Ethical Dilemma involving autonomy and COVID-19 testing
Dr Dabota Yvonne Buowari
Background: In December 2019, an atypical form of pneumonia was discovered in Wuhan, China and it has spread to different parts of the world including Nigeria. Testing for the causative agent which is the severe acute respiratory distress syndrome coronavirus-2 is one of the strategies to contain the pandemic. For some reason, some patients with clinical symptoms suggestive of COVID-19 may refuse to be tested for the disease.
Methodology: A review of studies conducted on COVID-19 testing and ethical dilemma associated with it was done using Google Scholar, PubMed and Cochrane reviews.
Conclusion: Ethical dilemma exists in testing for COVID-19 as some patients may refuse testing even when it is necessary and they present with symptoms suggestive of COVID-19. The right to autonomy according to the principles of medical ethics is necessary for every medical consultation but may not be important in pandemics as the person becomes a health threat and harmful to the public.
Keywords: COVID-19, Ethical Dilemma, Autonomy, Medical Ethics
An atypical form of interstitial pneumonia was identified in December 2019, in Wuhan, Hubei Province, China and it has spread to several countries worldwide with no continent spared1-5. This form of pneumonia was traced to a market as most of the patients were linked to the market either as owners of stalls, traders or customers that had visited the market. Samples collected from the market in December 2019 isolated the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) which led to the speculation that the market was the source of the infection. This led to the closure of the market on New Year day of 20202. The COVID-19 infection was declared a pandemic by the World Health Organization (WHO) on March 11, 20201,6. The novel virus (SARS-CoV-2) responsible for this new disease is a beta-coronavirus7. This novel virus has been found to have increased mortality more than the seasonal flu3. This SARS-CoV-2 virus is a global threat that is yet to be contained even though vaccines have been discovered against it4,5,8. Besides SARS-CoV-2, there are other coronaviruses such as the Middle East Respiratory Syndrome coronavirus (MERS-CoV)9. The disease caused by the SARS-COV-2 virus was named Coronavirus 2019, abbreviated as COVID-192,10,11. The disease is very infectious and has spread to other countries in a very short time faster than it can be handled by various health systems as there are several uncertainties and complexities associated with the COVID-19 pandemic10-14. It is a public health emergency of international concern. People all over the globe have contracted the novel virus irrespective of their gender, race and nationality10,15. The COVID-19 illness manifests primarily with symptoms of the respiratory system although other clinical manifestations affect other systems of the body. In severe cases, patients manifest with respiratory distress, and some patients may present with diarrhoea, anosmia, weakness, fatigue and loss of taste13.
The global spread of COVID-19 has led to various psychological and economic impacts, affecting people of various socio-economic groups16,17. Several strategies were set by the WHO to contain the novel virus2. Some of which are testing of suspected cases, isolation, quarantine, physical and social distancing, wearing of face masks and avoiding gatherings. Some governments have also taken some other measures in addition to that instituted by the WHO such as observing a curfew, partial and total lockdown, closure of public recreational places such as parks, markets, educational institutions, places of religious activities and travel restrictions. In different countries, protocols for screening for COVID-19 were adapted to meet the local need based on clinical symptoms and epidemiological factors18.
Healthcare workers especially physicians are useful human resources in the fight against COVID-19 as they are in the frontline of the pandemic19,20. Several healthcare workers have contracted this virus in the course of their work. According to Adam and Walls, it was estimated that 3000 healthcare workers had contracted the SARS-COV-2 with 22 deaths in China as of April 20203. Healthcare workers contracting the virus at the medical workplace put the lives of their household also and every other person they come into contact with at-risk21. This is because of their exposure to the virus while attending to sick people who unknowingly may be carrying the virus22,23. Healthcare workers continue to work even in the face of emerging and novel contagious diseases like COVID-19. The COVID-19 pandemic has been considered the worst threat that humans have encountered in the modern world24. Therefore it is necessary to protect healthcare professionals from this new nosocomial infection and minimizing the exposure of healthcare professionals should be a priority of managers and chief executives of healthcare25. One of the ways of containing the novel virus and also to protect healthcare workers is testing as this will aid in isolation of suspected cases and commencement of treatment for confirmed cases26.
Testing was one of the strategies put in place to contain the novel virus. This depended on the economic capability of the country as developed countries had more widespread testing when compared to developing countries. Different countries had protocols for screening and testing for COVID-19. These testing modalities are adopted to meet situations peculiar to every setting9. In some hospitals, all patients admitted must be tested for COVID-19 irrespective of their diagnosis and clinical presentation27 but this creates an ethical dilemma as some patients may refuse to be tested. As time went on, testing was made a requirement for international travel and participation in sporting activities. Despite the several measures taken by the government, health promotion and awareness campaigns in print and virtual media, some persons refused to be tested even when presenting with clinical symptoms suggestive of COVID-19 infection.
Ethical Dilemma in COVID-19 Testing
Several ethical and legal challenges have been raised by the COVID-19 pandemic especially testing, screening, isolation and conducting studies on COVID-196,28,29. The practice of medicine is guided by the principles of medical ethics which are autonomy, justice, maleficence and non-beneficence. Medical practitioners sometimes have to make delicate decisions that are difficult and challenging30,31 leading to an ethical dilemma and conflicting with the principles of medical ethics. Several ethical dilemmas have emerged following the COVID-19 pandemic28. One of the medical ethics affected by the COVID-19 is autonomy. This principle refers to the capacity an individual possesses to make their own decisions and decide on their health after they have been counselled by a healthcare worker in simple language devoid of medical jargon28. In the patient-doctor relationship, patient autonomy is very vital, but this medical principle of autonomy may be breached when testing to protect medical staff, other patients and the community26. Some hospitals have advocated for compulsory testing of all patients who visit their health facility and some also included periodic testing of healthcare workers32. The American Society of Anesthesiology (ASA) made a recommendation that all patients scheduled for surgery and who will receive anaesthesia must be tested for COVID-1933. Even though COVID-19 is a highly contagious infectious disease, some people will refuse testing even when they manifest clinical symptoms suggestive of the disease12. An ethical dilemma results from testing for COVID-1912. This is because healthcare workers can contract the virus at the medical workplace, especially if it is from a patient with suspicious symptoms that refuses COVID-19 testing33,34. The health of others is compromised when a patient refuses to be tested for COVID-1926,32,33. The recommendation of the American Society of Anesthesiology concerning the refusal of COVID-19 testing by a patient is that the procedure should be suspended until the patient decides to get tested for COVID-19 and has a negative result or the procedure be rescheduled until the patient is asymptomatic for a minimum of 10 days after they have had symptoms suggestive of COVID-1933.
Following the medical ethical principle of autonomy, a patient should be allowed the free will of decision making. A patient who refuses to be tested for COVID-19 may be causing more harm to other people in the community hence leading to an ethical dilemma for the attending physician. Though there is no legislation in some countries that prescribes a fine or penalty for patients that refuse to be tested, it is still a very delicate issue. It is necessary to integrate the protection of human rights and allow shared responses35. Some studies have identified stigma and discrimination of patients diagnosed with the COVID-19 as some of the reasons for the refusal of COVID-19 testing18. The diagnostic test is used for the identification of the SARS-CoV-2 virus in an individual36. Testing is very important for contact tracing and also for confirmation that flu-like symptoms are caused by the contagious and deadly virus33. Some persons may decide not to be tested for COVID-19 while in the hospital27 even if they present as an emergency. Healthcare professionals during the COVID-19 pandemic are required to take it as a serious illness even though patients suspected of COVID-19 should be treated with respect and utmost care37. This is why patients are counselled in a language they can understand without using medical terms and jargon. This made Raus et al opined that during a future pandemic and any other wave of the COVID-19 pandemic, ethical issues associated with the epidemic or pandemic should be given priority5. Tracking and identification of new cases are required for tracking the spread of the disease36. Where the community spread remains unidentified, undiagnosed persons will keep on spreading the infection without knowing it. Effectively isolating patients that test positive to COVID-19 is key at this point.
Human rights and patients autonomy is always upheld during any doctor-patient interaction38. Therefore since a patient have the right to say no to any medical investigation or procedure. Some patients may decline COVID-19 testing even though it is harmful and encourages community spread of the infection. The values that should be respected by all healthcare professionals in the cause of their work known as medical ethics and autonomy is one of the principles of medical ethics38. Some scholars believe that during the COVID-19 pandemic, the consequences of refusing COVID-19 testing should be explained to the patient, also healthcare professionals should try as much as possible to persuade and coerce patients to accept testing.
Coronavirus disease-2019 (COVID-19) is ravaging the world as it has spread to several countries in all the continents globally with high rates of morbidity and mortality and that is why the WHO declared it as a pandemic. Testing for the causative agent is one of the strategies put in place by several governments to bring the pandemic to an end. This is encumbered with challenges as some patients refuse to be tested. This is a dilemma when applying the medical ethical principle of autonomy.
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