Ethical Pandemic Control Through the Public Health Code of Ethics

During the COVID-19 pandemic, public health practitioners are daily faced with new situations that require ethical thinking, for instance, prioritizing access to scarce resources, employing measures that do not exacerbate health inequities, and collaborating beyond institutional boundaries. In late 2019, shortly before the emergence of the COVID-19 epidemic in China, the American Public Association published a revision of its Code of Ethics.^1,2 In addition to listing general ethical principles in public health, the new Code also listed particular principles for 12 public health domains. Although the ethical policies and practices are not specific to a pandemic, they provide helpful guidance on a range of public health situations, including a pandemic. We provide a few examples in each of four settings of a pandemic response: preparation, community, hospital, and aftermath.

PREPARATION

Preparing for a pandemic or epidemic before it occurs is arguably the most important phase of a pandemic response. Plans made and processes implemented in this stage can eliminate or mitigate ethical decisions that might arise later in the community and the hospital. The Code of Ethics states that public health institutions should “detect, recognize, and acknowledge public health threats promptly and efficiently.”^1(p14)

China reported a cluster of pneumonia cases of unknown cause to the World Health Organization on December 31, 2019. By early January, US intelligence reports were warning of a likely pandemic.³ Intelligence reports are outside a country’s standard disease surveillance system, but having a system to monitor diseases occurring in other countries allows a public health system to detect a threat promptly.

Before a crisis is also the time to “establish formal structures, such as ethics committees, to address and resolve ethical disagreements and challenges and to enhance organizational ethics and decision making” ^1(p29) as stated by the Code of Ethics. When preparing for an anticipated influenza pandemic, each state created a pandemic response plan. A systematic review of the plans found that few of them incorporated ethics preparedness,⁴ and among those expressing the intent to further develop their ethical decision-making ability, a review of their progress a few years later found that only a couple of states had followed through.⁵ In the absence of established processes to identify and address ethical issues, governments stand the risk of committing avoidable missteps that create or exacerbate existing injustices.

COMMUNITY

Once an epidemic is detected, the government is to “be honest and accurate” in how it communicates about the risks and actions needed, according to the Code. Honesty and accuracy are vital to establishing and maintaining public trust, which is perhaps public health’s most valuable asset in achieving public cooperation. The US government’s record in communicating with the public about COVID-19 has been mixed. Early intelligence about a likely pandemic was not passed on to the American people. For months, the president downplayed its seriousness. Although other voices in the federal government conveyed a more pessimistic and urgent message, the absence of a unified government message created confusion and delays.

In May, because of quarantine fatigue and a struggling economy, many states relaxed social isolation requirements. Some have suggested that a serological test could signal individuals’ recovered infection and immunity, allowing them greater freedom of movement and employment. If reliable, the test could create a stratification of society based on immune response. Those who achieve immunity first (and could certify it) would have both a greater burden to work to restore the economy and greater privileges in the freedom to return to a socially engaged life. Conversely, those with the ability to remain isolated may do so while waiting to see whether infections resurge as social isolation mandates are lifted. The greatest burden, however, will fall to those who have not achieved immunity and cannot remain isolated. Such is the case for many essential workers. Although the Code of Ethics does not address this specifically, it does say:

Public health practitioners and organizations have an ethical obligation to use their knowledge, skills, experience, and influence to promote equitable distribution of burdens, benefits, and opportunities for health, regardless of an individual’s or group’s relative position in social hierarchies.^1(p5)

The lifting of universal social isolation, as we’ve begun to see in some states, will challenge the ethical practice of public health in a way that today’s professionals have not experienced.

HOSPITAL

In cities where transmission has become established, medical staff have been reduced to choosing which patients should or should not receive the benefit of a life-saving technology, such as a ventilator. In this hellish situation, the Public Health Code of Ethics reminds us,

Reduce or eliminate negative impacts on communities and the environment, particularly as these negative impacts tend to be disproportionately experienced by individuals already faced with health inequities.^1(p20)

To follow this practice, a hospital system needs to recognize that its means of allocating scarce life-saving resources could exacerbate existing health inequities. It could do this, for example, by giving preference to those with the fewest underlying health conditions.

So that health care workers can recognize when an inequity is emerging, their institutions should “provide ethics education as a central part of public health education and ongoing training.” ^1(p25) Countries vary in the degree to which they consider hospital health care workers part of the country’s public health system. However, in a pandemic, everyone in every aspect of the health care system is on the same team, focused on the same task; and ethical concerns can emerge anywhere. Hospital health care workers can be equipped to recognize when a pattern of inequity is taking place and how to bring it to the attention of administrators.

AFTERMATH

When the crisis has passed and the cases have subsided, the pandemic response is not yet over. Public health systems are to “involve a commitment to a continuous improvement process for all essential programmatic components.” ^1(p25) Important information to guide the response to the next epidemic is in the successes, failures, and unforeseen twists of the one that just ended. Not only should the epidemic control steps be evaluated for their effectiveness, but governments and institutions should evaluate their processes for identifying and addressing ethical issues.

Policymakers should then “develop as appropriate strategic plans with measurable goals for essential program components.” ^1(p26) The goals might include, for example, training public health personnel, stockpiling essential equipment, or strengthening the disease surveillance system. With this step, the pandemic response becomes preparation for the next pandemic.

ADDITIONAL RESOURCES

A few documents resulting from consensus processes at the World Health Organization, the Centers for Disease Control and Prevention, and elsewhere were written during the preparation for pandemic influenza.^6,7 These documents provide helpful information on ethical responses to the COIVD-19 pandemic.

An online pandemic ethics dashboard created by one of the authors (J. C. T.), and available at https://pandemicethics.org, provides a means of quickly identifying ethical issues in each of the four pandemic response settings and the relevant ethical guidance in pandemic ethics consensus documents. The dashboard is designed to help policymakers and administrators when they have little time to research ethics in the midst of a pandemic.

Although the Public Health Code of Ethics was not written specifically for a pandemic response, it provides useful guidance on the implementation of public health in a novel crisis. The Code helps us preserve civil rights when responding to a threat to an entire population and to seek equity when expedience threatens to be the order of the day.