The SARS-CoV-2 virus that causes COVID-19 has spread throughout the world with the number of cases increasing daily, both due to spread and to extended testing. We have provided links to the Centers for Disease Control and Prevention’s websites that give up-to-date numbers and guidelines as the virus spreads.
Overview of the Virus
Let’s take a look at viruses in general and SARS-CoV-2 in particular. First, bacterial infections are different from viral infections. Antibiotics can be used against bacterial infections, such as bacterial pneumonia. Unfortunately, there is not an equivalent combatant to viral infections. Antiviral drugs are only available for certain viral infections—for example Tamiflu for the flu—but most antiviral drugs must be taken soon after a person is infected. The other way to combat viral infections is vaccines.
Things get confusing when viral infections cause bacterial infections, as can be the case with respiratory viruses like the influenza virus. Influenza can cause pneumonia. Pneumonia itself can be either viral or bacterial. Recent studies indicate that while the strain that caused the 1918 flu pandemic was particularly deadly, many of the victims probably died of bacterial pneumonia. Another contributing factor to the high mortality rate was World War I. Soldiers were living in sometimes crowded, squalid conditions with poor sanitation.
[1]
This is the opposite of the CDC’s recommendations for curbing the spread of COVID-19: social distancing and hand washing. Additionally, COVID-19 appears to cause viral pneumonia in some people.
[2]
So what about the SARS-CoV-2, or the coronavirus? Scientists and news outlets call this a “novel” virus, which is true, but the virus itself is part of a family of viruses known as “coronaviruses.” Corona is Latin for “crown,” and is also the name of the diffuse plasma layer that surrounds stars, including the sun. The coronavirus has spike-like protrusions, like a crown, coming out of it. SARS-CoV and MERS-CoV are examples of viruses in the coronavirus family (
Influenza is not a coronavirus).
The coronavirus family, like all viruses, has a strand of RNA housed within a membrane casing. The casing has proteins on its surface (the corona part on coronaviruses) that attach to receptors on the cell surface. Once the virus attaches to the cell, it enters the cell and commandeers the cell’s machinery to replicate the virus’s RNA and viral proteins. The new virus is released from the cell and moves on to infect the next cell in the body. As the virus continues to infect cells, the human body’s immune system mounts an attack against the virus. This leads to symptoms, such as a fever. Children seem to get mild symptoms, and people with other underlying conditions seem to get more severe symptoms. Scientists are still trying to figure out why COVID-19 causes some people to have more severe symptoms while others do not.
The virus’s RNA can undergo many mutations even within a single host. In places like Seattle, for example, epidemiologists have tried to trace the spread of COVID-19 by looking at differences in point mutations in different individuals who have contracted the virus. However, this is a time-consuming process that may or may not show the exact path of the virus.
Ethical Issues
From a bioethics standpoint, there are several issues. Of most importance is the responsibility we have to protect the vulnerable, which includes not over-taxing our medical system so people can get the support care that they need.
Another issue that was seen in Wuhan and now Italy is allocation of scarce medical resources. Disaster ethics deals with situations in which a crisis has led to a large number of people needing medical help. In the case of disasters, decisions must be made on who should receive medical care until more can arrive.
Related to scarce medical supplies is protecting medical workers so they are not infected. This involves providing the needed protection to ensure they are not infected, as well as reinforcements so medical workers can rest.
The CDC has websites with case numbers, how to prevent the spread of the virus, and additional guidelines for those that may be sick. The CDC continues to update their websites as they get new information.
More Information
Below are links to several common questions regarding COVID-19 and answers from the CDC website:
- Up-to-date information on Coronavirus Disease 2019 (COVID-19)
- Symptoms of the COVID-19
- What to do if you are sick
- Information regarding testing
- Number of cases and updates
- Travel guidelines
- Recommendations for schools, workplaces, and community locations
- Frequently Asked Questions
Relevant Books and Chapters
-John Kilner,
Life on the Line: Ethics, Aging, Ending Patients' Lives, and Allocating Vital Resources
.
See especially chapter 11, “Determining Who Lives.”
In chapter 11, “Determining Who Lives,” Kilner lays out several criteria for making ethical decisions regarding the allocation of scarce medical resources. He begins with criteria based on medical benefit and patient desire for treatment. If these are met, he argues that priority should be given to those who are at imminent risk of death, who need a small or temporary amount of a resource (if doing so will lead to greater life-saving ability), and to those on whom others’ lives depend (i.e., treating a doctor first so that he or she can in turn save others). Finally, he asserts that any resources still available should be distributed through a lottery system to ensure impartiality and justice.
-Donal P. O’Mathúna, Vilius Dranseika, and Bert Gordijn, eds.,
Disasters: Core Concepts and Ethical Theories
.
This
open access book
is the first to examine disasters from a multidisciplinary perspective. Justification of actions in the face of disasters requires recourse both to conceptual analysis and ethical traditions. Part 1 of the book contains chapters on how disasters are conceptualized in different academic disciplines relevant to disasters. Part 2 has chapters on how ethical issues that arise in relation to disasters can be addressed from a number of fundamental normative approaches in moral and political philosophy. Providing analysis of core concepts, and with real-world relevance, this book should be of interest to disaster scholars and researchers, those working in ethics and political philosophy, as well as policy makers, humanitarian actors and intergovernmental organizations. -Adapted from the publisher
-Donal P. O’Mathúna, Bert Gordijn, and Mike Clarke, eds.,
Disaster Bioethics: Normative Issues when Nothing Is Normal
.
With the growing awareness of the need for evidence to guide disaster preparedness and response, more research is being conducted in disasters. Any research involving humans raises ethical questions and requires appropriate regulation and oversight. The authors explore how disaster research can take account of survivors? vulnerability, informed consent, the sudden onset of disasters, and other ethical issues. Both parts examine ethical challenges where seeking to do good, harm can be done. Faced with overwhelming needs and scarce resources, no good solution may be apparent. But choosing the less wrong option can have a high price. In addition, what might seem right at home may not be seen to be right elsewhere. This book provides in-depth and practical reflection on these and other challenging ethical questions arising during disasters. -Adapted from the publisher
-Paul Ramsey,
The Patient as Person: Exploration in Medical Ethics
.
See especially chapter 7, “Choosing How to Choose: Patients and Sparse Medical Resources.”
In chapter 7, “Choosing How to Choose: Patients and Sparse Medical Resources,” Ramsey deals with the realities of resource scarcity and how we are to make decisions regarding who lives and who dies as informed by our medical and social priorities. Rejecting social evaluations of those seeking limited medical treatments (i.e., basing decisions on comparisons of age, marital status, dependents, income, community service, etc.), Ramsey argues that only a random lottery or a first-come, first-served system are well suited for allocating scarce medical resources. He does make certain exceptions, however, stating that triaging care is acceptable in very specific instances and given very specific limits (i.e., caring for a doctor first after a natural disaster so that he or she in turn can care for more patients).
-Allen Verhey,
Reading the Bible in the Strange World of Medicine
.
See especially chapter 10, “The Good Samaritan and Scarce Medical Resources.”
In chapter 10, “The Good Samaritan and Scarce Medical Resources,” Verhey seeks to answer the question “Can we still be Good Samaritans . . . in the midst of tragic choices imposed by scarcity?” He answers, “yes,” but nuances what it means to be good. A truly “good” Samaritan recognizes the realities of scarcity as well as the sanctity of every human life while also acknowledging there is a tension between the two. Regarding the scarcity of specific therapies, decisions should be made based on therapeutic benefit (without social valuations); if there is not enough to go around, random selection is the most fitting way to determine who will receive treatment.
New Articles on Ethics and COVID-19
In the midst of the current pandemic, a number of scholarly articles are being developed and published on a wide range of topics related to coronavirus, COVID-19, SARS-CoV-2. In an effort to stay abreast of the literature, CBHD staff are attempting to compile something of an annotated bibliography of new articles that discuss ethical issues that may or will arise.
If you know of new articles that may be applicable, please forward them to
research@cbhd.org.
Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line
Lisa Rosenbaum, M.D.
New England Journal of Medicine
March 18, 2020
Based on interviews with physicians practicing in Italy, the article describes the realities of caring for far more patients than hospitals, clinicians, and other caregivers are equipped to handle, which leads to excruciating decisions regarding limited resources such as ventilators.
Fair Allocation of Scarce Medical Resources in the Time of Covid-19
Ezekiel J. Emanuel, M.D., Ph.D., Govind Persad, J.D., Ph.D., Ross Upshur, M.D., Beatriz Thome, M.D., M.P.H., Ph.D., Michael Parker, Ph.D., Aaron Glickman, B.A., Cathy Zhang, B.A., Connor Boyle, B.A., Maxwell Smith, Ph.D., and James P. Phillips, M.D.
New England Journal of Medicine
March 23, 2020
Examines the allocation of various kinds of resources such as personal protective equipment (PPE), hospital beds, ICU beds, pharmaceuticals, ventilators, etc. in the current pandemic. The authors emphasize four values, “maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off,” and make six
recommendations: “maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients.” Recommends the use of triage officers or committees to lessen burdens on front-line personnel.
The Toughest Triage — Allocating Ventilators in a Pandemic
Robert D. Truog, M.D., Christine Mitchell, R.N., and George Q. Daley, M.D., Ph.D.
New England Journal of Medicine
March 23, 2020
Recommends the use of triage committees for decisions regarding mechanical ventilation in this time of pandemic.
References
