Together we stop the pandemic #COVID-19
Together we stop the pandemic #COVID-19

Ethical problems in children during COVID-19 outbreak


Fahisham Taib,

Paediatric Department, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan

Pengarang Koresponden:

Dr. Fahisham Taib

Paediatrician & Medical Lecturer
Paediatric Department, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia Email:

The SAR-CoV2 infection has affected more than 6 million of people around the globe with current mortality to up to 372000 lives1. It was reported that among those infected, approximately less than 5% were children under 18 and mostly were due to close contact2. In Malaysia, 317 cases were confirmed by Ministry of Health of Malaysia3. Significant difference between the frequency of COVID-19 in children in comparison to adult was due to exposure to the public area. There is uncertainty on the future course of the disease and how the global pandemic will pan out. Most of COVID-19 in children runs a milder course, however, there are increasing reports of presentation mimicking Kawasaki disease4.

It is expected during the peak of disease spread, as previously seen in Italy and America, the death tolls may be on the increase on daily basis. Children would be facing in similar scenario.  The Ministry of Health of Malaysia has introduced clinical staging the illness into– those who are asymptomatic, symptomatic with no pneumonia, symptomatic with pneumonia, symptomatic with pneumonia and requiring oxygen supplement and critically ill with severe respiratory compromised and multi organ involvement5. Children who are suspected to have COVID-19 infection are labelled have Acute Respiratory Illness (ARI), Influenza-Like Illness (ILI) or Severe Acute Respiratory Illness (SARI)6. The influx of patients hypothetically may cause hospital resources to be exhausted. There are several ethical problems during this pandemic that require serious consideration in paediatric population (Summarize in Table 1)7;

Issue related to individual child

  • Physicians should offer clinical help according to needs and appropriateness in treatment. This determination of the decision making depends on the beneficence (does it benefit the child?) and distributive justice (does it benefit others as well?)
  • The presence of COVID-19 associated disease in itself should not give a patient either higher or lower priority for treatment. The principle of justice should be applied even if the child in the dying state. There is potential conflict between preserving society as a whole and protecting its weakest members. In public health emergencies, sacrificing physicians’ self-interest in favour of the common good is an essential.
  • Everyone matters equally but not everyone may be treated the same. Children ought to have equal access to health care resources (equality). Those who most need and require the greatest benefit from resources ought to be offered resources preferentially (equity). Resource allocation decisions should be guided by the ethical principles of utility and equity. An equal distribution of benefits and burdens may be considered fair, but in others, it may be fairer to give preference to groups that are worse off, such as the poor, the sick, or the vulnerable. Resources ought to be distributed to maximize benefits to the greatest number (utility, and efficiency).
  • Decisions should be individualised – this means that decisions must take into account patient’s individual characteristics, preferences, and prognosis. Decision-making should be ethically consistent. Different decision makers should reach similar decisions about treatment for the same patient. The decisions must be consistent across the populations regardless of their human condition (e.g. race, age, disability, ethnicity, ability to pay, socioeconomic status, pre-existing health conditions, social worth, perceived obstacles to treatment, past use of resources).
  • Rationing limited resources e.g. ventilators based on differences in socioeconomic status, quality of life, life-expectancy or first-come, first-served should be avoided. The clinical considerations are to help identify those most likely to benefit from access to a ventilator. Higher priority should be given to patients based on those who have the highest ‘capacity to benefit quickly’. Treatment should be directed to patients who have a higher chance of survival.

Issue related to institutional

  • Triaging allows paediatric patients admitted for emergency intervention (Table 2)8. Having a background that children would present in a milder form of COVID-19 infection, justification must be based on a various factors. The medical motives of triage are - sufficient medical resources, personnel with medical intervention capacity, and a system that will meet the medical necessities.
  • If people (physicians/ paediatricians) are asked to take risks (being the front liners), or face increased/disproportionate burdens during a pandemic influenza, they should be supported, and the risks and burdens should be minimized as far as possible. Priority for front liners are those with the likelihood to get occupational exposure leading to risk of infection-related mortality or serious morbidity to get adequate N95 and PPE protection
  • Decisions to refuse ICU admission, or withdraw treatment in order to allow admission of patients who are more likely to survive, may be needed. There should not be specific criteria such as socially disadvantaged or chronic illnesses in the community that are excluded.
  • When treatments are limited, prioritisation is ethically required. While prioritisation takes into place, hospital administrators should also take all appropriate steps to increase capacity and availability of treatment.


Issue related to social policy

  • Measures implemented should be proportionate to the level of threat and risk. This includes home quarantine (exposed people may be forced into isolated quarantine to prevent the spread of SARS CoV2); restriction of mass gatherings; restriction of travel within and outside the state and country; closure of childcare; restriction on hospital visit and policy related to separation between parent and children during admission
  • As a result from containment, mitigation and contagion planning, many will lose jobs due to their dependency on daily life and wages. Hospital needs to be sensitive on the social policy rules during the pandemic.
  • Any plan related to admission, management, discharge and follow up must be adapted to new knowledge and evidence. This should be transparent and spelled out to minimize the risk involved to public inspection.
  • Limited supply of treatment, food items and potentially vaccine in the future may influence the survival of the population. Although individual decision making will be implemented, however, many factors have to be considered to give chance equally to the all.


The “clinical reasonableness” or “soft utilitarian” approach is one of the approach in the face of resource scarcity has been practiced in Italy during the peak pandemic time. Though many guidelines did not suggest that age or other specific factors should be the determining factor for resource allocation, it is acknowledged that an age limit for ICU admission may ultimately need to be set. Under the difficult circumstances, rationing is often better tolerated when done silently9. In disaster relief studies, respecting human rights, culture, beliefs, structures, and customs of the communities should be considered. Recent commentary on ethical decision making still focusing on four values as per table 310. Difficult decision-making are made on a regular basis in both public health and clinical medicine practice; however, in the process for decision making, including the framework and reasoning that support ethical choices, may not always be clearly articulated.

Table 1: Reasons for choosing patients during the pandemic7




Medical measures

Medical needs

Sickest first

Patients medical needs

Urgency of need

Risk of serious sequelae

Clinical evaluation result

Victims’ underlying illnesses and injuries

Likely to benefit

Possible benefit to the patient

Maximize positive outcomes

Medical effectiveness



Medical prognosis

Pre-existing conditions

Acute versus chronic conditions

Non-medical measures

Saving the most lives (Utilitarianism)

Save the most lives

Maximize the number of lives saved

Youngest First

Lifecycle principle

Save the most life years

Saving better QOL

Change in quality of life (QOL)

Save the most quality of life-years’

Perceived QOL

Protecting vulnerable groups

Protecting children, women, pregnant women

Greater vulnerability

Promoting social justice

Differences in social vulnerability

Saving function of society

Saving first responders

Public safety staff, and government decision-makers

Irreplaceability in the critical infrastructure workforce

Most productive people

Required resources

Consideration of availability of resources

Requiring resources that cannot be provided

Resource conservation

Expected duration of resources

The required resources

Unbiased selection


First come, first served


Table 2: Assessment of triage factors8



High risk (eg >80%) of dying or of suffering serious harm if patient does not receive treatment in the near future


Moderate risk (eg 30-70%) of dying or of suffering serious harm if patient does not receive treatment in the near future


Low risk (eg <20%) of dying or of suffering serious harm if patient does not receive treatment in the near future



Patient has a high chance (eg. >80%) of survival if provided with treatment


Patient has a moderate chance (eg 30-70%) of survival if provided with treatment


Patient has a low chance (eg <20%) of survival if provided with treatment

Likelihood of rapid benefit


Patient has a high probability (eg >80%) of requiring only a short duration of support (ie intensive care admission) if provided with treatment


Patient has a moderate probability (eg 30-70%) of requiring only short duration support if provided with treatment


Patient has a low probability (eg <20%) of requiring short duration of support if provided with treatment (ie prolonged duration is likely)

Table 3: Ethical Values to Guide Rationing of Absolutely Scarce Health Care Resources in a Covid-19 Pandemic10

Ethical values and Guiding principles

Application to COVID-19

Maximize benefits

·         Save most lives

·         Save most life-year – maximize prognosis

Receives the highest priority

Receives the highest priority

Treat people equally

·         First come, first served

·         Random selection

Should not be used

Used in patients with similar prognosis

Promote and reward instrumental value (benefit to others)

·         Retrospective – priority to those who have made relevant contributions

·         Prospective – priority to those who are likely to make relevant contributions

Gives priority to research participants when other factors such as maximizing benefits are equal

Gives priority to healthcare workers

Give priority to the worst off

·         Sickest first

·         Youngest first

Used in aligns with maximizing benefit

Used in aligns with maximizing benefit


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