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Ethical dilemmas during the COVID-19 pandemic

Abstract

This article aims to reflect on the ethical dilemmas faced by health professionals, patients and family members during the COVID-19 pandemic. The pandemic raised ethical issues in health caused by the lack of material and human resources and the fear of the unknown. Patients and family members were also affected by social distancing in hospitalization and mourning. Health profissionals faced ethical dilemmas that raise questions about the duty to assist patients and the guarantee of personal safety, dealing with the challenge of acting ethically amid work overload and insecurity of the context. The family and patients face a scenario of adaptation of health care with the lack of technologies that allow feelings of care in the face of the need for distancing, including in the process of farewell rituals of the late. Investments in health can thus drive changes in care, in compliance with social justice and respect for human dignity.

Pandemics; Bioethics; Coronavirus infections; Health personnel; Patients

Resumo

Este artigo objetiva refletir acerca dos dilemas éticos enfrentados pelos profissionais de saúde, pacientes e familiares durante a pandemia da covid-19. A pandemia irrompeu questões éticas na saúde, ocasionadas pela falta de recursos materiais, humanos e o medo do desconhecido. Pacientes e familiares também foram afetados pelo distanciamento na internação e no luto. Profissionais da saúde depararam com dilemas éticos que suscitam questões sobre o dever de assistir o paciente e a garantia da segurança pessoal, lidando com o desafio de agir com ética em meio à sobrecarga e à insegurança do contexto. A família e os pacientes enfrentam um cenário de adaptação do cuidar em saúde com a carência de tecnologias que permitam acolhimento diante da necessidade de distanciamento, inclusive no processo dos rituais de despedida dos finados. Assim, investimentos em saúde podem impulsionar mudanças no cuidado, em observância da justiça social e do respeito à dignidade humana.

Pandemias; Bioética; Infecções por coronavírus; Pessoal de saúde; Pacientes

Resumen

Este artículo reflexionó sobre los dilemas éticos que enfrentan los profesionales de la salud, los pacientes y familiares durante la pandemia del covid-19. La pandemia hizo estallar cuestiones éticas en salud, provocadas por la falta de recursos materiales y humanos, y el miedo a lo desconocido. Los pacientes y sus familias fueron afectados por el distanciamiento en la hospitalización y el duelo. Los profesionales de la salud afrontaron dilemas éticos en cuanto al deber de asistir al paciente y la garantía de seguridad personal, y el desafío de actuar éticamente durante la sobrecarga e inseguridad en ese contexto. Los pacientes y sus familias enfrentan una adaptación de la atención a la falta de tecnología para acogerles ante el distanciamiento, incluso en el proceso de despedida al difunto. Las inversiones en salud pueden promover cambios en la atención en observancia de la justicia social y el respeto a la dignidad humana.

Pandemias; Bioética; Infecciones por coronavirus; Personal de salud; Pacientes

The pandemic triggered by the new Coronavirus (SARS-CoV-2), or COVID-19, as it became better known, forced several areas to face challenges, adaptations, and changes. The virus, the cause of an outbreak of respiratory disease, was first detected in Wuhan, China, which led the World Health Organization (WHO) to declare an international public health emergency on January 30, 202011. Nohama N, Silva JS, Simão-Silva DP. Desafios e conflitos bioéticos da covid-19: contexto da saúde global. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421 .

The disease had one of the most devastating impacts in the history of humanity and was considered even more aggressive than the swine flu, whose pandemic took place years ago. This is due to the poor knowledge about prevention, pathogenesis, and treatment of COVID-19, as well as its high transmission capability. Coronavirus continues to plague society and cause an exorbitant number of deaths worldwide11. Nohama N, Silva JS, Simão-Silva DP. Desafios e conflitos bioéticos da covid-19: contexto da saúde global. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421 . Affected by the pandemic, Brazil also faces great social inequality, with people living in precarious housing, hygiene, and sanitation conditions in often crowded areas due to the high number of family members, and with chronic problems of access to water22. Werneck GL, Carvalho MS. A pandemia de COVID-19 no Brasil: crônica de uma crise sanitária anunciada. Cad Saúde Pública [Internet]. 2020 [acesso 28 jul 2021];36(5):e00068820. DOI: 10.1590/0102-311X00068820 .

Such a complex situation produces ethical dilemmas since it tests values, principles, and priorities, generating doubts that involve all social actors’ decision-making, such as: Should we save the economy or lives? Who should we choose to save in an overloaded public system? Should we prioritize individuals’ protection and rights or infringe them for the collective interest? These ethical impasses are difficult to solve or even insoluble33. Perea JGF. Algunas reflexiones sobre dilemas éticos del cuidado en un entorno de pandemia. Psicol Soc [Internet]. 2020 [acesso 28 jul 2021];32:e020003. DOI: 10.1590/1807-0310/2020v32239528 .

Thus, it is evident that ethical dilemmas, especially in a pandemic, refer to the conflict of more than one moral reference regarding health and its agents: healthcare providers, patients, and family members. The delicateness and complexity of the situation is evident due to its object: human life. On the other hand, these subjects encourage us to think about resolutions for conflicting situations and evaluate whether the decision was acceptable for the situation faced33. Perea JGF. Algunas reflexiones sobre dilemas éticos del cuidado en un entorno de pandemia. Psicol Soc [Internet]. 2020 [acesso 28 jul 2021];32:e020003. DOI: 10.1590/1807-0310/2020v32239528 .

It is neither simple nor fair to deliberate on individuals’ lives based on social values. Thus, this article is justified in view of the relevance of the theme for healthcare providers, who, even based on laws and codes of ethics and endowed with principles, still encounter several challenges in their professional practice given the pandemic and the atypical situation in which they perform their activities. This context also presents the dilemmas experienced by patients who, in most cases, face social isolation since hospitalization forbids the presence of companions. Thus, families face distancing and anguish for information about patients’ conditions.

The following questions arose in this context: what are the ethical dilemmas faced by healthcare providers during the pandemic? And what are the ethical dilemmas faced by patients and family members? This article aims to reflect on the ethical issues faced by healthcare providers, patients, and family members during the COVID-19 pandemic.

Ethical dilemmas faced by healthcare providers

In health, ethical dilemmas are intensified since decisions directly impact human lives. Considering this peculiarity facilitates our understanding of the challenge of facing an ethical dilemma during a pandemic which caused public calamity, with insufficient personal protective equipment, medicines and structure; limited access due to overcrowding; and increased absence of professionals due to infection33. Perea JGF. Algunas reflexiones sobre dilemas éticos del cuidado en un entorno de pandemia. Psicol Soc [Internet]. 2020 [acesso 28 jul 2021];32:e020003. DOI: 10.1590/1807-0310/2020v32239528 , 44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 .

This scenario affects healthcare providers since they deal directly with human vulnerability, and, due to the pandemic, still face the new or unknown, which can generate fear in them. Thus, healthcare providers should aim to maintain their physical and mental well-being to deal with the imposed situation, assist patients well, and protect themselves44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 . It is important, thus, to understand some aspects in the daily life of healthcare providers to understand their routine and what influences their decision-making which triggers ethical dilemmas. Thus, to better understand the theme, we divided it into the following topics: i) fear and mental health; ii) lack of personal protective equipment; and iii) lack of resources and equipment.

Fear and mental health

Health care requires a professional diversity that includes health workers and support services, such as servants, food service worker, security guards, among others44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 . Physical and mental exhaustion is even greater among these workers, conflicting with their ethics and responsibility amidst work overload. Treating critically ill patients infected with a relatively unknown virus requires accurate and cautious care, especially due to stress and the possibility of death. Moreover, healthcare providers face the lack of protocols guaranteeing humanization and reception – necessary changes in the practice of care –, fear, and insecurity55. Jackson D, Bradburry-Jones C, Baptiste D, Gelling L, Morin K, Neville S, Smith GD. Life in the pandemic: some reflections on nursing in the contexto of COVID-19. J Clin Nurs [Internet]. 2020 [acesso 28 jul 2021];29(3):2041-3. DOI: 10.1111/jocn.15257 .

This scenario intensifies feelings, such as fear, anguish, concern, anger, and helplessness, among others. They stem from the front line in the fight against a disease whose orientations and treatment arise concomitantly with its accelerated spread in the world44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 . Social isolation, imposed on family members to ensure greater safety, caused many healthcare providers to leave their homes to temporarily live in hotels, inns or other real estate to avoid endangering their families, an act of love involving loneliness, longing, and the uncertainty of a reunion55. Jackson D, Bradburry-Jones C, Baptiste D, Gelling L, Morin K, Neville S, Smith GD. Life in the pandemic: some reflections on nursing in the contexto of COVID-19. J Clin Nurs [Internet]. 2020 [acesso 28 jul 2021];29(3):2041-3. DOI: 10.1111/jocn.15257 .

Researchers have focused on mental health, another problem of the pandemic, manifest in increased symptoms of anxiety, depression, insomnia, sleep disorders, indiscriminate use of drugs, psychosomatic symptoms, post-traumatic stress disorder (PTSD), low job satisfaction, and fear of infection and transmission66. Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade R, Espiridião MA. A saúde dos profissionais de saúde no enfrentamento da pandemia de COVID-19. Ciênc Saúde Cole [Internet]. 2020 [acesso 28 jul 2021];25(9):3465-74. DOI: 10.1590/1413-81232020259.19562020 , 77. Bezerra GD, Sena ASR, Braga ST, Santos MEN, Correia LFR, Clementino KMF et al. The Covid-19 pandemici’s impact on the mental health of health personnels: integrative review. Rev Enferm Atual In Derme [Internet]. 2020 [acesso 28 jul 2021];93:e-20012. DOI: 10.31011/reaid-2020-v.93-n.0-art.758
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A study in China, the first country to face the consequences of COVID-19, conducted with nurses, doctors, respiratory therapists, auxiliary staff, and other health workers, showed that those in the front line were more prone to emotional tension and physical exhaustion when caring for diverse audiences with greater potential for complications. Caring for co-workers whose situation worsened with the disease or who died also left them at a high level of stress. The scarcity of personal protective equipment, concerns about infecting family members, shortage of ventilators and other medical equipment, anxiety about taking on new or unknown functions, work overload, and limited access to mental health services affect healthcare providers not only in China but also in all countries plagued by the disease. Moreover, women were more likely to report such symptoms than men88. Avanian JZ. Mental health needs of health care workers providing frontline covid-19 Care. JAMA Health Forum [Internet]. 2020 [acesso 28 jul 2021];1(4):e200397. DOI: 10.1001/jamahealthforum.2020.0397 .

Ethical impasses are also present and latent for those not on the front line or on temporary leave since they may show psychological distress in health emergencies. Thus, “vicarious” or “secondary traumatization,” which occurs when a person, even distant from the traumatic situations of the pandemic, starts to show psychological symptoms due to their empathy for those who suffered from them or, still, show guilt, anger, frustration, and sadness for being unable to care for patients, making it necessary and important to develop psychological care strategies for healthcare providers during the pandemic99. Schmidt B, Crepaldi MA, Bolze, SDA, Neiva-Silva L, Demenech LM. Mental health and psychological interventions during the new coronavirus pandemics (Covid-19). Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e-200063. DOI: 10.1590/1982-0275202037e200063 .

Though difficult to solve, ethical dilemmas arising from mental health issues can be controlled or minimized if health services provide adequate support to their healthcare providers, including training strategies aimed at managing anxiety and stress1010. Duarte MLC, Silva DG, Bagatini MMC. Enfermagem e saúde mental: uma reflexão em meio à pandemia de coronavírus. Rev Gaúcha Enferm [Internet]. 2021 [acesso 28 jul 2021];42(n esp):e20200140. DOI: 10.1590/1983-1447.2021.20200140 . Mental health care, such as telemedicine, remote care with mental health professionals, mobile applications, online resources, and virtual support can be very positive for healthcare providers88. Avanian JZ. Mental health needs of health care workers providing frontline covid-19 Care. JAMA Health Forum [Internet]. 2020 [acesso 28 jul 2021];1(4):e200397. DOI: 10.1001/jamahealthforum.2020.0397 .

Other guidelines from the WHO include reducing the consumption of news which can generate anxiety or stress, prioritizing news from reliable sources; maintaining healthy eating, regular sleep, and physical exercises or meditation; keeping contact with family members, even if via virtual meetings; and taking breaks at work, especially for those who are in home office1010. Duarte MLC, Silva DG, Bagatini MMC. Enfermagem e saúde mental: uma reflexão em meio à pandemia de coronavírus. Rev Gaúcha Enferm [Internet]. 2021 [acesso 28 jul 2021];42(n esp):e20200140. DOI: 10.1590/1983-1447.2021.20200140 .

Lack of personal protective equipment

Healthcare providers manufactured or purchased their own personal protective equipment (PPE) since they feared that their work environment would adequately unable to adequately provide them. This was a part of healthcare providers’ daily lives, a situation which increases exhaustion regarding the risk of infection and transmission, making the work for health teams unsafe and frightening44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 .

Many healthcare providers experience ethical and moral hesitation when assisting patients without adequate PPE as they put their, patients, health teams, and their families’ lives at risk. This situation is a conflict of values since healthcare providers are subjected by law to the Brazilian Penal Code1111. Brasil. Decreto-Lei n° 2.848, de 7 de dezembro de 1940. Código de Processo Penal. Diário Oficial da União [Internet]. Rio de Janeiro, 31 dez 1940 [acesso 28 jul 2021]. Disponível: https://bit.ly/3DxqAIg
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and to their professional bodies if they fail to offer aid. This context, however, offers personal risks, raising a dilemma for healthcare providers since working conditions hinder proper assistance1212. Conselho Federal de Medicina. Resolução nº 2.217, de 27 de setembro de 2018. Aprova o Código de Ética Médica. Diário Oficial da União [Internet]. Brasília, p. 179, 1º nov 2018 [acesso 28 jul 2021]. Seção 1. Disponível: https://bit.ly/3MN8ffk
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Regarding nursing professionals, ethical aspects guarantee their right to individually or collectively suspend their activities if workplaces fail to offer adequate and safe conditions for professional practice and/or disrespect the legislation in force, except in urgent and emergency situations. It is up to these professionals to formalize their decision in writing or electronically to their institutions and Regional Nursing Councils44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 .

Moreover, nursing professionals are forbidden to deny care in urgent situations, emergencies, epidemics, disasters, and catastrophes unless it endangers their physical integrity. Thus, nursing professionals can deny care to patients with COVID-19 due to inadequate PPE or unsafe working conditions. However, this situation configures an ethical and moral impasse for these professionals who daily risk their lives for their patients. Thus, nursing professionals’ lives and civil liability enter in conflict, which may have consequences for their health and safety in performing their work activities44. Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702 .

The Code of Medical Ethics, chapter II, ensures physicians’ right to refuse to practice in institutions, whether public or private, whose conditions are undignified or may harm their health or that of their patients and other professionals, justifying their decision to their technical director, Regional Council and ethics committee, if applicable. However, this item conflicts with the subsequent one, which mentions the right to suspend activities, except for urgent and emergency situations1212. Conselho Federal de Medicina. Resolução nº 2.217, de 27 de setembro de 2018. Aprova o Código de Ética Médica. Diário Oficial da União [Internet]. Brasília, p. 179, 1º nov 2018 [acesso 28 jul 2021]. Seção 1. Disponível: https://bit.ly/3MN8ffk
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Moreover, physical therapists should protect client/patient/users, as well as the institution/programs in which they work from the damages which malpractice, negligence or recklessness may incur. These professionals must also assume technical responsibility to offer their services in urgencies or in cases in which they are the only professionals in the sector, individually and collectively unable to deny assistance in urgencies1313. Costa MD, Loiola EAC. Ethical and legal aspects related to physiotherapy care during the Public Health Emergency of National importance (ESPIN) resulting from the Covid-19 pandemic. Assobrafir Ciência [Internet]. 2020 [acesso 28 jul 2021];11(supl 1):241-6. DOI: 10.47066/2177-9333.AC20.covid19.023 .

Thus, it is worth reflecting that pandemics, as a public health problem, are characterized by a constant state of alertness, in which urgent and emergency situations take place at all times. Thus, should care and procedures be maintained even if they bring risks to all involved? Should one life be maintained at the expense of another? As an ethical dilemma, one must choose between two paths, but the principle which should prevail is protecting and promoting life on both sides by providing health workers with adequate and sufficient PPE, thus offering a quality service for the population that may need it.

Thus, the 1988 Federal Constitution inaugurated an environment of renewal and challenges by occupying the core of the judicial system within the system of rules and principles, controlling and validating the entire infraconstitutional norm. It established a framework grounded in democratic pillars, which the entire social, political and legal system must follow1414. Souza EAL. A constituição federal de 1988 e a vedação a “Escolha da Sofia” na covid-19. BJHR [Internet]. 2020 [acesso 28 jul 2021];3(4):10600-10. Disponível: https://bit.ly/3KGbKTc
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Lack of resources and equipment

We see the discussions on health investments and the impasse of saving the economy during a pandemic in principles such as equity, which is based on granting more to those who need it most, considering the needs of the most vulnerable groups. Thus, this should be the focus of concern and priority of government actions. In practical terms, equity is a benchmark for comparing, for example, the extent of financial aid packages in relation to other resources making up the public budget1515. Nohama N, Silva SJ, Simão-Silva DP. Covid-19 bioethical challenges and conflicts: global health context. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421 .

The pandemic has highlighted chronic problems in health, such as physicians’ arduous task of enabling patients to access scarce resources, such as intensive care unit beds (ICU), supplies, and hospital structure and proper functioning. Moreover, we also highlight the lack of decent remuneration for healthcare providers. COVID-19 worsened all these factors1515. Nohama N, Silva SJ, Simão-Silva DP. Covid-19 bioethical challenges and conflicts: global health context. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421 .

Recently, the state of Amazonas suffered from lack of oxygen tanks to treat patients hospitalized for COVID-191616. Covid em Manaus: sem oxigênio, pacientes dependem de ventilação manual para sobreviver em Manaus. BBC News Brasil [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bbc.in/35WijlB
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. A task force was organized, especially by civil society, to transport oxygen tanks to patients. They arrived too late for those who could not survive the absence of this input. This reflects the need for public managers to plan how to cope with the pandemic. In the press and social media, healthcare providers reported losing patients from an entire sector, patients sharing tanks without a perspective of a next one arriving, and health workers on the limit of their physical and psychic conditions1616. Covid em Manaus: sem oxigênio, pacientes dependem de ventilação manual para sobreviver em Manaus. BBC News Brasil [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bbc.in/35WijlB
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In general, what the pandemic has daily shown is that before thinking about offering mechanical ventilators and inputs, such as oxygen tanks, we need to think of a specialized workforce. Though new healthcare providers have been invited to work, they lack sufficient knowledge, training, and experience to manage this equipment in such complex situations66. Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade R, Espiridião MA. A saúde dos profissionais de saúde no enfrentamento da pandemia de COVID-19. Ciênc Saúde Cole [Internet]. 2020 [acesso 28 jul 2021];25(9):3465-74. DOI: 10.1590/1413-81232020259.19562020 , 1515. Nohama N, Silva SJ, Simão-Silva DP. Covid-19 bioethical challenges and conflicts: global health context. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421 .

In view of this, it is essential to act to promote training through courses and simulators, enable access to telemedicine, support technological development to manufacture ventilators with more accessible technology, use components and inputs that are independent of the international market, seek alternative ventilatory support offering low risk of contamination to health workers. Moreover, it is necessary to invest in input maintenance, such as individual equipment, mechanical ventilation accessories, sedatives, analgesics, and neuromuscular-blocking drugs. For this, investments should be a priority for universities, industry sectors, and health entities1717. Holanda MA, Pinheiro BV. Covid-19 pandemic and mechanical ventilation: facing the presente, designing the future. J Bras Pneumol [Internet]. 2020 [acesso 28 jul 2021];46(4):e20200282. DOI: 10.36416/1806-3756/e20200282 .

The need to prioritize and decide based on a conduct grounded on the criterion of justice was evidenced in the preparation of a protocol by the Brazilian Association of Intensive Care Medicine (Amib) to allocate scarce resources during the COVID-19 pandemic. The protocol includes screening all patients affected by the virus as a criterion of justice so patients with the highest chances of benefitting from treatment and surviving are prioritized1414. Souza EAL. A constituição federal de 1988 e a vedação a “Escolha da Sofia” na covid-19. BJHR [Internet]. 2020 [acesso 28 jul 2021];3(4):10600-10. Disponível: https://bit.ly/3KGbKTc
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Healthcare providers should seek better solutions which reflect on assistance, care, and appropriate treatment choice. We should note that the struggle for improvement is the responsibility of other actors in society, especially the State. In the current context, these conditions promote dilemmas. How can one choose the right treatment without equipment and resources? Given this reality, is making arrangements the way to save patients? Would using one equipment for two people save both or put them at risk? We suppose many healthcare providers have found themselves in this situation and, amidst chaos, have sought training in the available courses in partnership with health institutions or universities. There was also a demand for necessary equipment and resources, better wages, and working conditions1414. Souza EAL. A constituição federal de 1988 e a vedação a “Escolha da Sofia” na covid-19. BJHR [Internet]. 2020 [acesso 28 jul 2021];3(4):10600-10. Disponível: https://bit.ly/3KGbKTc
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15. Nohama N, Silva SJ, Simão-Silva DP. Covid-19 bioethical challenges and conflicts: global health context. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421

16. Covid em Manaus: sem oxigênio, pacientes dependem de ventilação manual para sobreviver em Manaus. BBC News Brasil [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bbc.in/35WijlB
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17. Holanda MA, Pinheiro BV. Covid-19 pandemic and mechanical ventilation: facing the presente, designing the future. J Bras Pneumol [Internet]. 2020 [acesso 28 jul 2021];46(4):e20200282. DOI: 10.36416/1806-3756/e20200282
- 1818. Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Bioethical perspectives on decision-making in times of pandemic. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(3):410-7. DOI: 10.1590/1983-80422020283401 .

Ethical dilemmas faced by patients and family members

In addition to the ethical challenges and dilemmas faced by healthcare providers, it is important to consider another facet: to whom care is provided – i.e., not only patients, but their support network. Patients affected by the Coronavirus are vulnerable, as they face treatment with scarce evidence, fear of the unknown, demotivating news, and social isolation and distancing from their families. It is common to find a patient or family member requesting discharge on request or hospital evasion99. Schmidt B, Crepaldi MA, Bolze, SDA, Neiva-Silva L, Demenech LM. Mental health and psychological interventions during the new coronavirus pandemics (Covid-19). Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e-200063. DOI: 10.1590/1982-0275202037e200063 .

After the discovery of the virus, its spread, and forms of transmission, many countries adopted measures to contain the spread of the virus, especially quarantines and social distancing. One of the greatest health crises of this century has brought a devastating change in human and ethical issues. Those infected experience isolation from their families and society since the virus is extremely aggressive and transmissible99. Schmidt B, Crepaldi MA, Bolze, SDA, Neiva-Silva L, Demenech LM. Mental health and psychological interventions during the new coronavirus pandemics (Covid-19). Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e-200063. DOI: 10.1590/1982-0275202037e200063 .

This change in reality also affected the traditional ways of coping with death and mourning. Visits, wakes, and rituals to bid farewell to the deceased infected by COVID-19 are forbidden to family and friends due to the great risk of contagion, generating anguish and suffering to loved ones. People with COVID-19 experience the process of death alone. Moreover, funeral homes send these people to cemeteries without the respect and dignity such a painful moment requires and without the right to the humanized practice of palliative care. Finitude and death should receive a dignified treatment, treating patients in their integral structure. In this practice, patients’ physical, psychological, social, and spiritual pain is treated, humanely reaching patients, family members, and healthcare providers1919. Dantas CR, Azevedo RCS, Vieira LC, Côrtes MTF, Federmann ALP, Cucco LM et al. O luto nos tempos da COVID-19: desafios do cuidado durante a pandemia. Rev Latinoam Psicopatol Fundam [Internet]. 2020 [acesso 28 jul 2021];23(3):509-33. DOI: 10.1590/1415-4714.2020v23n3p509.5
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The devastating advance of this pandemic hindered the creation of strategies to confront religious and spiritual issues, constituting the ethical and human challenge of producing the technological resources allowing patients and family members to bid their farewell with dignity, including burial. For this, it is necessary to adapt to the conditions imposed by the pandemic2020. Crepaldi MA, Schmidt B, Noal DS, Bolze SDA, Gabarra LM. Terminalidade, morte e luto na pandemia de COVID-19: demandas psicológicas emergentes e implicações práticas. Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e200090. DOI: 10.1590/1982-0275202037e200090 .

This reality made the National Congress discuss a bill providing for the right to family members to virtually visit patients via video calls. It aimed to establish a right, safeguarded by law, of visiting hospitalized loved ones, even if by technology (since physical presence is vetoed)2121. Brasil. Projeto de Lei n° 2136 de 23 de abril de 2020. Dispões sobre a visita virtual, por meio de videochamadas, com familiares a pacientes internados em decorrência do novo coronavírus (covid-19). Câmara dos deputados [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bit.ly/35TeDRC
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The fact that family members are forbidden to visit burial sites, accompany the body on special occasions aimed at the deceased, perform the rituals reconnecting them with the sacred, console themselves with friends, neighbors, and relatives, creates an abyss of pain to be overcome by the families of the deceased. Thus, new ethical and bioethical challenges arise which require new strategies to deal with death and mourning2020. Crepaldi MA, Schmidt B, Noal DS, Bolze SDA, Gabarra LM. Terminalidade, morte e luto na pandemia de COVID-19: demandas psicológicas emergentes e implicações práticas. Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e200090. DOI: 10.1590/1982-0275202037e200090 .

Another reality experienced that raises dilemmas is the care of the older adults in ICU, a situation affecting families and patient since the demand of older adults infected by COVID-19 has increased. Older adults show disadvantages for hospitalization eligibility due to their age and comorbidities. At this point, we invite readers to consider placing themselves in patient and families’ shoes to better understand a reality experienced by many. An example that expresses this situation well took place in Italy, the first European country to be the focus of the pandemic, in which its government adopted guidelines that highlighted this ethical, such as the allocation of resources in ICUs, limited age-related screening, comorbidities and functional status of critical patients admitted to ICUs, and of palliative care in worsened outcomes after discharge from intensive care2222. Fhon JRS, Silva LM, Leitón-Espinoza ZE, Matiello FB, Araújo JS, Rodrigues FAP. Hospital care for elderly covid-19 patients. Rev Latinoam Enferm [Internet]. 2020 [acesso 28 jul 2021];28:e3396. DOI: 10.1590/1518-8345.4649.3396 .

This problem is concretely reflected in the ethical challenges and dilemmas raised during the pandemic. Affected patients and families, fearing the unknown, are vulnerable. Moreover, lack of resources and health investments in some places even forces the separation of family members, as happened in Manaus when patients needed to be transferred to other states due to lack of oxygen tanks. In addition to illness and social distancing, these patients faced displacement. This is the drama of families which, often due to precarious financial conditions, are unable to follow-up family members1616. Covid em Manaus: sem oxigênio, pacientes dependem de ventilação manual para sobreviver em Manaus. BBC News Brasil [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bbc.in/35WijlB
https://bbc.in/35WijlB...
.

Final considerations

The pandemic undoubtedly created a scenario that raised ethical dilemmas for healthcare providers, patients, and families. Health workers experienced impasses such as the lack of adequate PPE due to high demand which generated questions about their duty to assist patients and guarantee their own personal safety. The lack of working conditions and resources is still reflected in doubts and questions that involve choice and priority regarding human lives. Moreover, being on the front line against a little-known virus triggers fear and challenges mental health maintenance. These dilemmas permeate health workers’ routines.

Note that one limitation of this study is failing to address other workers who are also part of health care, although indirectly, such as hygiene teams, stretcher operators, ambulance drivers, nutrition service teams, equipment maintenance teams, and workers involved in burial services. They are workers who are exposed daily to the risk of contamination and need to be remembered.

The ethical dilemmas experienced by patients and their family permeate distancing, especially when patients need hospital care. In this case, family members wish to be close to loved ones and protect them. Patients have requested discharge, evaded, or even had to be transferred from their municipalities for lack of resources. In this context, many families experienced lack of information, which led them to adopt new approximation and shelter strategies, such as video calls.

Ethical dilemmas arise before this dramatic scenario of marks and challenges generated by COVID-19, which may promote solutions and the drive for changes and improvements. At least they highlight the need for urgent health investments with responsibility, social justice, and respect for human dignity.

Referências

  • 1
    Nohama N, Silva JS, Simão-Silva DP. Desafios e conflitos bioéticos da covid-19: contexto da saúde global. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421
  • 2
    Werneck GL, Carvalho MS. A pandemia de COVID-19 no Brasil: crônica de uma crise sanitária anunciada. Cad Saúde Pública [Internet]. 2020 [acesso 28 jul 2021];36(5):e00068820. DOI: 10.1590/0102-311X00068820
  • 3
    Perea JGF. Algunas reflexiones sobre dilemas éticos del cuidado en un entorno de pandemia. Psicol Soc [Internet]. 2020 [acesso 28 jul 2021];32:e020003. DOI: 10.1590/1807-0310/2020v32239528
  • 4
    Miranda FMA, Santana LL, Pizzolato AC, Saquis LMM. Working conditions and the impacto n the health of the nursing professionals in the contexto of covid-19. Cogitare Enferm [Internet]. 2020 [acesso 28 jul 2021];25:e72702. DOI: 10.5380/ce.v25i0.72702
  • 5
    Jackson D, Bradburry-Jones C, Baptiste D, Gelling L, Morin K, Neville S, Smith GD. Life in the pandemic: some reflections on nursing in the contexto of COVID-19. J Clin Nurs [Internet]. 2020 [acesso 28 jul 2021];29(3):2041-3. DOI: 10.1111/jocn.15257
  • 6
    Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade R, Espiridião MA. A saúde dos profissionais de saúde no enfrentamento da pandemia de COVID-19. Ciênc Saúde Cole [Internet]. 2020 [acesso 28 jul 2021];25(9):3465-74. DOI: 10.1590/1413-81232020259.19562020
  • 7
    Bezerra GD, Sena ASR, Braga ST, Santos MEN, Correia LFR, Clementino KMF et al. The Covid-19 pandemici’s impact on the mental health of health personnels: integrative review. Rev Enferm Atual In Derme [Internet]. 2020 [acesso 28 jul 2021];93:e-20012. DOI: 10.31011/reaid-2020-v.93-n.0-art.758
    » https://doi.org/10.31011/reaid-2020-v.93-n.0-art.758
  • 8
    Avanian JZ. Mental health needs of health care workers providing frontline covid-19 Care. JAMA Health Forum [Internet]. 2020 [acesso 28 jul 2021];1(4):e200397. DOI: 10.1001/jamahealthforum.2020.0397
  • 9
    Schmidt B, Crepaldi MA, Bolze, SDA, Neiva-Silva L, Demenech LM. Mental health and psychological interventions during the new coronavirus pandemics (Covid-19). Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e-200063. DOI: 10.1590/1982-0275202037e200063
  • 10
    Duarte MLC, Silva DG, Bagatini MMC. Enfermagem e saúde mental: uma reflexão em meio à pandemia de coronavírus. Rev Gaúcha Enferm [Internet]. 2021 [acesso 28 jul 2021];42(n esp):e20200140. DOI: 10.1590/1983-1447.2021.20200140
  • 11
    Brasil. Decreto-Lei n° 2.848, de 7 de dezembro de 1940. Código de Processo Penal. Diário Oficial da União [Internet]. Rio de Janeiro, 31 dez 1940 [acesso 28 jul 2021]. Disponível: https://bit.ly/3DxqAIg
    » https://bit.ly/3DxqAIg
  • 12
    Conselho Federal de Medicina. Resolução nº 2.217, de 27 de setembro de 2018. Aprova o Código de Ética Médica. Diário Oficial da União [Internet]. Brasília, p. 179, 1º nov 2018 [acesso 28 jul 2021]. Seção 1. Disponível: https://bit.ly/3MN8ffk
    » https://bit.ly/3MN8ffk
  • 13
    Costa MD, Loiola EAC. Ethical and legal aspects related to physiotherapy care during the Public Health Emergency of National importance (ESPIN) resulting from the Covid-19 pandemic. Assobrafir Ciência [Internet]. 2020 [acesso 28 jul 2021];11(supl 1):241-6. DOI: 10.47066/2177-9333.AC20.covid19.023
  • 14
    Souza EAL. A constituição federal de 1988 e a vedação a “Escolha da Sofia” na covid-19. BJHR [Internet]. 2020 [acesso 28 jul 2021];3(4):10600-10. Disponível: https://bit.ly/3KGbKTc
    » https://bit.ly/3KGbKTc
  • 15
    Nohama N, Silva SJ, Simão-Silva DP. Covid-19 bioethical challenges and conflicts: global health context. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(4):585-94. DOI: 10.1590/1983-80422020284421
  • 16
    Covid em Manaus: sem oxigênio, pacientes dependem de ventilação manual para sobreviver em Manaus. BBC News Brasil [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bbc.in/35WijlB
    » https://bbc.in/35WijlB
  • 17
    Holanda MA, Pinheiro BV. Covid-19 pandemic and mechanical ventilation: facing the presente, designing the future. J Bras Pneumol [Internet]. 2020 [acesso 28 jul 2021];46(4):e20200282. DOI: 10.36416/1806-3756/e20200282
  • 18
    Sanches MA, Cunha TR, Siqueira SS, Siqueira JE. Bioethical perspectives on decision-making in times of pandemic. Rev. bioét. (Impr.) [Internet]. 2020 [acesso 28 jul 2021];28(3):410-7. DOI: 10.1590/1983-80422020283401
  • 19
    Dantas CR, Azevedo RCS, Vieira LC, Côrtes MTF, Federmann ALP, Cucco LM et al. O luto nos tempos da COVID-19: desafios do cuidado durante a pandemia. Rev Latinoam Psicopatol Fundam [Internet]. 2020 [acesso 28 jul 2021];23(3):509-33. DOI: 10.1590/1415-4714.2020v23n3p509.5
    » https://doi.org/10.1590/1415-4714.2020v23n3p509.5
  • 20
    Crepaldi MA, Schmidt B, Noal DS, Bolze SDA, Gabarra LM. Terminalidade, morte e luto na pandemia de COVID-19: demandas psicológicas emergentes e implicações práticas. Estud Psicol [Internet]. 2020 [acesso 28 jul 2021];37:e200090. DOI: 10.1590/1982-0275202037e200090
  • 21
    Brasil. Projeto de Lei n° 2136 de 23 de abril de 2020. Dispões sobre a visita virtual, por meio de videochamadas, com familiares a pacientes internados em decorrência do novo coronavírus (covid-19). Câmara dos deputados [Internet]. 2021 [acesso 28 jul 2021]. Disponível: https://bit.ly/35TeDRC
    » https://bit.ly/35TeDRC
  • 22
    Fhon JRS, Silva LM, Leitón-Espinoza ZE, Matiello FB, Araújo JS, Rodrigues FAP. Hospital care for elderly covid-19 patients. Rev Latinoam Enferm [Internet]. 2020 [acesso 28 jul 2021];28:e3396. DOI: 10.1590/1518-8345.4649.3396

Publication Dates

  • Publication in this collection
    09 May 2022
  • Date of issue
    Jan-Apr 2022

History

  • Received
    17 June 2021
  • Reviewed
    18 Feb 2022
  • Accepted
    23 Feb 2022
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