Coronavirus: Explanations and Ethical Issues

March 23, 2020

The SARS-CoV-2 virus that causes COVID-19 has spread throughout the world with the number of cases increasing daily, both due to spread and to extended testing. We have provided links to the Centers for Disease Control and Prevention’s websites that give up-to-date numbers and guidelines as the virus spreads.

Overview of the Virus

Let’s take a look at viruses in general and SARS-CoV-2 in particular. First, bacterial infections are different from viral infections. Antibiotics can be used against bacterial infections, such as bacterial pneumonia. Unfortunately, there is not an equivalent combatant to viral infections. Antiviral drugs are only available for certain viral infections—for example Tamiflu for the flu—but most antiviral drugs must be taken soon after a person is infected. The other way to combat viral infections is vaccines.

Things get confusing when viral infections cause bacterial infections, as can be the case with respiratory viruses like the influenza virus. Influenza can cause pneumonia. Pneumonia itself can be either viral or bacterial. Recent studies indicate that while the strain that caused the 1918 flu pandemic was particularly deadly, many of the victims probably died of bacterial pneumonia. Another contributing factor to the high mortality rate was World War I. Soldiers were living in sometimes crowded, squalid conditions with poor sanitation.[1] This is the opposite of the CDC’s recommendations for curbing the spread of COVID-19: social distancing and hand washing. Additionally, COVID-19 appears to cause viral pneumonia in some people.[2]

So what about the SARS-CoV-2, or the coronavirus? Scientists and news outlets call this a “novel” virus, which is true, but the virus itself is part of a family of viruses known as “coronaviruses.” Corona is Latin for “crown,” and is also the name of the diffuse plasma layer that surrounds stars, including the sun. The coronavirus has spike-like protrusions, like a crown, coming out of it. SARS-CoV and MERS-CoV are examples of viruses in the coronavirus family (Influenza is not a coronavirus).

The coronavirus family, like all viruses, has a strand of RNA housed within a membrane casing. The casing has proteins on its surface (the corona part on coronaviruses) that attach to receptors on the cell surface. Once the virus attaches to the cell, it enters the cell and commandeers the cell’s machinery to replicate the virus’s RNA and viral proteins. The new virus is released from the cell and moves on to infect the next cell in the body. As the virus continues to infect cells, the human body’s immune system mounts an attack against the virus. This leads to symptoms, such as a fever. Children seem to get mild symptoms, and people with other underlying conditions seem to get more severe symptoms. Scientists are still trying to figure out why COVID-19 causes some people to have more severe symptoms while others do not.

The virus’s RNA can undergo many mutations even within a single host. In places like Seattle, for example, epidemiologists have tried to trace the spread of COVID-19 by looking at differences in point mutations in different individuals who have contracted the virus. However, this is a time-consuming process that may or may not show the exact path of the virus.

Ethical Issues

From a bioethics standpoint, there are several issues. Of most importance is the responsibility we have to protect the vulnerable, which includes not over-taxing our medical system so people can get the support care that they need.

Another issue that was seen in Wuhan and now Italy is allocation of scarce medical resources. Disaster ethics deals with situations in which a crisis has led to a large number of people needing medical help. In the case of disasters, decisions must be made on who should receive medical care until more can arrive.

Related to scarce medical supplies is protecting medical workers so they are not infected. This involves providing the needed protection to ensure they are not infected, as well as reinforcements so medical workers can rest.

The CDC has websites with case numbers, how to prevent the spread of the virus, and additional guidelines for those that may be sick. The CDC continues to update their websites as they get new information.

More Information

Below are links to several common questions regarding COVID-19 and answers from the CDC website:

  1. Up-to-date information on Coronavirus Disease 2019 (COVID-19)
  2. Symptoms of the COVID-19
  3. What to do if you are sick
  4. Information regarding testing
  5. Number of cases and updates
  6. Travel guidelines
  7. Recommendations for schools, workplaces, and community locations
  8. Frequently Asked Questions

 

Encouragement for those on the Front Lines of Medicine (from Friends of CBHD)

The Impossible Ethics of Pandemic Triage
April 3, 2020, The New Atlantis
Aaron Kheriaty, MD, University of California Irvine School of Medicine

This is a very helpful and readable introduction to and overview of some of the most difficult questions, truly life and death decisions, that may come to face healthcare clinicians over the next few weeks. Dr. Kheriaty describes the complexity involved in various scenarios and provides words of comfort and encouragement to those who may face them.

Exhortation to My Former Students (Video)
March 26, 2020, YouTube
Jeffrey P. Bishop, MD, PhD, St. Louis University

Dr. Bishop encourages those practicing medicine to rely on the training they’ve received and the experience they gained to guide them through this time of pandemic.

Respirators, Our Rights, Right and Wrong: Medical Ethics in an Age of Coronavirus
March 22, 2020, New York Daily News
Daniel Sulmasy, MD, PhD, Kennedy Institute of Ethics

A helpful and encouraging overview of the pandemic and the ethical implications it brings to bear on those in healthcare and government as well as on those of us in the general public.

Battlefield Promotions
March 18, 2020, The New Atlantis
Aaron Kheriaty, MD, University of California Irvine School of Medicine

Dr. Kheriaty addresses third- and fourth-year medical students who are entering the field of medicine in the midst of a situation not seen unprecedented in the history of modern medicine.

New Articles on Ethics and COVID-19

In the midst of the current pandemic, a number of scholarly articles are being developed and published on a wide range of topics related to coronavirus, COVID-19, SARS-CoV-2. In an effort to stay abreast of the literature, CBHD staff are attempting to compile something of an annotated bibliography of new articles that discuss ethical issues that may or will arise. 

If you know of new articles that may be applicable, please forward them to research@cbhd.org.

Ethics of controlled human infection to study COVID-19
May 7, 2020, Science
Seema K. Shah et al.

Given the extraordinary nature of the pandemic, our framework and analysis support laying the groundwork for SARS-CoV-2 controlled human infection studies (CHIs)—for example, by developing a challenge strain, drafting consensus protocols that address ethical concerns, and engaging stakeholders to enhance their social value, minimize risks, and build public trust.

End-of-life Decisions and Care in the midst of a Global Coronavirus Pandemic
April 2, 2020, Intensive and Critical Care Nursing
Editorial 

This essay addresses the question, “how do health professionals prepare for providing large scale end-of-life care in critical care in a pandemic?” The authors highlight several resources from the literature on H5N1 and H1N1 as well as “The COVID 19: Rapid Guidance for Critical Care” and others. They also emphasize the need to address the longer-term effects the current crisis situation will have on healthcare providers once the acute phase of the pandemic has passed. Notably, the article asserts in its introductory remarks that the key tension in the ethics of resource allocation in pandemic involves tradeoffs between autonomy and utilitarianism. It may well be worth considering whether framing the ethical questions differently might help to address at least some of the concerns this article raises.

Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line
March 18, 2020, New England Journal of Medicine
Lisa Rosenbaum, M.D.

Based on interviews with physicians practicing in Italy, the article describes the realities of caring for far more patients than hospitals, clinicians, and other caregivers are equipped to handle, which leads to excruciating decisions regarding limited resources such as ventilators. 

Fair Allocation of Scarce Medical Resources in the Time of Covid-19
March 23, 2020, New England Journal of Medicine
Ezekiel J. Emanuel, M.D., Ph.D., Govind Persad, J.D., Ph.D., Ross Upshur, M.D., Beatriz Thome, M.D., M.P.H., Ph.D., Michael Parker, Ph.D., Aaron Glickman, B.A., Cathy Zhang, B.A., Connor Boyle, B.A., Maxwell Smith, Ph.D., and James P. Phillips, M.D. 

Examines the allocation of various kinds of resources such as personal protective equipment (PPE), hospital beds, ICU beds, pharmaceuticals, ventilators, etc. in the current pandemic. The authors emphasize four values, “maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off,” and make six recommendations: “maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients.” Recommends the use of triage officers or committees to lessen burdens on front-line personnel. 

Allocating Medical Resources in the Time of Covid-19
April 28, 2020, New England Journal of Medicine
Various Authors

Responses to “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” NEJM, March 23, 2020. 

The Toughest Triage — Allocating Ventilators in a Pandemic
March 23, 2020, New England Journal of Medicine
Robert D. Truog, M.D., Christine Mitchell, R.N., and George Q. Daley, M.D., Ph.D.

Recommends the use of triage committees for decisions regarding mechanical ventilation in this time of pandemic.

References

[1] Richard Gunderman, “Ten Myths about the 1918 Flu Pandemic,” Smithsonian Magazine, March 17, 2020, www.smithsonianmag.com/history/ten-myths-about-1918-flu-pandemic-180967810/.

[2] Cynthia Liu et. al., “Research and Development on Therapeutic Agents and Vaccines for COVID-19 and Related Human Coronavirus Diseases,” ACS Central Science (March 12, 2020):  pubs.acs.org/doi/10.1021/acscentsci.0c00272.