The Society of Critical Care Anesthesiologists

Ethical and Moral Principles During a Pandemic

The COVID-19 pandemic has raised many ethical and moral dilemmas in the realm of public health, social order, duty of care, and fair distribution of resources. Difficult decisions must be made about how, where, when, and to whom resources should be allocated. Physicians and health care workers are bound by a duty of care, therefore, obligations to the patient’s well-being are generally considered to be primary. This is grounded in the principle of beneficence, among others. There is also a reciprocal obligation placed on health systems to provide the best possible infection control modalities at the disposal of healthcare workers, to provide them preferential access to care should they become ill, and to consider the well-being of the families as critical to supporting healthcare workers. Appropriate remuneration and protection of healthcare workers from stigma and medico-legal liabilities are also regarded as important norms. In the absence of such reciprocal obligations being met, healthcare workers cannot legitimately be expected to assume a significant risk of harm to themselves and their families.

Several ethical frameworks have been previously developed for pandemic preparedness by the WHO and other ethics organizations, especially after the previous Ebola and SARS outbreaks across the world. They highlight the importance of many ethical values. These include:

  1. Individual liberty, including freedom from restriction of movement
  2. Protection of the public from harm and loss of privacy
  3. Proportionality, wherein steps taken to mitigate disease spread must be proportional to the threat
  4. Duty to provide care
  5. Reciprocity, including societies’ obligation to healthcare workers
  6. Equity, and although all patients will have the right to receive care, some will be given more than others
  7. Utility, or the maximum good for the maximum number of people
  8. Trust, which is essential to uphold between society and policy makers, as well as healthcare workers
  9. Solidarity to achieve common goals
  10. Stewardship, whereby those entrusted with decision making must adhere to these principles and be reasonable, responsive, accountable, and transparent

In the months ahead, the application of these principles must be informed by evidence as much as possible. As the disease takes its toll on the population, including healthcare and other frontline workers, we need to balance these principles with our own safety. This is possible only if policy-makers and leaders act in a trustworthy manner by applying procedural principles fairly and consistently, being open to review based on new and relevant information, and acting with the genuine input of affected communities. In addition, a synchronized approach is essential to the success of any response effort. There will be, and already is, a devastating burden on the lives and psyches of the population and countless frontline workers. These individuals must be supported by society in the years to come for having forged ahead for the greater good and putting their own safety second to their sense of duty.

  1. WHO Guidance for Managing Ethical Issues in Infectious Disease Outbreaks. 2016
  2. Maxwell Smith and Ross Upshur, Pandemic Disease, Public Health, and Ethics . The Oxford handbook of public health ethics.


Shahla Siddiqui, MBBS, MSc (Medical ethics)
Beth Israel Deaconess Medical Center
Boston, Massachusetts