Ethical public health policy decisions on medical care in a situation of uncertainty
This article provides a general overview of the ethical content of public health policy for critical care medicine during the COVID-19 pandemic in Mexico.
COVID-19 is an emerging infectious disease caused by the SARS-CoV-2 virus with very serious clinical manifestations in approximately 6% of the infected population.1 At present, there is no prophylactic or curative treatment for COVID-19 and, although progress is being made on the basic science and a number of clinical trials are under way, no vaccine currently exists.
The spread of the virus worldwide, its rate of contagion and mortality, and its impact on life, people’s habits, healthcare systems and economies have led to a global healthcare crisis of enormous proportion that requires exceptional contingency and care plans.
Mexico recognized the declaration of a pandemic caused by the SARS-CoV-2 virus issued by the World Health Organization on 11 March 2020.2 On 19 March 2020, Mexico’s General Health Council (Consejo de Salubridad General – CSG) recognized the disease caused by the SARS-CoV-2 virus, COVID-19, as a serious disease requiring priority care. On 30 March 2020, the CSG reached an agreement whereby the disease epidemic caused by the SARS-CoV-2 virus (COVID-19) was declared a healthcare emergency caused by force majeure.
A few days after the World Health Organization (WHO) declared the pandemic, the Ethics Committee of the CSG Scientific Commission called on renowned bioethicists and specialists in law, philosophy, medicine and psychology to organize drafting a triage bioethics guide with two objectives: fundamentally, to save as many lives as possible; and, importantly, to prepare Mexican healthcare professionals for facing a situation of resource scarcity in critical medicine and to help them take decisions.
“The Bioethics Guide seeks to save as many lives as possible, stating from the outset that all lives are of equal value”
On 11 April 2020, the CSG Ethics Committee decided to publish a working document on its website entitled “Draft Bioethics Guide for Allocating Limited Critical Medicine Resources in an Emergency Situation”. The decision to publish a draft version as a working document was taken in order to fuel public health policy creation processes with transparency, information and accountability. Following several revisions of the draft guide published on the CSG website, on 30 April 2020 – after it was presented and discussed at a plenary session of the CSG, and with broad consensus supported by backing from the Pan-American Health Organization, Specialty Medicine Councils and civil society organizations – the CSG published its “Bioethics Guide for Allocating Limited Critical Medicine Resources in an Emergency Situation”4 (hereinafter, the Bioethics Guide) on its website.
The Bioethics Guide seeks to save as many lives as possible, starting from the outset that all lives are of equal value. The Bioethics Guide comprises a series of recommendations aimed at achieving this goal and supporting the healthcare community in decisions concerning access by patients to critical medicine units when resources are insufficient or overwhelmed by a healthcare emergency situation. The ethical and action guidelines in the Bioethics Guide help steer the actions taken by healthcare professionals while also making uniform decision-making easier, with fair criteria regarding patient care and critical situations. One crucial aspect of the Bioethics Guide is a respect for patient autonomy in their decisions about healthcare, intubation, critical care and palliative care, which can be expressed via advanced statements about their wishes or in the medical records themselves. It calls for protocols to be drawn up in this regard for improved communication and to allow relatives to say farewell. The use of video-calls and other technologies are incorporated so as not to put families at risk and to keep them in contact with their loved ones.
Another fundamental cornerstone of the Bioethics Guide is the bioethics principle of social justice, placing an emphasis on protecting the common good over the individual good without detriment to the importance of the latter. It underlines the principle of non-exclusion and nondiscrimination, emphasizing equal measures and equal treatment. It recognizes the value of healthcare professionals as they take the biggest risks to deal with the pandemic and therefore recognizes their priority in access to critical care medicine. Importantly, in tiebreak situations between two patients with the same diagnosis and in which insufficient resources exist for both, consideration should be given to historically vulnerable groups and gender as decision-making mechanisms in such situations. The medical and scientific criteria are based on public health objectives, using existing scales of situation, diagnosis and seriousness. They consider such indicators as: likelihood of survival, duration of hospital admittance and the quality/years of life ratio to prevent the futile use of scarce resources.
This guide was drawn up to deal with the COVID-19 pandemic based on fundamental principles of ethics in public health and human rights principles, meaning it can be applied to other healthcare emergency situations.
