Desafios, problemas e dilemas bioéticos em tempos de Covid-19 / Challenges, problems and bioethical dilemmas in Covid 19 times

A gestão das questões bioéticas deve alicerçar-se em princípios e recomendações bem estabelecidas. Neste estudo do tipo bibliométrico, fez-se o levantamento do volume de publicações científicas no âmbito da Covid-19 (e cumulativamente em Bioética), publicados na base de dados (BD) Biblioteca Virtual de Saúde (BVS) durante o período de 1 de Janeiro de 2020 à 31 de Março de 2021, identificando-se diversos tópicos focados, visando disponibilizar aos profissionais e investigadores na área das ciências Médicas e da Saúde, particularmente em Angola, evidências que promovam a eticidade das políticas e práticas no combate a esta pandemia, na atenção às populações e na assistência aos doentes. No período de estudo estabelecido a BD devolvia 118 483 publicações (260/dia) para a expressão "Covid", e 158 (0,35/d) para Bioética e Covid". Destas, foram incluídas no estudo 57 artigos que possuiam como assunto principal o objectivo da nossa pesquisa. Os principais tópicos pesquisados foram ética da pesquisa 11(19,3%), a justiça/injustiça 10(17,5%) e a alocação de recursos escassos 6 (10,5%). As três questões adicionadas as 25 já existentes sobre Bioética e Covid foram: é ético não informar ou desinformar (infodemia)?, é ético o "nacionalismo vacinal"?, é ético penalizar alguém pela não-vacinação ou escolha da vacinação anti Covid-19?). Assim sendo, concluimos que a prevenção, combate e assistência à Covid-19 possui uma profunda dimensão Bioética, unida mas distinta de aspectos legais, organizativos e de gestão. É recomendável promover investigação bioética em Covid-19 e a sua translacção nas políticas e práticas. Deve aprofundar-se o estudo da "Ethosprudência" e elaborar antecipadamente "protocolos de ética médica" para apoiar o processo de decisão.

The management of bioethical issues should be based on well-established principles and recommendations. In this bibliometric study, we surveyed the volume of scientific publications on Covid-19 (and cumulatively on Bioethics), published in the database (DB) Virtual Health Library (VHL) from January 1st 2020 to March 31st 2021, identifying several focused topics, in order to provide professionals and researchers in the field of medical and health sciences, particularly in Angola, with evidence that promotes the ethics of policies and practices in combating this pandemic, in caring for the population and, patients. In the established study period, the DB returned 118 483 publications (260/day) for the expression "Covid", and 158 (0.35/day) for "Bioethics and Covid". Of these, 57 articles that had our research objective as their main subject were included in the study. The main topics searched were research ethics 11(19,3%), justice/injustice 10(17,5%) and allocation of scarce resources 6(10,5%). The three questions added to the 25 already existing on Bioethics and Covid were: is it ethical to not inform or misinform (infodemy)?, is "vaccine nationalism" ethical?, is it ethical to penalize someone for non-vaccination or choice of antiCovid-19 vaccination?). Therefore, we conclude that preventing, combating and assisting Covid-19 has a profound bioethical dimension, united but distinct from legal, organisational and managerial aspects. It is recommended to promote bioethical research on Covid-19 and itstranslation into policies and practices. The study of 'Ethosprudence' should be deepened and 'medical ethics protocols' developed in advance to support the decision-making process.

Ethical Dilemma involving autonomy and COVID-19 testing

Background: In December 2019, an atypical form of pneumonia was discovered in Wuhan, China and it has spread to different parts of the world including Nigeria. Testing for the causative agent which is the severe acute respiratory distress syndrome coronavirus-2 is one of the strategies to contain the pandemic. For some reason, some patients with clinical symptoms suggestive of COVID-19 may refuse to be tested for the disease. Methodology: A review of studies conducted on COVID-19 testing and ethical dilemma associated with it was done using Google Scholar, PubMed and Cochrane reviews. Conclusion: Ethical dilemma exists in testing for COVID-19 as some patients may refuse testing even when it is necessary and they present with symptoms suggestive of COVID-19. The right to autonomy according to the principles of medical ethics is necessary for every medical consultation but may not be important in pandemics as the person becomes a health threat and harmful to the public.

Comorbidity in context: Part 2. Ethicolegal considerations around HIV and tuberculosis during the COVID-19 pandemic in South Africa

The COVID-19 pandemic has brought discussions around the appropriate and fair rationing of scare resources to the forefront. This is of special importance in a country such as South Africa (SA), where scarce resources interface with high levels of need. A large proportion of the SA population has risk factors associated with worse COVID-19 outcomes. Many people are also potentially medically and socially vulnerable secondary to the high levels of infection with HIV and tuberculosis (TB) in the country. This is the second of two articles. The first examined the clinical evidence regarding the inclusion of HIV and TB as comorbidities relevant to intensive care unit (ICU) admission triage criteria. Given the fact that patients with HIV or TB may potentially be excluded from admission to an ICU on the basis of an assumption of lack of clinical suitability for critical care, in this article we explore the ethicolegal implications of limiting ICU access of persons living with HIV or TB. We argue that all allocation and rationing decisions must be in terms of SA law, which prohibits unfair discrimination. In addition, ethical decision-making demands accurate and evidence-based strategies for the fair distribution of limited resources. Rationing decisions and processes should be fair and based on visible and consistent criteria that can be subjected to objective scrutiny, with the ultimate aim of ensuring accountability, equity and fairness

Consent for critical care research after death from COVID-19: Arguments for a waiver

Pandemics challenge clinicians and scientists in many ways, especially when the virus is novel and disease expression becomes variable or unpredictable. Under such circumstances, research becomes critical to inform clinical care and protect future patients. Given that severely ill patients admitted to intensive care units are at high risk of mortality, establishing the cause of death at a histopathological level could prove invaluable in contributing to the understanding of COVID-19. Postmortem examination including autopsies would be optimal. However, in the context of high contagion and limited personal protective equipment, full autopsies are not being conducted in South Africa (SA). A compromise would require tissue biopsies and samples to be taken immediately after death to obtain diagnostic information, which could potentially guide care of future patients, or generate hypotheses for finding needed solutions. In the absence of an advance written directive (including a will or medical record) providing consent for postmortem research, proxy consent is the next best option. However, obtaining consent from distraught family members, under circumstances of legally mandated lockdown when strict infection control measures limit visitors in hospitals, is challenging. Their extreme vulnerability and emotional distress make full understanding of the rationale and consent process difficult either before or upon death of a family member. While it is morally distressing to convey a message of death telephonically, it is inhumane to request consent for urgent research in the same conversation. Careful balancing of the principles of autonomy, non-maleficence and justice becomes an ethical imperative. Under such circumstances, a waiver of consent, preferably followed by deferred proxy consent, granted by a research ethics committee in keeping with national ethics guidance and legislation, would fulfil the basic premise of care and research: first do no harm. This article examines the SA research ethics framework, guidance and legislation to justify support for a waiver of consent followed by deferred proxy consent, when possible, in urgent research after death to inform current and future care to contain the pandemic in the public interest

Perspectives of Nigerian doctors on the practice of rebates, fee-splitting, and kickbacks

Background: Fee splitting is a global pandemic in the health-care industry, whereby financial and nonfinancial inducements are offered to health-care practitioners in exchange for guaranteed patient referral, continuous patronage, or preferential usage/prescription of the payer's products. Methods: We surveyed 280 medical doctors from August 2017 to October 2017 to assess their knowledge, perception, and attitude toward fee-splitting using self-administered questionnaires.Results: The majority (89%) of our respondents indicated that they were aware of the existence of fee-splitting in the Nigerian health-care industry. About 34% accept rebates, while 70% admitted to knowing other colleagues who accept rebates. The amount received as rebates was ≤20% of the cost of an investigation. More than half of the respondents (52%) opined that the practice is a nationwide phenomenon. An astonishing 78% of respondents either did not know (61%) or asserted wrongly (17%) that the practice is not a violation Nigerian Medical Council rules. Only 46% affirmed that the practice is unethical. Compared to private hospitals, fee-splitting is less in public hospitals. Sixty-one percent noted that other health-care workers (besides physicians) are also involved. The primary allures of fee-splitting were a quest for an extra source of income (64%), poor/irregular salaries (60%), ignorance of its illegality (56%), and greed (47%). The identified deleterious consequences were unnecessary investigations/procedures, inflated health-care cost, quackery, delayed treatment/prolonged hospital stay, beclouded clinical judgment, and negative public perception.Conclusion: Stricter regulatory enforcement and continuous ethics education are needed to disrupt the widespread fee-splitting culture

Feasibility of rapid ethical assessment for the Ethiopian health research ethics review system

One of the challenges in the process of ethical medical research in developing countries; including Ethiopia; is translating universal principles of medical ethics into appropriate informed consent documents and their implementation. Rapid Ethical Assessment (REA) has been suggested as a feasible approach to meet this application gap. In the past few years REA has been employed in few research project in Ethiopia and have been found to be a useful and practical approach. Feasibility assessment of REA for the Ethiopian research setting was conducted between 2012-2013 in order to inform the subsequent introduction of REA into research ethics review and governance system in the country. REA was found to be an appropriate; relevant and feasible venture. We argue that REA can be integrated as part of the ethics review and governance system in Ethiopia. REA tools and techniques are considered relevant and acceptable to the Ethiopian research community; with few practical challenges anticipated in their implementation. REA are considered feasible for integration in the Ethiopian ethics review system