Don't Miss...
Webinar - How Can We (and Why Should We) Analyze the Ethics of Paternalistic Policies in Public Health? Click to watch and listen to the recording of the webinar.

Webinar NCCHPP & NCCAH - Structures of Indifference: An Indigenous Life and Death in a Canadian City.

NCCHPP & NCCDH Webinar - Public Health Ethics and Equity: Naming and Navigating Ethical Issues in Public Health Practice. Click to watch and listen to the recording of the webinar.

Presentation - How To (and Why) Analyze the Ethics of Paternalistic Policies in Public Health

NCCHPP & NCCMT Webinar - Priority-setting in Public Health: Evidence and Ethics in Decision-making
Click to watch and listen to the recording of the webinar.

NCCHPP & NCCID Webinar - Public Health Ethics: A Case in Infectious Disease Prevention and Control
Click to watch and listen to the recording of the webinar.

NCCHPP & NCCEH Webinar - Public Health Ethics: A Case in Environmental Health,
Click to watch and listen to the recording of the webinar.

Repertoire - Ethics Frameworks for Public Health 

Utilitarianism in Public Health
 1.3 MB

'Principlism' and Frameworks in Public Health Ethics
 1.2 MB

Introduction to Public Health Ethics 3: Frameworks for Public Health Ethics
 772 K

An Introduction to the Ethical Implications of Economic Evaluations for Healthy Public Policy


Links
Bulletin on what's new in public health ethics [in French, with resources in Fr/En]. From the Public health ethics committee secretariat (Institut national de santé publique du Québec).

Ethics and public health: Forging a strong relationship. By Callahan, D. & Jennings, B. (2002). In the American Journal of Public Health, 92(2), 169-76. On the site of PubMed Central.

Population Health Ethics: Annotated Bibliography. By Greenwood, H.L. and Edwards, N. (2009). On the site of the Canadian Institutes of Health Research – Institute of Population and Public Health (CIHR-IPPH).

Re-visioning Public Health Ethics: A Relational Perspective. By Kenny, N., Sherwin, S. and Baylis, F. (2010). Can J Public Health 2010; 101(1) 9-11. On the site of the Canadian Journal of Public Health.

The contribution of ethics to public health. By Coleman, C.H. et al. (2008). In the Bulletin of the World Health Organization, 86 (8). On the site of the World Health Organization.

Framework of Values to Support Ethical Analysis of Public Health Actions. By Filitrault, F., Désy, M. and Leclerc, B. (2015). On the site of l'Institut national de santé publique du Québec.

Éthique et santé publique. Enjeux, valeurs et normativité. By Massé, R. (2003). Québec : Les Presses de l'Université Laval. (In French only).

WHO guidelines on ethical issues in public health surveillance. World Health Organization. (2017). Geneva. On the site of the World Health Organization.


Contact

Michael Keeling

Public Health Ethics and COVID-19: Selected Resources
This list is a work in progress – we will continue adding relevant resources, each with a brief synthesis of what you will find in the document. Please send us a note to advise us of additional resources that should be shared here. Contact Michael Keeling at: michael.keeling@inspq.qc.ca.
Created March 30, 2020. Last updated May 26, 2020. Description.
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The resources are organized by category. Click to access them directly.

Ethics frameworks and guidance for pandemics and public health emergencies
Equity
Indigenous health
Priority-setting/allocation of resources
Research and surveillance
Communication
Global health, global justice
Civil liberties
Physical (or social) distancing: balancing benefits and harms
Duties of society/professionals/citizens (and expectations of reciprocal support)


 Printable version

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Ethics frameworks and guidance for pandemics and public health emergencies

Ethics guidance on issues raised by the novel coronavirus disease (COVID-19) pandemic
Pan American Health Organization. (2020).
https://www.paho.org/en/documents/ethics-guidance-issues-raised-novel-coronavirus-disease-covid-19-pandemic
8 pages.

This document underlines the importance of obtaining good surveillance data during an emergency, and distinguishes surveillance from research. It focuses on equity, solidarity, responsibility and transparency as essential to developing appropriate public health responses to a pandemic, with particular emphasis on not increasing inequalities and on developing clear, transparent criteria for priority-setting in the allocation of scarce resources such as ventilators. The document highlights the importance of clear, comprehensible and non-stigmatizing communication for advancing public engagement and trust. Finally, the document discusses issues related to research, including fast-tracking projects, ethics review, consent of participants, secondary use of data and the duty to share research data and results.


Ethical framework for health care institutions responding to novel coronavirus SARS-CoV-2 (COVID-19) & Guidelines for institutional ethics services responding to COVID-19
Berlinger, N., Wynia, M., Powell, T., Hester, D. M., Milliken, A., (...) & Jenks, N. P. (2020).
https://www.thehastingscenter.org/ethicalframeworkcovid19/
12 pages.

This document, published by the Hastings Center, sets out to balance the ethics of clinical duties (i.e., patient-centred care) with the ethics of public health (i.e., considerations of equity and the just distribution of benefits and harms) by drawing population-level thinking into the clinical context. The document identifies two competing sources of moral authority that must be held in balance, the duty to care for individuals and duties to promote equity and just distribution. States and public authorities, as represented by health care leaders, have three principal duties to practitioners and community during a public health emergency. They are the duty to plan for the ethical challenges that arise (i.e., anticipating triages with respect to staff, supplies and space); a duty to safeguard (i.e., supporting healthcare workers and vulnerable populations); and a duty to guide (i.e., contingency planning across a range of resource stresses during a surge). The document includes 24 institutional policies and processes and 6 guidelines for institutional ethics services to take into account for the context of Covid-19.


Cadre de réflexion sur les enjeux éthiques liés à la pandémie de COVID-19
Désy, M., St-Pierre, J., Leclerc, B., Couture-Ménard, M-È., Cliche, D., & Maclure, J. (2020).
https://www.inspq.qc.ca/publications/2958
18 pages.

This framework, published in French by the Institut national de santé publique du Québec, sets out to clarify ethical issues and support decision making during the Covid 19 pandemic. The authors outline the key guiding values as beneficence, precaution, justice, responsibility, non-maleficence, solidarity, confidence, transparency, respect for confidentiality, proportionality and liberty. Four main categories of ethical issues are identified. They are: (i) distancing, isolation and quarantine (which balance beneficence and precaution against liberty, calling for proportionality); (ii) health monitoring and surveillance (calling into play the importance of respect for confidentiality, beneficence and non-maleficence); (iii) communications with the public (which rely on the public's confidence and transparency, and which can reinforce solidarity and responsibility); and (iv) resource allocation and access to health services (which call into play beneficence, equity, and justice).


Covid-19 ethical decision making framework

BC Centre for Disease Control & BC Ministry of Health. (2020).
https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/covid-19/ethics_framework_for_covid_march_28_2020.pdf
10 pages.

The authors of this ethics framework begin by identifying two central dilemmas in public health ethics as balancing the autonomy and privacy of individuals with the greater good of the population, and making resource allocation decisions if need is greater than supply. It proceeds in three steps, going through a consideration of ethical principles and values, an ethical decision-making process, and a checklist for evaluating options and articulating a decision. The key principles and values are identified as: respect, the harm principle, fairness, least coercive and restrictive means, working together, reciprocity, proportionality, flexibility and procedural justice (including transparency, inclusiveness, accountability, and reasonableness). The decision-making process asks users to: (1) define the issue, (2) clarify the facts, (3) identify stakeholders/perspectives, (4) identify and analyze the principles and values, (5) identify alternative actions, (6) make a decision, (7) implement the decision, and (8) review and document. The checklist calls upon users to go through a structured process, responding to specific questions, to ensure that the ethical values are used to analyze proposed actions.


Statement on COVID-19: Ethical considerations from a global perspective
UNESCO International Bioethics Committee and UNESCO World Committee on the Ethics of Scientific Knowledge and Technology (COMEST). (2020).
https://unesdoc.unesco.org/ark:/48223/pf0000373115
4 pages.

This March 2020 statement outlines 11 vital ethical issues from a global perspective, calling for urgent action to affirm that: (1) policies must be interdisciplinary (politics, science, ethics and law) and evidence-based; (2) policies “not based on sound scientific knowledge and practices are unethical” (p. 2); (3) pandemics test healthcare systems and reveal the importance of resource allocation, which must be based on justice, beneficence and equity; (4) it is of great importance to attend to the vulnerable; (5) it is important to recognize the rights and duties of individuals, communities and governments; (6) “information issued by politicians, scientists, authorities and the media need to be timely, accurate, clear, complete and transparent” (p. 3); (7) in the search for a vaccine, there should be international coordination and a common understanding for ethical review processes; (8) it is important that the urgency of the situation does not preclude responsible research practices; (9) ethical, social and political issues relating to digital technologies be attended to; (10) extreme measures like barriers across borders should not impair international collaboration and must not perpetuate xenophobia or discrimination; and (11) pandemics show the interdependency of states, calling for international collaboration and solidarity.


Ethical considerations in responding to the COVID-19 pandemic
Nuffield Council on Bioethics. (2020).
https://www.nuffieldbioethics.org/assets/pdfs/Ethical-considerations-in-responding-to-the-COVID-19-pandemic.pdf
11 pages.

This document outlines four principles that must be taken into account by states developing public health measures to address Covid-19.
1. Interventions should be based on evidence, they should be proportionate, and the aims, science, values and judgments underpinning those interventions should be clearly communicated to the public.
2. Coercion and intrusion should be kept to the minimum necessary to achieve the public health aims.
3. People should be treated with respect, as moral equals. People's sacrifices for the common good (self-isolation, quarantine) should be recognized in intervention design and implementation.
4. Solidarity is crucial at every level: internationally (between governments), by states (in bearing costs of interventions), by businesses (in social responsibility) and by individuals (in our day to day lives).
Ethical considerations highlighted in the document include (for states) proportionality, effectiveness, necessity, public justification, maintaining trust, fair and respectful treatment, and solidarity; and (for individuals and companies) solidarity, trust and corporate social responsibility.


Quick reference ethics support for health care providers
Nova Scotia Health Ethics Network (NSHEN). (2020).
http://www.nshen.ca/wp-content/uploads/2020/04/2020-Quick-reference-ethics-support-for-health-care-providers.pdf
2 pages.

This document highlights issues that may arise for care providers due to conflicts between individual freedom/common good, duty to care/safe working environment and resource allocation. The document succinctly raises: changing priority from individual- to population-level thinking (autonomy to community); redeployment of skilled workers; concerns arising from changing structures; concerns that arise from a perception of excessive authority; moral distress; conflicting interests (e.g., duty to care and feeling unprotected); conflicting roles (e.g., parent and care worker); conflicting views about safety and risk; conflicting views about fairness (e.g., institutional triage protocols); physical, emotional and psychological well-being; and balancing solidarity with boundaries.


Ethical dimensions of Covid 19 for frontline staff
Royal College of Physicians. (2020).
https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic
8 pages.

The authors propose fairness as the best model for approaching the ethical issues that will arise in the pandemic. The principal values to consider are accountability, inclusivity, transparency, reasonableness and responsiveness. They make eleven ethical recommendations: (1) care must be equitable and not disadvantage any group; (2) care should not favour either Covid-19 or non-Covid-19 patients; (3) decisions to start, withhold or withdraw care should be made in teams, documented, and as per national guidance; (4) staff remain fully accountable for their decisions under all circumstances; (5) support from ethicists and others is available for difficult decisions; (6) staff should discuss advance care plans with patients and be aware of their wishes; (7) intensive care beds should be continually assessed and prioritized subject to national guidelines (UK-specific guidelines are referenced); (8) doctors' duty to care may require them to work outside of their area of practice but not outside of their sphere of competency; (9) staff over 70 or with pre-existing conditions have a right to protect themselves that may require that they be reassigned outside of direct contact areas; (10) staff must be provided with personal protective equipment; and (11) certain specialities may develop specific advice for practitioners.


Roles for ethicists in Covid-19 response
Warren, M. (2020).
https://impactethics.ca/2020/03/18/roles-for-ethicists-in-covid-19-response/
3 pages (approx.).

In this blog article from Impact Ethics, the author observes that ethicists should help to minimize the difficult choices that health care providers must make, and when that is not possible, to ensure that they are equipped with what they need to make decisions and to act. The best time to do this is in planning for pandemics, not during them. That said, ethicists can contribute during pandemics by: clearly articulating relevant values, building ethics capacity, developing tools and frameworks, translating values into guidance, showing how values are balanced against one another, providing consultation support for difficult decisions, reducing moral distress by affirming that there is no one “right” answer, supporting the justifiability of decisions made by tracing the ethical values and decision-making processes, and following-up after an emergency to strengthen processes and to reflect.


Responding to Covid-19: How to navigate a public health emergency legally and ethically
Gostin, L. O., Friedman, E. A., & Wetter, S. A. (2020).
https://www.thehastingscenter.org/responding-to-covid-19-how-to-navigate-a-public-health-emergency-legally-and-ethically/
9 pages.

This article in the Hastings Center Report touches upon several issues to provide a broad scan of the ethical and legal issues we face in responding to Covid-19. The authors briefly address the following issues/questions, among others: triage and resource allocation in a surge; physical distancing (flattening the curve) to reduce the strain on the health system; physicians' duties to individual patients as compared to broader responsibilities in a system strained by overwhelming demand for care; equity considerations and fair access to scarce resources; health and justice concerns relating to access to care for the most vulnerable; physical distancing and public cooperation; reciprocal concern for some populations obliged to practise distancing; communications issues; isolation and quarantine issues – legal and ethical; balancing public health and civil liberties; and deciding how far governments should go vis-à-vis the exercise of powers.


Guidance for managing ethical issues in infectious disease outbreaks

World Health Organization. (2016).
https://apps.who.int/iris/handle/10665/250580
68 pages.

This document was produced in the context of Ebola but was intended to “look beyond issues specific to particular epidemic pathogens and instead focus on the cross-cutting ethical issues that apply to infectious disease outbreaks generally” (p. 7). It identifies six key ethical principles: justice, beneficence, respect for persons, liberty, reciprocity and solidarity. These underlie 14 guidelines that address key aspects of responding to an epidemic. For each guideline there is a set of questions to aid in deliberation. Guidelines cover a broad range of issues, including governments' responsibilities, engaging communities, attending to vulnerability, allocating scarce resources, surveillance, restrictions on liberty, medical obligations to treat, research, emergency use of unproven interventions, data sharing, storage of samples, sex- and gender-based differences, response workers' rights and duties, and issues relating to humanitarian aid workers.


Public Health Ethics. Selected Resources: Ethics in a Pandemic

National Collaborating Centre for Healthy Public Policy. (2011).
http://www.ncchpp.ca/127/publications.ccnpps?id_article=609
33 pages.

This document provides an introduction to the field of Public Health Ethics (PHE) as applied to policy and practice responses in times of pandemic. It contains a selection of works that provide a foundation for exploring the ethical implications of infectious disease control and pandemic response. This includes: short summaries of a selection of papers, frameworks and guidelines; links to additional resources on ethics and pandemics, including articles, presentations, case studies and other learning tools, websites, blogs, and news sources.


A Survey of Ethical Principles and Guidance Within Selected Pandemic Plans
National Collaborating Centre for Healthy Public Policy. (2011).
http://www.ncchpp.ca/127/publications.ccnpps?id_article=629
43 pages.

This document provides a survey of the explicit goals, ethical principles, and ethics-related recommendations put forward by a selection of national, sub-national and international pandemic preparedness plans and policies.


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Equity

Health justice strategies to combat Covid-19: Protecting vulnerable communities during a pandemic
Benfer, E. A. & Wiley, L. F. (2020).
https://www.healthaffairs.org/do/10.1377/hblog20200319.757883/full/
10 pages.

In this document, the authors present guidance and actions that (US) authorities can take to support the ability of low-income and marginalized communities (including low-income workers, people with disabilities, people experiencing homelessness or unstable housing, people of colour, immigrants, refugees and others more prone to neglect or mistreatment by government authorities) to safely shelter in place. They start out by taking a health justice approach by focusing on (i) addressing the social determinants of health, (ii) ensuring that interventions focusing on changes in behaviour have the necessary protections and supports, and (iii) ensuring that responses address both immediate (emergency) needs and root problems. The article indicates that state and local plans should: protect workers, place a moratorium on eviction, protect the homeless and increase affordable housing, place a moratorium on utility shut-off, proactively enforce safe and healthy homes regulations, ensure access to food and other necessities, and ensure that any mandatory order is consistent with civil liberties.


Beyond sex and gender analysis: An intersectional view of the COVID-19 pandemic outbreak and response
Hankivsky, O. & Kapilashrami, A. (2020).
https://www.qmul.ac.uk/media/global-policy-institute/Policy-brief-COVID-19-and-intersectionality.pdf
5 pages.

The authors call for an intersectional approach to inform Covid 19 responses. They critique singular approaches (like male-female, racialized-non) to understanding vulnerability and advantage, as these fail to account for the interplay of factors such as age/health status, disability, sex/gender, socioeconomic status, Indigeneity, migration status, geographic location, and race/ethnicity. These factors do not operate in isolation. An intersectional approach would have us understand humans as “shaped by the interaction of different social locations … within a context of connected systems and structures of power” (p. 1.) creating systemic privilege and oppression through racism, ableism, patriarchy, colonialism, etc. Because the impacts of Covid 19 such as physical distancing, unemployment, increased care work and resource allocation affect people differently, Covid responses should also reflect this. The authors conclude with recommendations for enriching data, undertaking intersectional analyses, prioritizing support for those most at risk, making policy responses cross-sectoral, moving beyond a deficit model, and committing to diversity in leadership.


Les inégalités sociales et raciales amplifiées par la crise sanitaire dans certains quartiers, déplore la Commission des droits de la personne et des droits de la jeunesse
Gouvernement du Québec. (2020).
http://www.fil-information.gouv.qc.ca/Pages/Article.aspx?aiguillage=ajd&type=1&idArticle=2805014388
2 pages.

This note (in French) reports on an announcement from Québec's commission for human rights and the rights of youth (la Commission des droits de la personne et des droits de la jeunesse). Reacting to the development that Montréal's lowest-income neighbourhoods have become the city's Covid-19 hotspots, the commission calls upon different levels of government to take immediate measures to address social and racial inequalities, in particular by supporting community organizations. The commission notes the high percentage of recent immigrants from racialized minorities, especially women, in the care sector most affected by Covid-19. It highlights the social and economic disparities faced by Indigenous, racialized, and immigrant personas and those living with disabilities and notes how these disparities are amplified by the pandemic. For the commission, a fight against racism and discrimination is indistinguishable from a fight against poverty. It recommends several immediate policy measures relating to housing, food security, and access to computers. The commission calls for leaving behind business as usual approaches to governmental programming and policy making, and recommends taking on discrimination using an intersectional approach.


Addressing human rights as key to the Covid-19 response
World Health Organization. (2020).
https://apps.who.int/iris/handle/10665/331811
4 pages.

This WHO document addresses the moral imperative of integrating human rights protections into responses to the pandemic, focusing on six categories of note. (1) Stigma and discrimination: these have been directed against infected persons, persons of Asian descent, care workers and others. These practices should be identified and stopped. (2) Gender equality and prevention of violence against women: social norms put girls and women more at risk of the virus, their access to essential health services is affected, and stay at home orders put them at increased risk of violence. Societies must address these. (3) Support for vulnerable populations: the dignity and rights of the most vulnerable demand additional attention in Covid-19 responses. (4) Quarantine and restrictive measures: restrictions must be part of comprehensive public health and social responses that integrate rights, with appropriate oversight and accountability in place. (5) Shortages of supplies and equipment: governments must take all measures to protect healthcare workers; WHO has published guidance on this. (6) Obligations of international assistance and cooperation: wealthy states have obligations to lower- and middle-income states that are not subordinate to their obligations within their own borders.


Plus que jamais, les inégalités sont nocives pour la santé
Chung, R. (2020).
https://nouvelles.umontreal.ca/article/2020/04/07/plus-que-jamais-les-inegalites-sont-nocives-pour-la-sante/
4 pages (approx.).

In this blog article (in French), the author discusses health as a basic right, social determinants of health and global health in the context of the pandemic and what it reveals about our societies. The current crisis highlights and amplifies health effects of inequalities, at home and globally, both in terms of the effects of the virus but also the measures taken in response, which affect people differentially according to social status. The crisis reveals the unethical and costly structural inequalities that we are willing to tolerate under normal circumstances, which ought to inspire deep reflection as well as preventive measures to health systems and policy to ensure that the more disastrous effects of inequalities do not arise in future crises. At the level of global health, the author highlights the importance of multilateralism, universal human rights, solidarity, cooperation, and social, international and intergenerational justice as antidotes to insularity, profound inequalities and xenophobia.


Social distancing is a privilege
Blow, C. (2020).
https://www.nytimes.com/2020/04/05/opinion/coronavirus-social-distancing.html
3 pages (approx.).

This short opinion piece takes on the popular notion that viruses are equal opportunity, infecting any and all regardless of social status. However, based on the emerging evidence, “in the real world, this virus behaves like others, screeching like a heat-seeking missile toward the most vulnerable in society. And this happens not because it prefers them, but because they are more exposed, more fragile and more ill” (p. 1). In Milwaukee, Chicago and Detroit, African-Americans are vastly overrepresented among the dead due to Covid 19. Disproportionately, black and brown people cannot practise social distancing because they must go out to work, or starve. And some of those who have the privilege to stay home may then chastise those who take crowded transit, those who line up for work or for take-out food. The author calls upon those of us who occupy positions of privilege to stop scolding those scratching to survive.


A relational account of public health ethics
Baylis, F., Kenny, N. & Sherwin, S. (2008).
https://academic.oup.com/phe/article-abstract/1/3/196/1570681 (paywall).
14 pages.

This document is important for many reasons, but among those is its critically contrasting individualistic approaches to pandemic planning with collective approaches. The authors call for an ethics of public health that focuses on common good and the public interest through attending to relational personhood, relational autonomy, social justice, and relational solidarity. This document provides an essential critical lens for approaching public health emergencies like Covid-19: notably, it ensures that our focus does not stray far from the vulnerable and marginalized, and it helps us extend the boundaries of our solidarity from us/them to us all.


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Indigenous health

Highlights from a Covid-19 fireside chat with Indigenous health professionals
Yellowhead Institute. (2020).
https://yellowheadinstitute.org/resources/highlights-from-a-covid-19-fireside-chat-with-indigenous-health-professionals/
4 pages.

This document provides highlights from a webinar hosted by Idle no More and Indigenous Climate Action, featuring Indigenous health professionals and leaders. It is intended to inform Indigenous health planners who are preparing to address Covid-19. The speakers emphasized that “now is the time to reflect, to find grounding in Indigenous ways and to consider what Indigenous strategies to support the health and wellbeing of families and communities could look like” (p. 1). The document provides guidance on social distancing, gloves and masks, caring for kids, traditional medicines, gathering and participating in ceremony, and concludes with words of hope and encouragement: find strength in family and community, honour elders, practice self-care, and trust in what we know.


Covid 19 update from the Waakebiness-Bryce Institute for Indigenous Health
Waakebiness-Bryce Institute for Indigenous Health
http://www.dlsph.utoronto.ca/institutes/wbiih/
2 pages (approx.).

This update provides context for understanding that Indigenous peoples are already highly marginalized and that Covid 19 will hit them harder, notably through: economic hardship, difficulty in distancing or self-isolation due to crowded and inadequate housing, access to and quality of health care, existing health burdens, lack of water, difficulty travelling to access treatment or supplies, and precarious employment, among others. The authors note several current issues: Indigenous peoples are more vulnerable to community spread; urban Indigenous populations are being ignored by authorities; Indigenous communities are not getting clear messaging, and misinformation is circulating among them; Healers and Elders are not being consulted; government is imposing colonial models of public health and health on-reserve and in urban settings, focusing on biomedical-only services. The Waakebiness-Bryce Institute for Indigenous Health and Well Living House are developing an Urban Indigenous Response to COVID-19, to be released as soon as possible.

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Priority-setting/allocation of resources

An ethics framework for making resource allocation decisions within clinical care: Responding to Covid 19
Sydney Health Ethics. (2020).
https://www.sydney.edu.au/content/dam/corporate/documents/faculty-of-medicine-and-health/research/centres-institutes-groups/she.-clinical-ethics.-resource-allocation-framework.-version-1.-2-april-2020.pdf
7 pages.

The authors propose an ethics framework for allocation of scarce resources that is consistent with four clinical aims: appropriate care relative to need, continuity and sustainability in health and public health systems, maintenance of trust in the health system, and research and innovation to improve care. They propose planning ahead, defining processes, designating triage committees, and three key conditions: equal value of all; getting the most out of resources; and giving priority to those in need. The authors propose that decision making proceed by: (1) defining the tipping point (for conditions of scarcity); (2) determining ICU eligibility (i.e., excluding those who refuse, who do not need it, or who are terminally ill); (3) prioritizing the eligible candidates from high to low (highly likely to recover vs may recover); (4) prioritizing among high priority candidates (to be discussed and justified but may include care workers, home caregivers, Indigenous persons, etc.); and (5) regularly reviewing patients' status and resources to change course as needed. They do not see a valid distinction between Covid and non-Covid patients for prioritizing resources. The authors address the obligations of organizations and clinicians, and the importance of conducting ongoing research.


A framework for rationing ventilators and critical care beds during the Covid 19 pandemic
White, D. B. & Lo, B. (2020).
https://jamanetwork.com/journals/jama/fullarticle/2763953
6 pages.

This article addresses the following question: under the present circumstances, when clinicians' priorities shift from concern for individual patients to concern for many in need, when there is greater demand for ventilators than supply, by what criteria should rationing decisions be made? The authors reject the categorical exclusion of any group, whether due to comorbidities or any other traits; thus there is no discrimination against anyone as “not worth saving.” They exclude likelihood of survival as a sole criterion for triage, instead arguing that other criteria are ethically relevant, including expected life-years (prioritizing youth), access to the range of life-stages (prioritizing youth), and instrumental value (prioritizing healthcare workers). The authors explicitly exclude other criteria as morally irrelevant (“sex, race, religion, intellectual disability, insurance status, wealth, social status, or social connections”). They propose a framework that deploys a scoring system for likelihood of survival and likelihood of achieving longer-term survival, adjusting scores to favour healthcare workers; in the event of equal scores between patients, youth is a tiebreaker. Finally, the authors treat ventilator withdrawal and reallocation separately, focusing on time-limited but not-too-brief allocations, conferring decisions onto triage officers or teams, and attending to the importance of palliative care.


Fair allocation of scarce medical resources in the time of Covid 19
Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020).
https://www.nejm.org/doi/full/10.1056/NEJMsb2005114
7 pages.

The authors observe that this pandemic will most likely exceed hospitals' ICU, ventilator, personal protective equipment (PPE) and staffing capacities. Given inevitable shortages, it is therefore important to set consistent and ethical limits on resources and not make ad hoc decisions in the heat of the moment. Past analyses have focused on four fundamental values as criteria for rationing: maximizing benefits (life-years saved), treating people equally (lottery), promoting instrumental value (care workers first), and favouring the worst off (either the sickest, or youth - who have more to lose). Based on these four, the authors propose six recommendations, in order of priority: (1) maximize benefits in terms of saving lives and saving life years; (2) prioritize care workers; (3) other things being equal, equality demands a lottery rather than first-come first-served as a criterion; (4) evidence, context, and prognosis should inform prioritization guidelines; (5) participants in Covid-19 clinical research should receive some prioritization for interventions; and (6) there should be no difference in resource allocation “between patients with Covid-19 and those with other medical conditions” (p. 6). The authors propose triage officers or committees to relieve clinicians of this burden.


The toughest triage: Allocating ventilators in a pandemic
Truog, R. D., Mitchell, C., & Daley, G. Q. (2020).
https://www.nejm.org/doi/pdf/10.1056/NEJMp2005689
3 pages.

This short article in the New England Journal of Medicine begins with the observation that the US will soon face a never-before seen shortage of critical supplies at this scale; among these, ventilator shortages will lead to the most problematic type of rationing. In a time of extreme shortage, we can envision situations where mechanical ventilation is either withheld or withdrawn when its use would be non-futile and would save a life. The moral distress involved in making such decisions is extreme, and the authors propose that physicians should be buffered from these tragic choices. In their place, decision making should be done by triage committees acting with prior written guidance. They cite several advantages to this approach: physicians and nurses can maintain their fiduciary roles as advocates for their patients, the moral burden of the choice is spread over a committee and not one individual, physicians can be relieved of the role of communicating to families the decision to withdraw life-saving ventilation, as well as the task of withdrawing the ventilation itself. In short, “Creation and use of triage committees … can help mitigate the enormous emotional, spiritual, and existential burden to which caregivers may be exposed” (p. 2).


Structural racism, white fragility and ventilator rationing policies
Galarneau, C. (2020).
https://www.thehastingscenter.org/structural-racism-white-fragility-and-ventilator-rationing-policies/
2 pages (approx).

In this short article, the author argues that many leaders in health care turn themselves in knots denying that their policies differentially affect people of colour, saying that disability, race, ethnicity, etc. have no bearing on care decisions. This she views as an instance of white fragility, a term coined by Robin DiAngelo. “This avoidance of dealing with race and racism stems in part, [DiAngelo] says, from whites not understanding themselves as raced, not owning up to being the dominant racial group […] and to having racial privilege” (p.1). The way forward consists in white people, the dominant racial group, accepting the reality that they are the beneficiaries of a hierarchy that has hurt others; recognizing that structural racism is present in health institutions; and trusting that those most affected by racism have knowledge that is crucial to ending it.


The way we ration ventilators is biased
Schmidt, H. (2020).
https://www.nytimes.com/2020/04/15/opinion/covid-ventilator-rationing-blacks.html
3 pages (approx.).

The author of this article agrees that rationing may be necessary, and that on first glance the model guidance for saving the most lives possible seems fair. However, he argues that there are biases baked into the “saving most lives” formula that disadvantages groups facing worse health due to historical and structural reasons. Baseline health is much worse among some groups, including low-income, disabled, uninsured, and some racial and ethnic groups, for reasons that are overwhelmingly structural and historical, whether due to environment, social status, etc. These produce disadvantages in health and those must be acknowledged in triage decisions. The author proposes that fairness be built into a weighting system to recognize historic disadvantage as a factor in triage decision making, going beyond measures that rely on simple physiology and life expectancy.


Not who, but what professional bioethicists should prioritize when responding to the Covid-19 pandemic?
Stramondo, J. (2020).
http://www.bioethics.net/2020/04/post-3-not-who-but-what-professional-bioethicists-should-prioritize-when-responding-to-the-covid-19-pandemic/
3 pages (approx.).

In this short article, the author relies on the work of Shelley Tremain to argue that it is very difficult to overcome ableist biases in triage protocols. While there is a great deal of work being done to refine protocols to make them more equitable, it may not be something that can be overcome. Meanwhile, this attention to protocols distracts us from advancing a more important conversation: reducing the need to make these triage choices at all. Needing to make triage choices is not inevitable; it will be determined by economic, social and political choices beforehand. Given these observations, the author argues that bioethicists should focus on reducing the need for triage rather than on perfecting protocols, and offers two specific recommendations for how to do so. First, bioethicists can help to keep stay at home orders in place and advocate for a safety net so that citizens can shelter in place without undue hardship. Second, bioethicists can use their influence to push for a massive scale-up of the production of personal protective equipment. Both of these will add to society's ability to avoid triage in the first place and help to reduce systemic injustices.


Disablism in a time of pandemic: Some things don't change
Scully, J. L. (2020).
http://www.ijfab.org/blog/2020/04/disablism-in-a-time-of-pandemic-some-things-dont-change/
4 pages (approx.).

In this blog article, the author addresses the ethics of triage (moral guidance for what to do if ICU beds and ventilators do not meet need, and how to justify difficult choices) claiming that there is a worrying degree of disablism (prejudice against disabled people) in recently-published resources. In response to these, the author analyzes disablist assumptions and norms at play and proposes recommendations for producing better clinical guidelines. Assumptions are made about disabled people's diminished health status, quality of life and social utility, suggesting that they are harder-to-save, have less valuable lives, etc. Unexamined norms relating to human form, function and behaviour shape the published guidance in a way that can exclude people with disabilities from consideration for critical care. Recommendations include: triage guidance should explain its reasoning; disability status should not be used to represent health status; critical care decisions should be based on the individual's health, not just on medical records or assumptions; critical care decisions should exclude broad social utility criteria; and triage guidance should explicitly state that disabled persons are equally valuable and worthy of care.


ICU triage in an impending crisis: Uncertainty, pre-emption and preparation
Wilkinson, D. (2020).
https://jme.bmj.com/content/medethics/early/2020/04/01/medethics-2020-106226.full.pdf
2 pages.

The author argues that in a pandemic triage situation that ICUs may face due to Covid 19, “at a basic level the key values are those of benefit and fairness” (p. 1), where benefit focuses on maximizing outcomes while fairness focuses on equity. When ICU capacity is not overtaxed, it is possible to focus on fairness. When resources become scarce, the value balance must shift to benefit. This means prioritizing patients with the highest chance of surviving and with the shortest duration of ICU stay. The author considers the uncertainty faced during an approaching pandemic surge and offers three suggestions: plan to revise triage decisions as the situation evolves; determine how to support ICU clinicians in their decision making; and accept that during a crunch it may be reasonable to withdraw treatment depending on how a patient's progress changes.


Pandemic palliative care: Beyond ventilators and saving lives
Arya, A., Buchman, S., Gagnon, B., & Downar, J. (2020).
https://www.cmaj.ca/content/cmaj/early/2020/03/31/cmaj.200465.full.pdf
5 pages.

The authors take a different angle on triage questions by reviewing the challenges related to providing palliative care, arguing that a failure to provide high-quality palliative care to patients who are not provided access to a ventilator would compound the tragedy of the pandemic. Palliative care focuses on three main dimensions: managing symptoms, discussing patients' wishes, expectations and values, and supporting families. The article presents the main considerations for Covid-19 palliative care in Canada as follows: services will be needed in many care settings including ICUs, wards, emergency departments and long-term care (where resources are particularly limited); patients' autonomy to choose life-prolonging measures or the place of their death may be limited, and some may be isolated; much has been written on how to triage in emergencies, but there is little guidance on how to manage patients for whom life-sustaining measures are not offered; authorities should plan for palliative care needs by preparing stuff, staff, spaces, systems, means for family connections, communications plans, and ensuring a focus on equity. These can serve as a guide to ensure that Canada provides effective palliative care during this crisis.


Contextualizing ethics: Ventilators, H1N1 and vulnerable populations
Silva, D., Nie, J. X., Rossiter, K., Sahni, S., & Upshur, R. E. G. (2010).
https://www.longwoods.com/content/21613/healthcare-quarterly/contextualizing-ethics-ventilators-h1n1-and-marginalized-populations
6 pages.

This 2010 article contemplates rationing criteria for ventilator shortages in the context of the H1N1 crisis. The discussion is relevant to today's concerns. The authors critique the criteria that they had seen proposed to date, as they were predominantly based on the principles of utility and efficiency, i.e., maximizing the greatest good for the greatest number. They note that such an approach would be at the expense of marginalized populations, groups that are already at greatest risk, thereby magnifying existing inequalities. For example, Indigenous persons were disproportionately affected by H1N1, and may not be well-served by the bare application of utility and efficiency as criteria. To correct this, the authors recommend adding other principles to the discussion, including equity (“distributing resources on the basis of trying to rectify social inequalities”) and need (“prioritizing those persons who are in the worst conditions”) (p. 34), and engaging in consultation with those who would be disproportionately affected in order to inform decision makers.

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Research and surveillance

Ethical standards for research during public health emergencies: Distilling existing guidance to support COVID-19 R&D
World Health Organization. (2020).
https://apps.who.int/iris/handle/10665/331507 
4 pages.

After highlighting the ethical duty to conduct research during an emergency, this document summarizes the key ethical standards for research. They are: scientific validity, collaborative partnership, fair and voluntary participation, equal moral respect for participants and affected communities, social value, reasonable risk-benefit ratio and independent review. It follows up with examples of the application of these standards during an emergency. Questions addressed include coordination/non-interference with emergency responses, collaboration and community engagement, adapted ethics review and research methodologies, participant recruitment, informed consent, data sharing and just distribution of the benefits of research.


Research in global health emergencies: Ethical issues. Short report
Nuffield Council on Bioethics. (2020).
https://www.nuffieldbioethics.org/publications/research-in-global-health-emergencies/read-the-short-report
9 pages.

This document is the summary version of a 308-page report. It is intended to apply an ethical focus to research conducted during emergencies, including those relating to infectious diseases. Ethical issues in global health emergencies include: study design and review processes, power and influence, consent processes, fairness in collaborations, data and sample management and sharing, and providing ethical support for researchers. The document proposes an “ethical compass” as a reflection tool with three principal points: helping reduce suffering (defining, prioritizing and targeting needs), fairness (collaborating, transparently distributing benefits and burdens) and equal respect (engaging communities to define values, design research, and provide feedback throughout the process).


WHO guidelines on ethical issues in public health surveillance
World Health Organization. (2016).
https://apps.who.int/iris/bitstream/handle/10665/255721/9789241512657-eng.pdf
56 pages.

This document is a key reference document for public health surveillance, providing 17 guiding principles for the ethical design, development and implementation of surveillance systems. The authors set out to situate surveillance as a fundamental public health practice, but not one that justifies any and all activities. Rather, the principles taken together have to be balanced against one another. They reflect authorities' duty to conduct surveillance and to share data under certain circumstances in order to achieve public health goals, but these are balanced against the rights and interests of individuals and populations, such as the obligation to reduce unnecessary risks, to consult communities and to respect privacy and confidentiality. While this document is not Covid-19-specific, it is a core reference for any surveillance activity.


Health surveillance during Covid 19 pandemic: How to safeguard autonomy and why it matters
Calvo, R. A., Deterding, S., & Ryan, R. M. (2020).
https://www.bmj.com/content/bmj/369/bmj.m1373.full.pdf
2 pages.

The authors of this editorial caution us about new health surveillance technologies (AI, facial recognition, location data mining) that allow us to follow people's paths, identify the infected, trace contacts and enforce distancing. In particular, they focus on the risks associated with surveillance creep, i.e., when the technologies used for one specific task are deployed more widely and permanently. Such extended uses that go beyond an “exceptional uses for exceptional times” approach can have negative effects on civil rights and psychological well-being, most notably for their negative influence on people's sense of autonomy. The authors offer some advice for how to design surveillance and AI tools, noting that the engagement of citizens in the process, protecting data, and aligning tools with the values of those under surveillance are promising directions for a productive alternative that endorses well-being as a jointly valued goal.

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Communication

We need to change our thinking and communication, urgently, to beat Covid-19
Carter, S., Braunack-Mayer, A., & Degeling, C. (2020).
https://croakey.org/we-need-to-change-our-thinking-and-communication-urgently-to-beat-covid-19/
4 pages (approx.).

The authors of this blog article set out to highlight that we are all connected; a pandemic shows us this. They propose the adoption of public values of solidarity, reciprocity and common good as being the most suitable values for addressing ethical issues in a pandemic. By contrast, they indicate that two individualistic, rather than collective, responses tend to hold sway in the sphere of communications: the Crocodile Dundee (“no worries, mate,” shrugging off risks and ignoring public orders) response, and the fearful preparation (hoarding, over-preparing and producing shortages) response. These both reflect selfish individualism and the authors claim that they are exacerbated by media during the pandemic, as the messaging focuses on risks to individuals, tending to separate “us” from “them.” They call for reframing media communications around solidarity, reciprocity and common good, concepts that Australians know well and can attach to if encouraged.


Communicating risk in public health emergencies: A WHO guideline for emergency risk communication (ERC) policy and practice
World Health Organization. (2017).
https://apps.who.int/iris/bitstream/handle/10665/259807/9789241550208-eng.pdf?sequence=2
78 pages.

This guidance document sets out to address the risk-communication challenges that emerged during recent public health emergencies. Some key issues include rapid change in communications technology, the prevalence of cellular communications, the use and influence of digital media (at the expense of traditional sources), changes in the means of accessing and the degree of trust in health information, and the contextual factors that influence people's risk analyses and behaviours, among others. The document provides three main sets of recommendations, under building trust and engaging with affected populations, integrating emergency risk communications into health and emergency response systems, and emergency risk communications practice. Recommendations within each of these categories are given a relative strength and a rating for the quality of evidence supporting the recommendation.


Guilt, fear, stigma and knowledge gaps: Ethical issues in public health communication interventions
Guttman, N. & Salmon, C. T. (2004).
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-8519.2004.00415.x (paywall).
22 pages.

For access to a one-page adapted summary, click here: http://www.ncchpp.ca/docs/2017_eth_frame_guttman_salmon_En.pdf
In this paper, the authors focus on eight themes that can help to illuminate the ethical issues that arise in public health communication initiatives. The themes are: the targets of the intervention, informed consent, persuasion tactics, responsibility and culpability, harm reduction, labelling and stigmatization, social and health equity, and the promotion of health as a value. This article is not pandemic or emergency specific, but may serve as a helpful reference document.


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Global health, global justice

World's most vulnerable in “third wave” for Covid-19 support, experts warn
Ahmed, K. (2020).
https://www.theguardian.com/global-development/2020/mar/20/worlds-most-vulnerable-in-third-wave-for-covid-19-support-warn-experts
2 pages (approx.).

This short article claims that we face an upcoming disaster: the world's most vulnerable people will be last in line for support to deal with Covid 19. In particular, countries facing refugee crises and humanitarian situations will lack the resources for dealing with the pandemic when it arrives. Wealthier countries are already struggling to cope, but less-resourced countries that have relatively few cases at present, those with weakened health systems, have not yet been hit. This calls for a more global approach to strengthening health systems and for coordination between humanitarian organizations and governments.


Covid 19 in humanitarian settings and lessons learned from past epidemics
Lau, L. S., Samari, G., Moresky, R. T., Casey, S. E., Kachur, S. P., Roberts, L. F., & Zard, M. (2020).
https://www.nature.com/articles/s41591-020-0851-2.epdf
2 pages.

Covid 19 has reached 79 refugee-hosting countries and transmission will inevitably spread to highly-vulnerable displaced populations. Based on lessons learned from their experience with past pandemics and epidemics, the authors present three broad recommendations. First, essential health services must be maintained to reduce additional deaths from Covid 19, as the indirect health effects of epidemics (due to disruptions and diversions of health resources) can exceed the death tolls from the disease, especially with respect to chronic diseases. Second, access to infection prevention, control, testing and treatment for refugees is essential, as these measures that are known to protect communities are just as important in crowded, poorly-resourced camps, high-density urban areas, detention facilities, etc. Third, controlling a pandemic depends upon community engagement and trust, as detection, communications and containment efforts all depend upon public cooperation. To conclude, the authors observe that “protecting the most vulnerable among us is not just a moral imperative but an urgent public health objective: the health of one is the health of all” (p. 2.).

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Civil liberties

Coronavirus: The effects on human rights
Amnesty International UK. (2020).
https://www.amnesty.org.uk/human-rights-uk/coronavirus-effect-human-rights
4 pages (approx.).

This document focuses on the UK context but it makes broad claims about the role and responsibilities of governments with respect to human rights and Covid 19, claiming that Covid 19 responses must be framed by a human rights focus. Human rights protect citizens from the power of the state and oblige governments use their power to protect health and well-being. The authors demand that governments ensure human rights are “at the centre of all prevention, preparedness, containment and treatment efforts, in order to best protect public health, welfare, and support the groups and individuals most at risk.” Government should support people economically, attending first to the most vulnerable and least protected. Emergency powers must be temporary, proportionate, in accord with international rights laws and subject to scrutiny. The document identifies groups subject to greater risk and makes the link between vulnerability and exclusion from the health care system, calling for, above all, support and respect for the most vulnerable.


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Physical (or social) distancing: balancing benefits and harms

Markets vs lives
Gonsalves, G. & Kapczynski, A. (2020).
http://bostonreview.net/science-nature/gregg-gonsalves-amy-kapczynski-markets-v-lives
8 pages (approx.).

In this (US) article, the authors accept that physical/social distancing is necessary for minimizing the transmission of Covid 19, for protecting the vulnerable, and for flattening the curve to reduce catastrophic outcomes. Their objective is to take on a backlash against distancing that pits efforts to stop Covid 19 against the economy. These arguments might be summed up as saying “the cure is worse than the disease” due to damage to the economy. The authors note that distancing has taken much of the workforce out of the economy in the name of a social and common good, and that this unpaid work does not show up in GDP, in the economy. This crisis calls for us to protect people from disease, to support them through this emergency, and to not treat anyone as expendable in the name of economic stability. To do so, the authors propose several priorities: coordinate to end the shortages of protective gear and medical equipment; dramatically increase testing; massively support clinics and hospitals with personnel, resources and support; do everything possible to develop vaccines; provide stable and appropriate income support for people; and attend to the needs of those who are vulnerable, whether incarcerated, homeless, elderly, or otherwise at risk.


Individual rights vs the common good in the age of Covid 19
Will, M. (2020).
https://frontporchne.com/article/individual-rights-vs-common-good-age-covid-19/
6 pages (approx.).

In this article from a suburban Denver newspaper, the author interviews local experts to discuss issues relating to whether (US) behavioural norms and political orientations are incompatible with the demands of the Covid 19 crisis. In particular, they reflect on the area's (as of late March 2020) half-hearted response to social isolation in order to flatten the curve. While on the one hand the crisis calls for coordinated efforts, including a robust, collective effort to practice distancing, this is less compatible with the individual-liberty focused or libertarian leanings of many citizens. What's more, distancing does harm, and while it may be justifiable early on in the pandemic, as time passes it is likely to become more difficult to justify and to enforce.


Cohesion in distancing
Shen, M. (2020).
https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2020-03/artm3-2004_0.pdf
2 pages.

We recommend that you click on the link for this, as it is a visual art piece. The artist is Dr. Michael Shen, a physician in New York City. In his commentary, he observes that as we are now required to distance ourselves from one another, contrary to our human needs and norms, this evokes a dramatic tension between separation and togetherness. By distancing ourselves, we show our cohesion, we manifest our solidarity.

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Duties of society/professionals/citizens (and expectations of reciprocal support)

What are the rights and responsibilities of healthcare providers in a pandemic? What can they expect from their employers, governments and us?
Gruben, V. & Czarnowski, A. (2020).
https://policyoptions.irpp.org/magazines/april-2020/what-are-the-rights-and-responsibilities-of-healthcare-providers-in-a-pandemic/
3 pages.

In this article, the authors set out to define our reciprocal duties towards one another, the duty to care of healthcare workers, the responsibilities of governments and employers and the responsibilities of the public. The duty to care obliges healthcare workers to act in the interests of their patients, but this duty has limits. Redeploying workers into higher risk settings or out of their fields of expertise is more problematic than expecting workers to continue in their chosen settings. Increasing personal risk to the worker under conditions of low benefit to the patient also diminishes the obligation to care. Obligations to families and loved ones can also justify stepping back. Governments have obligations to protect healthcare workers with protective equipment, testing, up-to-date information, systemic measures to reduce the burden on the system, counselling and other supports. The public also has responsibilities, including physical distancing, self-isolating if returning from abroad, etc., affirming that the duties of healthcare providers are not one-directional and there are corresponding societal duties towards them.


Covid-19 ethics analysis: What is the ethical duty of health care workers to provide care during Covid-19 pandemic?
BC Centre for Disease Control & BC Ministry of Health. (2020).
https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/covid-19/duty_to_care_during_covid_march_28_2020.pdf
20 pages (includes BC's Covid-19 Ethical Decision-Making Framework).

In this document, the authors examine the duty to care, which demands that patients' well-being should come first, and relates this to tensions and competing duties that can arise for healthcare workers in the context of Covid-19. They identify three features underlying the duty to care: (i) greater ability to care creates an obligation to provide care; (ii) choosing the profession implies accepting risks; (iii) society provides legitimacy to healthcare workers through an agreement that they will step up in an emergency. The authors turn to what is known about Covid-19 to contextualize risks for workers and consider potential limits to the duty to care, through an ethical analysis based on BC's Covid-19 Ethical Decision-Making Framework (summarized in the section Ethics frameworks and guidance for pandemics and public health emergencies, above). This analysis proceeds through a consideration of the ethical principles of reciprocity, respect, the harm principle, duty to care, fairness, proportionality, least coercive or restrictive means, working together, and procedural justice, considering each in the context of Covid-19. The article concludes with 14 specific recommendations for healthcare workers, organizational (hospital) leaders, and system-level (health authority and government) leaders.

The production of the NCCHPP website has been made possible through a financial contribution from the Public Health Agency of Canada.