Moral obligation to follow anti-COVID-19 measures strengthens the mental health cost of pandemic burnout.

BACKGROUND: It has been observed that people become gradually exhausted by receiving COVID-19-related information and adhering to the corresponding preventive measures as the pandemic unfolds. This phenomenon is known as pandemic burnout. Emerging evidence shows that pandemic burnout is related to poor mental health. This study extended the trendy topic by examining the idea that moral obligation, a crucial motivation driving people to follow the preventive measures, would amplify the mental health cost of pandemic burnout. METHODS: Participants were 937 Hong Kong citizens (88 % females, 62.4 % aged 31-40 years). They participated in a cross-sectional online survey reporting on pandemic burnout, moral obligation, and mental health problems (i.e., depressive symptoms, anxiety, and stress). RESULTS: Findings of moderation model analyses showed that higher levels of pandemic burnout and moral obligation were related to more mental health problems. Importantly, the "pandemic burnout-mental health problems" links were moderated by moral obligation, with those who felt more morally obliged to follow the measures reporting poorer mental health than those who felt less morally obliged to do so. LIMITATIONS: The cross-sectional design of the study may constrain the evidence about the directions and causality of the relationships. Participants were only recruited from Hong Kong and females were over-represented, thus limiting the generalizability of the findings. CONCLUSIONS: People who experience pandemic burnout while feeling more morally obliged to follow the anti-COVID-19 measures are at greater risk of mental health problems. They might need more mental health support from medical professionals.

Discriminatory attitudes against unvaccinated people during the pandemic.

During the COVID-19 pandemic, sizeable groups of unvaccinated people persist even in countries with high vaccine access1. As a consequence, vaccination became a controversial subject of debate and even protest2. Here we assess whether people express discriminatory attitudes in the form of negative affectivity, stereotypes and exclusionary attitudes in family and political settings across groups defined by COVID-19 vaccination status. We quantify discriminatory attitudes between vaccinated and unvaccinated citizens in 21 countries, covering a diverse set of cultures across the world. Across three conjoined experimental studies (n = 15,233), we demonstrate that vaccinated people express discriminatory attitudes towards unvaccinated individuals at a level as high as discriminatory attitudes that are commonly aimed at immigrant and minority populations3-5. By contrast, there is an absence of evidence that unvaccinated individuals display discriminatory attitudes towards vaccinated people, except for the presence of negative affectivity in Germany and the USA. We find evidence in support of discriminatory attitudes against unvaccinated individuals in all countries except for Hungary and Romania, and find that discriminatory attitudes are more strongly expressed in cultures with stronger cooperative norms. Previous research on the psychology of cooperation has shown that individuals react negatively against perceived 'free-riders'6,7, including in the domain of vaccinations8,9. Consistent with this, we find that contributors to the public good of epidemic control (that is, vaccinated individuals) react with discriminatory attitudes towards perceived free-riders (that is, unvaccinated individuals). National leaders and vaccinated members of the public appealed to moral obligations to increase COVID-19 vaccine uptake10,11, but our findings suggest that discriminatory attitudes-including support for the removal of fundamental rights-simultaneously emerged.

Vulnerability, Moral responsibility, and Moral Obligations: the case of Industrial Action in the Medical and Allied Professions.

The article addresses issues at the nexus of physician industrial action, moral agency, and responsibility. There are situations in which we find ourselves best placed to offer aid to those who may be in vulnerable positions, a behavior that is consistent with our everyday moral intuitions. In both our interpersonal relationships and social life, we make frequent judgments about whether to praise or blame someone for their actions when we determine that they should have acted to help a vulnerable person. While the average person is unlikely to confront these kinds of situations often, those in the medical professions, physicians especially, may confront these and similar situations regularly. Therefore, when physicians withhold their services for whatever reason in support of industrial action, it raises issues of moral responsibility to patients who may be in a vulnerable position. Using theories of moral responsibility, vulnerability, and ethics, this paper explores the moral implications of physician industrial action. We explore issues of vulnerability of patients, as well as the moral responsibility and moral agency of doctors to patients. Determining when a person is vulnerable, and when an individual becomes a moral agent, worthy of praise or blame for an act or non-action, is at the core of the framework. Notwithstanding the right of physicians to act in their self-interest, we argue that vulnerability leads to moral obligations, that physicians are moral agents, and the imperatives of their obligations to patients clear, even if limited by certain conditions. We suggest that both doctors and governments have a collective responsibility to prevent harm to patients and present the theoretical and practical implications of the paper.

Ethical values and principles to guide the fair allocation of resources in response to a pandemic: a rapid systematic review.

BACKGROUND: The coronavirus 2019 pandemic placed unprecedented pressures on healthcare services and magnified ethical dilemmas related to how resources should be allocated. These resources include, among others, personal protective equipment, personnel, life-saving equipment, and vaccines. Decision-makers have therefore sought ethical decision-making tools so that resources are distributed both swiftly and equitably. To support the development of such a decision-making tool, a systematic review of the literature on relevant ethical values and principles was undertaken. The aim of this review was to identify ethical values and principles in the literature which relate to the equitable allocation of resources in response to an acute public health threat, such as a pandemic. METHODS: A rapid systematic review was conducted using MEDLINE, EMBASE, Google Scholar, LitCOVID and relevant reference lists. The time period of the search was January 2000 to 6th April 2020, and the search was restricted to human studies. January 2000 was selected as a start date as the aim was to capture ethical values and principles within acute public health threat situations. No restrictions were made with regard to language. Ethical values and principles were extracted and examined thematically. RESULTS: A total of 1,618 articles were identified. After screening and application of eligibility criteria, 169 papers were included in the thematic synthesis. The most commonly mentioned ethical values and principles were: Equity, reciprocity, transparency, justice, duty to care, liberty, utility, stewardship, trust and proportionality. In some cases, ethical principles were conflicting, for example, Protection of the Public from Harm and Liberty. CONCLUSIONS: Allocation of resources in response to acute public health threats is challenging and must be simultaneously guided by many ethical principles and values. Ethical decision-making strategies and the prioritisation of different principles and values needs to be discussed with the public in order to prepare for future public health threats. An evidence-based tool to guide decision-makers in making difficult decisions is required. The equitable allocation of resources in response to an acute public health threat is challenging, and many ethical principles may be applied simultaneously. An evidence-based tool to support difficult decisions would be helpful to guide decision-makers.

Professional Oversight of Emergency-Use Interventions and Monitoring Systems: Ethical Guidance From the Singapore Experience of COVID-19.

High degrees of uncertainty and a lack of effective therapeutic treatments have characterized the COVID-19 pandemic and the provision of drug products outside research settings has been controversial. International guidelines for providing patients with experimental interventions to treat infectious diseases outside of clinical trials exist but it is unclear if or how they should apply in settings where clinical trials and research are strongly regulated. We propose the Professional Oversight of Emergency-Use Interventions and Monitoring System (POEIMS) as an alternative pathway based on guidance developed for the ethical provision of experimental interventions to treat COVID-19 in Singapore. We support our proposal with justifications that establish moral duties for physicians to record outcomes data and for institutions to establish monitoring systems for reporting information on safety and effectiveness to the relevant authorities. Institutions also have a duty to support generation of evidence for what constitutes good clinical practice and so should ensure the unproven intervention is made the subject of research studies that can contribute to generalizable knowledge as soon as practical and that physicians remain committed to supporting learning health systems. We outline key differences between POEIMS and other pathways for the provision of experimental interventions in public health emergencies.

Preventive behaviours during the pandemic: The role of collective rituals, emotional synchrony, social norms and moral obligation.

The present research focuses on the role of collective, social influence and intraindividual processes in shaping preventive behaviours during the COVID-19 pandemic. In two correlational studies conducted in Spain, we explored the impact of participation in the ritual of collective applause (carried out daily for over 70 days during the lockdown) and perceived social norms in fostering behavioural adherence to public health measures, as well as the mediating role of perceived emotional synchrony and a sense of moral obligation. The first study (general population, N = 528) was conducted in June 2020, just after the end of the lockdown, and the second study (students, N = 292) was carried out eight months later. The results of the structural equations modelling (SEM) consistently confirmed that active participation in collective applause was linked to more intense emotional synchrony and indirectly predicted self-reported preventive behaviour. Perceived social norms predicted self-reported behavioural compliance directly and also indirectly, via feelings of moral obligation. The discussion addresses some meaningful variations in the results and also focuses on the implications of the findings for both theory and psychosocial intervention.

Surgery during COVID-19 crisis conditions: can we protect our ethical integrity against the odds?

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients' outcome within the constraints of pandemic management and its long-term outlook.

'Healthcare Heroes': problems with media focus on heroism from healthcare workers during the COVID-19 pandemic.

During the COVID-19 pandemic, the media have repeatedly praised healthcare workers for their 'heroic' work. Although this gratitude is undoubtedly appreciated by many, we must be cautious about overuse of the term 'hero' in such discussions. The challenges currently faced by healthcare workers are substantially greater than those encountered in their normal work, and it is understandable that the language of heroism has been evoked to praise them for their actions. Yet such language can have potentially negative consequences. Here, I examine what heroism is and why it is being applied to the healthcare workers currently, before outlining some of the problems associated with the heroism narrative currently being employed by the media. Healthcare workers have a clear and limited duty to treat during the COVID-19 pandemic, which can be grounded in a broad social contract and is strongly associated with certain reciprocal duties that society has towards healthcare workers. I argue that the heroism narrative can be damaging, as it stifles meaningful discussion about what the limits of this duty to treat are. It fails to acknowledge the importance of reciprocity, and through its implication that all healthcare workers have to be heroic, it can have negative psychological effects on workers themselves. I conclude that rather than invoking the language of heroism to praise healthcare workers, we should examine, as a society, what duties healthcare workers have to work in this pandemic, and how we can support them in fulfilling these.

Relational ethical approaches to the COVID-19 pandemic.

Key ethical challenges for healthcare workers arising from the COVID-19 pandemic are identified: isolation and social distancing, duty of care and fair access to treatment. The paper argues for a relational approach to ethics which includes solidarity, relational autonomy, duty, equity, trust and reciprocity as core values. The needs of the poor and socially disadvantaged are highlighted. Relational autonomy and solidarity are explored in relation to isolation and social distancing. Reciprocity is discussed with reference to healthcare workers' duty of care and its limits. Priority setting and access to treatment raise ethical issues of utility and equity. Difficult ethical dilemmas around triage, do not resuscitate decisions, and withholding and withdrawing treatment are discussed in the light of recently published guidelines. The paper concludes with the hope for a wider discussion of relational ethics and a glimpse of a future after the pandemic has subsided.

Deontological or Utilitarian? An Eternal Ethical Dilemma in Outbreak.

Both deontological ethics and utilitarian ethics are important theories that affect decision making in medical and health care. However, it has been challenging to reach a balance between these two ethical theories. When there is a conflict between these two ethical principles in the medical context, the conflict must be addressed in order to reach an appropriate solution for patients and others involved. To demonstrate decisions made in terms of deontological ethics and utilitarian ethics, the study will use the film Outbreak as example to further understand these two ethics in relation to epidemiology and public health. The paper will also analyze film scenarios to examine how deontological ethics and utilitarian ethics are involved and strike a balance with different pearspectives to reach an appropriate public health solution. To reach more just solutions, it is essential to determine how to make wise decisions by balancing deontological ethics and utilitarian ethics. However, the decision-making process is complicated because any solution must consider not only medical ethics but also political, environmental, and military issues. In order to reach an appropriate public health decision, those involved should be inclined toward empathy and contemplate things from different ethical perspectives to deal with ethical/moral dilemmas and create greater beneficence and justice for patients and humanity at large.

Physician outreach during a pandemic: shared or collective responsibility?

In 'Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?' Strous and Karni note that the revised physician's pledge in the World Medical Association Declaration of Geneva obligates individual physicians to share medical knowledge, which they interpret to mean a requirement to share knowledge publicly and through outreach. In the context of the COVID-19 pandemic, Strous and Karni defend a form of medical paternalism insofar as the individual physician must reach out to communities who may not want, or know to seek out, medical advice, for reasons of public health and health equity. Strous and Karni offer a novel defence of why physicians ought to intervene even in insular communities, and they offer suggestions for how this could be done in culturally sensitive ways. Yet their view rests on an unfounded interpretation of the Geneva Declaration language. More problematically, their paper confuses shared and collective responsibility, misattributing the scope of individual physician obligations in potentially harmful ways. In response, this reply delineates between shared and collective responsibility, and suggests that to defend the obligation of medical outreach Strous and Karni propose, it is better conceptualised as a collective responsibility of the medical profession, rather than a shared responsibility of individual physicians. This interpretation rejects paternalism on the part of individual providers in favour of a more sensitive and collaborative practice of knowledge sharing between physicians and communities, and in the service of collective responsibility.

Integrity during pandemic times: The case for flexible adamancy.

The Covid-19 pandemic has dominated people's lives since late 2019, for more than nine months now. Healthcare resources and medicine have been completely consumed by the Covid 19 illness globally. This is a particularly difficult time for health systems because of the onerous responsibility to care for large numbers of sick people, protecting populations from contracting the infection by effective quarantine, isolation, and containment measures. In addition to this burden of work, healthcare providers are also overcome by fear of contracting the infection and transmitting it to their loved ones. It is during such difficult times that the integrity of healthcare providers is challenged. In this paper I will describe some challenges that a healthcare provider in a typical low resource setting faces during this pandemic time, and will propose the idea of "flexible adamancy" to address these challenges to the health system's integrity.

Equitable and Effective Distribution of the COVID-19 Vaccines - A Scientific and Moral Obligation.

The rapid development of coronavirus disease 2019 (COVID-19) vaccines has not been met with the assurance of an effective and equitable global distribution mechanism. Low-income countries are especially at-risk, with the price of the vaccines and supply shortages limiting their ability to procure and distribute the vaccines. While the COVAX initiative is one of the solutions to these challenges, vaccine nationalism has resulted in the hoarding of vaccines and the signing of parallel bilateral deals, undermining this formerly promising initiative. Moreover, inequity in local distribution also remains a problem, with clear discrimination of minorities and lack of logistical preparation in some countries. As we continue to distribute the COVID-19 vaccines, pharmaceutical companies should share their technology to increase supply and reduce prices, governments should prioritize equitable distribution to the most at-risk in all nations and low-income countries should bolster their logistical capacity in preparation for mass vaccination campaigns.

Among equity and dignity: an argument-based review of European ethical guidelines under COVID-19.

BACKGROUND: Under COVID-19 pandemic, many organizations developed guidelines to deal with the ethical aspects of resources allocation. This study describes the results of an argument-based review of ethical guidelines developed at the European level. It aims to increase knowledge and awareness about the moral relevance of the outbreak, especially as regards the balance of equity and dignity in clinical practice and patient's care. METHOD: According to the argument-based review framework, we started our research from the following two questions: what are the ethical principles adopted by the ethical guidelines produced at the beginning of the COVID-19 outbreak related to resource allocation? And what are the practical consequences in terms of 'priority' of access, access criteria, management of the decision-making process and patient care? RESULTS: Twenty-two ethical guidelines met our inclusion criteria and the results of our analysis are organized into 4 ethical concepts and related arguments: the equity principle and emerging ethical theories; triage criteria; respecting patient's dignity, and decision making and quality of care. CONCLUSION: Further studies can investigate the practical consequences of the application of the guidelines described, in terms of quality of care and health care professionals' moral distress.

If fetuses are persons, abortion is a public health crisis.

Pro-life advocates commonly argue that fetuses have the moral status of persons, and an accompanying right to life, a view most pro-choice advocates deny. A difficulty for this pro-life position has been Judith Jarvis Thomson's violinist analogy, in which she argues that even if the fetus is a person, abortion is often permissible because a pregnant woman is not obliged to continue to offer her body as life support. Here, we outline the moral theories underlying public health ethics, and examine the COVID-19 pandemic as an example of public health considerations overriding individual rights. We argue that if fetuses are regarded as persons, then abortion is of such prevalence in society that it also constitutes a significant public health crisis. We show that on public health considerations, we are justified in overriding individual rights to bodily autonomy by prohibiting abortion. We conclude that in a society that values public health, abortion can only be tolerated if fetuses are not regarded as persons.