How could a pandemic be managed ethically? The rationale for updating the WHO guidance.

By Abha Saxena, Paul Bouvier, Ehsan Shamsi-Gooshki, Johannes Köhler, Lisa Schwartz

As the COVID-19 pandemic unfolded, an impressive global research effort was quickly launched to shed light on the subject. Virologists set about dismantling the virus. Pharmacologists began to develop vaccines. Clinicians tested and established treatment strategies against COVID-19. The tools of science were able to shed  light on the darkness bit by bit. However, it soon became painfully clear that the COVID-19 pandemic also raised ethical challenges that could not be addressed using any microscope or scientific equations, but through thoughtful reasoning and action itself. Should borders be closed, thus drastically reducing people’s freedom of movement? Who has priority in a shortage of ventilation beds: the thirty-year-old family man or the seventy-year-old grandmother? What is more critical: pandemic containment, or the economic well-being of a country? Who should be vaccinated first? Should people be forced or incentivized to get the vaccine? Is it fair that rich countries, through their purchasing power, are able to vaccinate their populations first?

When doctors look for guidance, they often find it in clinical guidelines. The same idea has been increasingly applied to ethics. In the field of public health, ethical guidelines aim to provide decision- and policy-makers with a toolkit on how to address ethically sensitive issues, such as those occurring during an epidemic. Influenced by the experience of a raging Ebola epidemic in West Africa, the World Health Organization (WHO) developed and published a “Guidance for managing ethical issues in infectious disease outbreaks” in 2016. This document is perhaps the most comprehensive globally applicable ethics guidance for the management of infectious disease outbreaks.

Paul Bouvier and Abha Saxena were both teaching global health ethics to graduate students in April at the beginning of the COVID-19 pandemic; Paul was teaching international students in Switzerland, while Abha was giving a course at Harvard. They both agreed that it was pedagogically very useful to refer to a set of global guidelines while teaching about such a relevant, topical and evolving issue such as the pandemic. However, some of ethical challenges such as those relating to border closures, digital tracking, or triaging treatment were not adequately covered in the 2016 WHO guidance (or at least Paul and Abha, as professors of global health ethics, found them inadequate). As a result, they concluded that policy makers may also find it challenging to incorporate ethics in their pandemic-related policies. Talking to colleagues – Lisa Schwartz in Canada, Ehsan Shamsi-Gooshki in Iran, and Philippe Calain and Johannes Köehler in Switzerland – Paul and Abha realised that they were not alone in that thinking. As clinicians, academicians, humanitarians, policy advisers, and public health specialists, the authors and contributors to this paper all came to the conclusion that it would be worthwhile to revisit the WHO guidance and systematically identify the gaps.

In this paper (link to the paper here), we present an analysis of the issues and ethical challenges that, in our opinion, were either not covered or inadequately covered in the 2016 WHO guidance. We propose that WHO initiates the process of substantially revising the 2016 guidance to include these points. WHO remains in an excellent position to coordinate the development of an updated document through a collaborative process of reflection and sharing of global experience. These steps are key for the guidance to be internationally recognized and supported. While the updated guidance should integrate current developments and issues, we recognise that the pandemic is far from over, and our knowledge in the middle of a crisis is understandably of a limited nature. New ethical dilemmas will keep arising as the pandemic evolves. In this paper, we argue that the guidance can remain relevant in a complex environment of evolving need only if it also addresses the how of the decision-making process with the attendant uncertainties and threats to human well-being. Without the how, there is a risk that the guidance may only survive till the next big pandemic.


Paper titleWHO guidance on ethics in outbreaks and the COVID-19 pandemic: a critical appraisal.

Authors:  Abha Saxena (1), Paul Bouvier (2), Ehsan Shamsi-Gooshki (3), Johannes Köhler (4), Lisa Schwartz (5)

  1. Adjunct Professor Institute Éthique Histoire Humanités, University of Geneva, Switzerland; Independent Bioethics Advisor, Geneva, Switzerland.
  2. Institute of Global Health, Geneva University, and Department of social sciences, University of Fribourg, Fribourg, Switzerland
  3. Medical Ethics and History of Medicine Research Canter/Department of Medical Ethics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
  4. Department of Anesthesiology and Critical Care Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
  5. Arnold L. Johnson Chair in Health Care Ethics, Professor, Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada

Competing Interests: None

Social Media account: Twitter handle @saxenabioethics



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