Is it ethical to be a ‘whistleblower’ during COVID‐19 pandemic? Ethical challenges confronted by health care workers in China

Should healthcare workers (HCWs) tell the truth? The answer seems definite to be yes since every medical and nursing staff has taken an oath to the Hippocratic Oath or Nightingale Florence Pledge that only integrity and honesty deserve the trust of patients and commitment of saving life. HCWs who work in the medical system in normal times should follow biomedical ethics, and their primary responsibility is to safeguard the health rights and interests of individual patients. When it comes to public health emergencies, however, public health ethics should be followed, and the primary responsibility of HCWs is the public's health rights and interests. When the two responsibilities conflict, sometimes the person who tells the truth for the best of the public rights may be regarded as an unwelcome ‘tattletale’, informant, or ‘songbird’, collectively known as ‘whistleblower’. In uncertain times of COVID‐19, telling the truth appeared as an unprecedented ethical challenge. With such ethical confusion to answer, it is necessary to discuss three cases that received broad attention during the epidemic in accordance with the framework of public health ethics analysis.

1. CASE ONE: DR LI WENLIANG, THE EARLIEST TO ALERT COVID‐19

At 5 o'clock on 30 December 2019, Dr Li Wenliang, a former ophthalmologist from the Central Hospital of Wuhan, announced in the WeChat^® group of class of 2004 of the Clinical Medicine Department of Wuhan University that: ‘7 Severe Acute Respiratory Syndrome (SARS) cases have been confirmed in Wuhan Huanan Wholesale Seafood Market’ and reminded his fellow clinicians to: ‘let family members and relatives take precautions’ (Tan, 2020). On the same day, Wuhan Municipal Health Commission issued the Urgent Notice on the Treatment of Pneumonia with Unknown Causes, which required strict information reporting, and emphasized that: ‘no organization or individual should release patient care information without authorization’. On January 1, Dr Li Wenliang, due to his WeChat message screenshot that was spread among the public, was identified as a rumour‐monger by the police, together with other eight HCWs who had warned the existence of COVID‐19. On January 3, he was warned and reprimanded by the local police for his: ‘false statements on the Internet’. On January 8, he was infected when treating an ophthalmic patient and confirmed with COVID‐19 pneumonia later. In the early morning of February 7, Dr Li Wenliang died after all effort to save his life failed.

2. CASE TWO: THE NURSE WHO CALLED FOR SOCIAL DONATIONS OF PERSONAL PROTECTION EQUIPMENT TO SUPPORT HER COLLEAGUES IN THE HOSPITAL IN FIGHTING COVID‐19.

On 9 February Ms Yu, a nurse at a county‐level hospital near Wuhan, called for social donations for the support online due to insufficient personal protection for hospital medical staffs and was criticized by the hospital's public‐opinion‐managing team (Wang, 2020). The hospital criticized her as it was considered that she had brought great harm to the organization and the society by posting false statements on the Internet and asked Ms Yu to acknowledge her mistake, take the initiative to delete the online post, and write a self‐criticism review. The nurse's apology could not be accepted by the hospital administrators until she wrote three written self‐criticisms and admitted that she had: ‘started a rumour’.

3. CASE THREE: THE NURSE WHO WROTE TO THE LANCET AND CALLED FOR INTERNATIONAL COMMUNITY TO ASSIST CHINA IN FIGHTING AGAINST COVID‐19

On 24 February The Lancet published a letter from a reader online under the title: ‘Chinese medical staff request international medical assistance in fighting against COVID‐19’ (Wen‐xue‐city, 2020). This was a professional communication about the current nursing work situation in Wuhan sent by Zeng Yingchun, a researcher from the Nursing Department of the Third Affiliated Hospital of Guangzhou Medical University, and Zhen Yan, from the Chinese Medicine Department of Sun Yat‐sen Memorial Hospital of Sun Yat‐Sen University, on behalf of the Chinese HCWs who were working on the front line in Wuhan. Later, Guangdong medical aid team in Wuhan pointed out that the letter was seriously inconsistent with facts and demanded the authors to apologize and retract it. At present, two authors have applied to The Lancet for withdrawal.

The common feature of all these three HCWs is that they told the truth when they thought they should, and they were all determined by their leaders or law enforcement agencies that the information they provided was seriously inconsistent with the facts. They were severely criticized and asked to admit that they started a rumour, and finally made a self‐criticism or apology and became an unwelcome ‘whistleblower’. North American public health experts have proposed a public health ethics analysis framework that includes the following six steps to determine whether the relevant public health policy, research plan, intervention methods, or behaviour of medical staff is ethically desirable: (Kass, 2001):

1. What are the public health goals that the action or plan aims to achieve?

2. To what extent is the action or plan effective in achieving the stated goal?

3. What are the actual or potential burdens or harms?

4. Whether the burdens can be minimized and whether there exist any alternatives?

5. Is the action or plan implemented fairly?

6. How can the benefits and burdens be more balanced procedurally?

Based on the above six steps, we can analyse step by step whether the behaviours of HCWs and the intervention conducted by the organizations in the three cases mentioned above are in line with public health ethics. First, it is necessary to ask whether the goals to be achieved by the parties' behaviours are conducive to the realization of general public health goal, which is to promote the health of the population, reduce morbidity and mortality while maximizing individual freedom and reducing social injustice.

Dr Li Wenliang, known to the Chinese public as the ‘whistleblower’ of COVID‐19, spoke to journalists from the Caijing, saying that: ‘Since this virus is very similar to SARS and there existed obvious human‐to‐human transmission… Though there were not so many cases yet, I am afraid that there will be an outbreak, and the virus will spread.’ From his responsibility as a doctor, he exercised due care and love for his classmates and colleagues, he promptly issued a warning of protection, although he asked his classmates to keep this warning in their medical groups only. The information was released to the society as a consequence. It is necessarily to draw the distinction between what he was telling his medical colleagues and health authorities and how it went into the public domain. Either way it was not a rumour, more an advance and empirically informed warning of what was to come. Early outbreak warning has historically been the most crucial intervention in public health crisis management to reduce morbidity and mortality. Compared with the doctors who did not report the epidemic in time and were thus punished by revoking of their medical license during SARS in Taiwan (Hsin & Macer, 2004), Dr Li Wenliang was forced to apologize for giving early warning. Obviously, he was reprimanded by the police for illegally releasing false information, and violating the hospital's administrative rules in providing relevant information to the outside world, and was deemed to have done potential harm to cause social panic. However, the potential social panic could have been minimized if the Chinese Center for Disease Control and Prevention (CDC) had organized staff members to collect and verify information, and released accurate information on epidemic prevention and virus infection control in a timely manner.

It is worth noting that, apart from the ‘whistleblower’, as an alternative way of early warning, some doctors had already reported the epidemic according to the procedure at that time. However, the hospital where Dr Li Wenliang worked, the local CDC, Health Commission of Hubei Province and Wuhan Municipal Government, after receiving the reports of cases with COVID‐19 and with the support of enough scientific evidence, did not announce the truth to HCWs and local people promptly, nor did they implement timely and effective epidemic monitoring and quarantine measures (Li et al., 2020). As a result, the critical opportunity for CDC to start national disease control at various levels and for other relevant departments to respond quickly was missed, leading to the rapid spread of epidemic during the Chinese Spring Festival, the rapid rise of morbidity and mortality, the exhaustion of a large number of human and material resources and a broader range of economic losses.

Nurses in cases 2 and 3, based on their own understanding of the front‐line situation in about the epidemic, did their best to call actively for the domestic and international communities to assist Wuhan and China to work against the epidemic when most people were aware of the problem but remained silent. Their goals were the same, which were: they hoped to make their own efforts to maximize the support for HCWs at the front line; prevent and control the epidemic as early as possible; and reduce morbidity and mortality. Objectively, their calls did receive positive responses and help from the domestic and international communities. However, the leaders of their respective hospitals considered their behaviour as exposing the lack of protective resources and shortage of human resources in the hospital, which was seriously inconsistent with the actual situation and caused great harm to the organization and society, and asked them to apologize and admit their mistakes. The unequal rights between hospitals and nurses eventually forced nurses to apologize for what they had done. Such forced apologies seriously hurt HCWs who overcame many difficulties to stay at the front line of the epidemic and cared about hospital affairs and epidemic prevention and control with a sense of ownership and professionism. Not only did the punishment fail to help hospitals reduce infection and mortality but also it might make it challenging to prevent the epidemic due to the violent disruption of ongoing support brought by the nurses' effectual calling.

As these cases reveal, any individual behaviour or organizational decision that deviates from general public health goal is a violation of basic principles of public health ethics, and ultimately harms public health and is, therefore, unethical. According to this criterion, although the four ‘whistleblowers’ were punished, their behaviours did not violate the principles of public health ethics. For the sake of public safety and health, the ‘whistleblowers’ who violated executive orders can be said not only to have behaved ethically but also are worthy of the HCWs' respect and attention. In this editorial, we only apply the North American public health ethics analysis framework to analyse the cases that emerged in China. Due to the differences in political and legal systems between China and the USA, the above cases are not discussed from the political and legal perspective, but only from the perspective of public health. The analysis of the combination of public health ethics, politics and law is a complex task. If we are to establish a law‐based form ‘whistleblower’, further exploration is required alongside a consideration of the appropriate response and reward to the individual HCW's action.