Managing the ethical implications of coronavirus
doi:10.1038/nindia.2020.67 Published online 16 April 2020
While India has taken proactive steps to ensure dignity and safe disposal of bodies, the novel coronavirus pandemic has thrown open many ethical and logistic challenges for policy-makers.
As the COVID-19 pandemic grows in India, the safe disposal of bodies of infected patients is essential. India’s Health Ministry and several other institutes, such as the All India Institute of Medical Sciences, New Delhi have issued guidance for the management of the corpses of COVID-19 patients.
Experts point out that currently there are gaps in communicating this information to semi-urban and rural areas. The guidelines must now be made clear at the grassroot level to health workers and religious leaders.
“This is where NGOs can step in so that everyone concerned fully comprehends the need for cremation, and where this is not feasible, cementing of graves,” says Anant Bhan, a medical doctor who researches global health, health policy and bioethics.
Although standard protocols on the handling of bodies (hand hygiene, use of body bag and protective gear like masks, gloves, disposable gown and eye protection) are similar, the ministry’s guidance is more mindful of sentiments of family members of the deceased, and recognises the need for sensitivity by crematoria staff.
Bhan also feels a scarcity of electric crematoria in India may impede incineration as recommended by the guidelines.
The World Health Organization (WHO)1, Centers for Disease Control and Prevention (CDC)2, USA and Public Health England3 have issued similar guidelines. The WHO guidance emphasises upon the dignity of the dead, respect for their cultural and religious traditions and their families.
Such cultural and religious sensitivity is desperately needed in India. Culturally, in India, births, marriages and deaths are social events where everyone participates. Preclusion of this due to social distancing needs to be handled in a sensitive manner with emotional support for the family, Bhan points out.
Collection and safe disposal of waste from COVID-19 patients also pose a huge health risk to hospital nursing and cleaning staff. The Central Pollution Control Board has issued guidance on disposal of wastes. Innovations like a superabsorbent material for disinfection and safe disposal of respiratory and other body fluids designed by scientists at Sree Chitra Tirunal Institute for Medical Sciences and Technology may also help mitigate the risk.
Next of kin
The unprecedented global crisis has raised ethical concerns. In many countries, the next of kin of COVID-19 patients are often not allowed to visit hospitals and see their dying relatives. Such patients are dying alone. Sometimes multiple members of a family are affected or quarantined. If someone dies in such a family, the other family members are unable to pay their last respects.
"It is very difficult for everyone involved,” H. Clifford Lane, Deputy Director for Clinical Research and Special Projects at the National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA, told Nature India.
Some UK hospitals are helping loved ones share final moments, in person, where it's safe to do so, provided that suitable protection is in place, or by video link. “Preventing the spread of COVID-19 is vital, but we should not allow the ‘COVID fog’ to entirely cloud other important considerations, such as protecting psychological and emotional health, or recognising and honouring relationships,” Richard Huxtable, Director of the Centre for Ethics in Medicine at University of Bristol in UK told Nature India.
Bhan points to a recent case where a patient’s sons, who live in Australia, witnessed his funeral on video as international travel remains restricted. Such technology may be an urban privilege, he says, and may not be available to the rural poor. Governments, therefore, must ensure connectivity for those in isolation to enable them to communicate with their loved ones through video calls.
Dilemmas of triage
If India faces the eventuality of a difficult triage situation to prioritise patients, there are lessons to be learnt from the UK, where ventilators and ICU beds are in short supply. Huxtable says although national ethical guidance is emerging in the UK, individual hospitals are developing their own detailed protocols for triage in intensive care. Many hospitals are involving clinical ethicists to draw up their plans and sharing them to ensure consistency and fairness.
The Italian model of triaging solely on age is problematic, says Martin Utley, a professor at the Clinical Operational Research Unit of University College London, UK. It is illegal in the UK as per ethical guidelines issued by the British Medical Association4. “Also, since any triage protocol would eventually preclude certain patients from intensive care, difficult decisions take a toll on the mental health of doctors."
Bhan says India has no triage protocols yet, though several groups are considering these issues. He feels the country definitely needs to frame broad guidelines to prepare for this worst-case scenario.
To mask or not to mask
The mandatory use of protective face masks in public has sparked debates about whether they are being used to best effect. Reports have emerged of people stockpiling N95 masks that are in short supply and desperately needed by front line health care workers. India’s Principal Scientific Adviser (PSA) and the health ministry’s recent advisories on how to make and wear home-made fabric masks offer potential solutions.
Viral RNA fragments are shed in faeces of COVID-19 patients5. This implies that the virus is actively replicating in the gastrointestinal tract and could remain viable in the environment for days, potentially leading to faecal-oral transmission. About 2–10% of confirmed COVID-19 patients present with diarrhoea6. In India, where open defecation is widespread, this might be a cause for concern, should community transmission become rampant.
Experts point to the potential enteric transmission and presence of SARS-CoV-2 in sewage water7,which may harm those working with human waste and wastewater, such as sewage workers and manual scavengers.
A study8 by the Indian council of Medical Research (ICMR) says the lockdown as a drastic public health measure and questions its effectiveness. In a National Bureau of Economic Research working paper9, researchers say that people are much less likely to comply with shutdowns if the anticipated time frames are longer than expected.
The financial consequences of the lockdown in India are being felt most acutely by daily wagers, poor urban and rural households without ration cards, migrants and others living on the margins. Migrant unrest and protests have been reported from several states. The prolonged lockdown in Wuhan, China, caused a spike in domestic violence and alcohol abuse. In India, too, there have been reports of such social problems arising from the lockdown.
As India entered phase two of its lockdown on 15 April 2020, social distancing has worsened the epidemic of loneliness among the aged. A study10 that looked at the effects of school closures on coronavirus outbreaks in China, Hong Kong and Singapore found limited benefit on slowing the spread of the virus. The authors say that closures may have repercussions like restrictions in learning and socialising, and lack of access to school-provided free lunches and vaccinations.
Preeti Tewari, an an associate professor at the University of Delhi says, “Although most states have announced various measures to continue providing mid-day meals to students during the lockdown, the success of such steps remains to be seen.”
As classes shift online, the digital divide may grow further with children from low-income and rural settings without reliable internet connections falling off. With the looming possibility of some children never returning to school, the current health crisis could well pan out into a social crisis, Tewari says. “There is no substitute for classroom teaching. Not all students can access online learning, nor are all teachers trained to impart online education.”
Disruption of prenatal and postnatal11 care due to overstretched health services, and the burden of care for children and the elderly, and household chores is also adversely affecting the well-being of women.
The data hunger
To inform policy, scientists believe that more data needs to be generated on the current infection prevalence by testing random samples in the population and periodically repeating this exercise to estimate the number of new infections. With limited testing, India, like many other countries, lacks this data. Wastewater surveillance for SARS-CoV-2 (as done for poliovirus) might provide indirect evidence of prevalence of the virus, which could inform health policy.
Although accurate information is desperately needed, hastily done research uploaded to preprint servers, like medRxiv and bioRxiv, without peer-review, also pose an ethical problem. A case in point is an Indian study claiming a similarity between the spike protein of SARS-CoV-2 and HIV proteins that was later withdrawn.
Bhan feels that though discerning peer-review definitely ensures good quality data, many times half-baked information is taken at face value and circulated widely on social media without critical review and may incorrectly inform policy. By the time the paper is retracted, the damage may have been already done.
Utley adds that many journals are working hard to speed up the reviewing processes. Although intervention studies need the same level of scrutiny as always, a lighter touch review might be appropriate for very valuable descriptive analyses of observational data, he says.
Independent data analyses have also pointed to statistical discrepancies in the government figures on the number of people being tested in India.
Safety versus privacy
Close surveillance and isolation of infected patients in China, Singapore and South Korea helped control the spread of disease and limited the death toll. The Indian government recently launched the COVID-19 tracking app ‘Aarogya Setu’ that allows digital monitoring of movement of people in real-time and their contacts in hotspots. Prime Minister Modi urged people to download the mobile app in one of his televised addresses.
While this ensures safety, the possibility of data breach raises serious security and ethical concerns. Mukesh Choudhary, a cyber security expert, who heads Cyberops Infosec, told Nature India that the government audits and certifies any app as ‘safe to host’ before uploading it on a live server for the public to use and, hence, security and confidentiality are not compromised by the app.
Another data security expert said on conditions of anonymity that some vulnerabilities, which had been detected in the app earlier, have been patched and it is now safe to use. He, however, adds that the app has not yet undergone Vulnerability Assessment and Penetration Testing (VAPT).
VAPT, says cyber security expert Rizwan Shaikh, is a type of security testing used to find vulnerabilities in an application or system to make it hack-proof. If not done, any app may be vulnerable to hacking and privacy breaches.
1. Infection prevention and control for the safe management of a dead body in the context of COVID-19. World Health Organization Interim guidance (2020)
2. Coronavirus Disease 2019: COVID-19 and funerals. Centers for Disease Control and Prevention (2020)
3. COVID-19: Guidance for care of the deceased. Public Health England (2020)
4. COVID-19 – Ethical issues. A guidance note. British Medical Association (2020)
5. Wu, Y. et al. Prolonged presence of SARS-CoV-2 Viral RNA in faecal samples. Lancet Gastroenterol. Hepatol. (2020) doi: 10.1016/S2468-1253(20)30083-2
6. Water, sanitation, hygiene, and waste management for the COVID-19 virus. World Health Organization Interim guidance (2020)
7. Lodder, W., de Roda Husman, A.M. SARS-CoV-2 in wastewater: Potential health risk, but also data source. Lancet Gastroenterol. Hepatol. (2020) doi: 10.1016/S2468-1253(20)30087-X
8. Chatterjee, P. et al. The 2019 novel coronavirus disease (COVID-19) pandemic: A review of the current evidence. Indian J. Med. Res. (2020) doi: 10.4103/ijmr.IJMR_519_20
9. Briscese, G. et al. Compliance with COVID-19 social-distancing measures in Italy: The role of expectations and duration. National Bureau of Economic Research Working Paper No. 26916 (2020)
10. Viner, R.M. et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc. Health (2020) doi: 10.1016/ S2352-4642(20)30095-X
11. Editorial. The gendered dimensions of COVID-19. Lancet 395, 1168 (2020) doi: 10.1016/S0140-6736(20)30823-0
12. Kissler, S. et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science eabb5793 (2020) doi: 10.1126/science.abb5793
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