The SARS-CoV-2 pandemic has highlighted the situation of national health systems and, therefore, the preparation, planning, coordination and prevention of countries in the face of a situation of high demand for care. Our health service has been overload by the absence of a plan to deal with the pandemic, which has led to an allocation of resources that, in each hospital, nursing home, health center, autonomous community, were taken without having clear basic bioethical guidelines.
Pandemics are part of the history of humanity. Since the fourteenth century, there has been an average of three per century. These are exceptional circumstances that generate situations of imbalance, not only at a health level but also economically and socially. These specific events require extraordinary responses, since they are going to put the resources we have at risk.
In times of crisis, we must not change our ethical values, but cling to them more than ever. This requires a solid debate that has the broad consensus of all the actors involved. Planning is necessary to anticipate the details and the answers. Bioethics must be taken into account in the preparation of health crises, since it must examine public policies and their consequences and offer alternatives.
The precedent of the Severe Acute Respiratory Syndrome (SARS) virus in 2003 alerted the international scientific society. The then director general of the World Health Organization (WHO), Dr. Harlem Bruntland, stated “SARS is just a warning” that “has put the most advanced public health systems to the test. Next time we may not be so lucky.1”
This virus constituted the first pandemic of the 21st century. Earlier this year, the US National Academy of Medicine (formerly the Institute of Medicine) organized a workshop, entitled “Learning from SARS: Preparing for the Next Disease Outbreak.” The objective was to analyze the SARS epidemic, to improve the preparation and response of the international community to future global outbreaks of infectious diseases.
In one of his sessions, Robert Webster, from the department of infectious diseases at St Jude Hospital, stated “it is possible that the future will bring a more contagious and deadly form of SARS“.
SARS was the first recent warning of how the international community, and therefore each country, should evaluate its health system to face a future outbreak of an infectious disease.
The planning of public health policies should entail an analysis of the legal and ethical changes involved in the adoption of measures that curtail individual rights: limitation of movement; quarantine and isolation; closure of educational centers, shops and public spaces; the limits of privacy in the study of contacts or the allocation of resources to those patients who require treatment, among others.
In 2004, Lawrence O. Gostin, professor of public health at Georgetown University, warned of a forthcoming pandemic, which had to meet three requirements: it had to be a new animal virus (pig, bird, etc.), that could affect humans and that there would be human-to-human transmission.
He also insisted on the need for transversal ethical values in public health plans: transparency, protection of the most vulnerable, fair treatment and social justice (he was already talking about affirming the dignity of the person) and the principle of proportionality in restrictive measures.
Following international warnings, our country was a pioneer in developing in 2005 a “national plan for preparation and response to an influenza pandemic” that brought together the recommendations of both the WHO and the European Union to minimize the impact of a pandemic and to work in a coordinated manner from the different public administrations.
It is a merely technical document, which lacks the necessary bioethical analysis of decision-making. Therefore, it does not take into account what to do in situations of scarcity of resources or how to allocate them. Since 2006 it has not been revised.
In a health emergency situation, it has been estimated, based on projections from previous pandemics, that 200% of the current supply of ventilators and 400% more ICU beds will be needed to guarantee assistance to all sick people.
At this point, if these resources are not available, a high percentage of patients with respiratory failure who require admission to an ICU or mechanical ventilation (MV) will not be able to access them. This is when ethical dilemmas will arise.
In a pandemic, medical decisions about each of the patients will be subordinated to public health objectives. The clinician’s action will be aimed not so much at the health of the citizens as at the welfare of the community. That is why the allocation of scarce resources must be based on public health guidelines and not on the unilateral decisions of each clinician, as is the case in normal practice.
There must be a necessary debate between the parties involved about what ethical principles should govern decision-making. In daily clinical practice, in normal situations, a person who needs life support measures receives them, unless it has been expressed, either verbally, by informed consent or advance directives, or it is considered therapeutic futility or obstinacy.
This situation is modified in crisis situations, because the objective of the clinician will no longer be each one of his patients but that of public health, and therefore that of the population. It is necessary an ethical debate on health emergency preparedness plans. Only 6% of preparedness plans published up to 2017 had an ethical orientation.
An open, transparent and participatory process is needed in which not only scientific society but also civil society is involved, to develop a pandemic/health crisis preparedness plan.
The bioethical dilemmas in prioritization would not have been such if the advance directive documents had been consulted or the patients (or their relatives) had been asked, establishing an advance care plan that respected their values, preferences and beliefs.
Ethical dilemmas and decision-making in daily clinical practice are common, and are aggravated by health crises. A bioethical reflection is necessary in the allocation of resources with the premise that every person, as a unique and unrepeatable human being, regardless of his age or functional status, has dignity and deserves to receive the necessary medical attention and care. (Article published in ILAPHAR -Ibero Latin American Journal of Health System Pharmacy).
Cristian Gómez Torrijos
Master in Bioethics. Catholic University of Valencia
Liria Hospital. Department of Health Valencia- Arnau de Vilanova- Liria (Spain)