We argue that children should be given an explanation of the changes that they will directly experience, including some changes to the process of their actual medical treatment; but not about increased risk associated with these changes, unless they specifically ask for this information.
• Mental Capacity Assessments for COVID-19 Patients: Emergency Admissions and the CARD Approach, Cameron Stewart, Paul Biegler, Scott Brunero, Scott Lamont, George F. Tomossy Abstract
  The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).

Related

• Symposium Part 1: Social and ethical implications of the COVID-19 pandemic: Part 1, ePub ahead of print, August 25, 2020 
• Read full versions of articles at the SpringerLink Journal of Bioethical Inquiry site.
• Notice—Coming Up: Special Symposium on Social and Ethical Implications of the COVID-19 Pandemic

Images

Image: “This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses.” [CDC / Alissa Eckert, MSMI; Dan Higgins, MAMS (2020)]