Ethical problems in children during COVID-19 outbreak

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.

Conclusion

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

Table 2: Assessment of triage factors⁸

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

References

• COVID-19 Worldwide Dashboard - WHO Live World Statistics‎ https://covid19.who.int/?gclid=Cj0KCQjwlN32BRCCARIsADZ-J4sIARYi7-TkuQ7Y4gzxAAHlNydPW06IkzziLcpthHGYj5FLRjyv4wEaAuH1EALw_wcB

• UNICEF. Epidemiology, Spectrum, and Impact of COVID-19 on Children, Adolescents, and Pregnant Women [Available from: https://mpaeds.my/wp-content/uploads/2020/07/UNICEF-IPA_COVID_brief_WEB_29June.pdf

• The Star. Covid-19: 317 cases detected among children under 12 years old. [Available from: https://www.thestar.com.my/news/nation/2020/05/16/covid-19-317-cases-detected-among-children-under-12-years-old

• Chiotos K, Bassiri H, Behrens EM,Blatz AM, Chang J, Diorio C, Fitzgerald JC, Topjian A, John ARO. Multisystem Inflammatory Syndrome in Children during the COVID-19 pandemic: a case series, Journal of the Pediatric Infectious Diseases Society, , piaa069, https://doi.org/10.1093/jpids/piaa069

• Garis Panduan Pengurusan COVID-19 di Malaysia (Updated May 2020) No.5/2020 https://www.moh.gov.my/moh/resources/Penerbitan/Garis%20Panduan/COVID19/Annex_2e_Clinical_Management_22032020.pdf

• Hospital USM Guideline for COVID-19. https://staffusm.sharepoint.com/sites/covid19/SharedDocuments/Forms/AllItems.aspx

• Ghanbari V, Ardalan A, Zareiyan A, Nejati A, Hanfling D, Bagheri A. Ethical prioritization of patients during disaster triage: A systematic review of current evidence. International Emergency Nursing 2019; 43: 126–132

• Ethics framework for use in acute paediatric settings during COVID-19 pandemic. https://www.rcpch.ac.uk/resources/ethics-framework-use-acute-paediatric-settings-during-covid-19-pandemic

• Rosenbaum L. Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. The New England Journal of Medicine 2020. DOI: 10.1056/NEJMp2005492

• Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 2020. DOI: 10.1056/NEJMsb2005114

• Biddison ELD, Faden R, Gwon HS,Mareiniss DP, Regenberg AC, Schoch-Spana M, Schwartz J, Toner ES. Too Many Patients.A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. CHEST 2019; 155(4):848-854

• O’Laughlin DT, Hick JL. Ethical Issues in Resource Triage. Respir Care 2008;53(2):190 –197.

• Torda A. Ethical issues in pandemic planning. MJA 2006; 185: S73–S76