Bioethical conflicts over social distance in times of pandemic

Abstract

This article reflects on social distancing measures in the covid-19 pandemic scenario, based on a bioethical perspective in public health. The research also discusses conflicts between respecting social distancing measures and individual freedoms, using reports available from online newspapers to exemplify relevant arguments and contribute to the overall debate. The topic was analyzed on the basis of principlism and social bioethics, in an attempt to uncover elements that may guide the decision-making process. The article concludes that bioethics is an instrumental tool for healthcare users and professionals, emphasizing the State’s responsibility to prevent diseases and ensure health. Finally, we argue that the need to deal with immediate public-health risks should prevail over individualism.

Ethics; Bioethics; Coronavirus infections; Public health

Resumo

Este artigo objetiva refletir sobre a medida de distanciamento social no cenário de pandemia de covid-19 sob o enfoque da bioética em saúde coletiva. Trata-se de estudo reflexivo que discute o conflito entre o respeito às medidas de distanciamento social e a liberdade individual, utilizando reportagens disponíveis em jornais on-line para exemplificar os argumentos envolvidos e contribuir com a reflexão. A temática foi analisada a partir do principialismo e da bioética social, buscando elementos que possam guiar o processo decisório. Conclui-se que a bioética é instrumental para a reflexão de usuários e profissionais da saúde, e ressalta-se a responsabilidade do Estado em prevenir doenças e garantir a saúde. Propõem-se que o risco para a saúde pública deve prevalecer sobre o individualismo.

Ética; Bioética; Infecções por coronavírus; Saúde pública

Resumen

Este artículo pretende reflexionar sobre las medidas de distanciamiento social en el escenario pandémico de la covid-19 bajo el enfoque de la bioética en salud pública. Se trata de un estudio reflexivo que discute el conflicto entre el respeto a las medidas de distanciamiento social y la libertad individual, utilizando informes disponibles en periódicos en línea para ejemplificar los argumentos involucrados y contribuir a la reflexión. El tema fue analizado desde el principialismo y la bioética social, buscando elementos que puedan guiar el proceso de toma de decisiones. Se concluye que la bioética aparece como un instrumento para la reflexión de usuarios y profesionales de la salud y se enfatiza la responsabilidad del Estado en la prevención de enfermedades y garantía de la salud. Se propone la prevalencia del riesgo de salud pública sobre el individualismo.

Ética; Bioética; Infecciones por coronavirus; Salud pública

The severe acute respiratory syndrome caused by Sars-CoV-2, known as “coronavirus disease 2019” (covid-19), was first reported in the city of Wuhan, Hubei Province, China, in December 2019¹ , ² . The disease spread throughout the world, eventually reaching Latin America³and prompting governments to take several measures to combat the pandemic. Among them, non-pharmacological physical interventions, such as hand hygiene, respiratory etiquette, and social distancing, stand out as the most efficient to date⁴.

Distancing measures include the prolonged closure of schools, religious temples and tourist attractions, remote work, and the suspension of sports competitions, among other actions adopted by countries to promote physical distancing and avoid crowds. A study carried out in Wuhan concluded that non-pharmacological interventions based on continued physical distancing have a strong potential to reduce the covid-19 epidemic peak, as well as the number of overall cases⁵.

Evidence indicates that the virus spreads by direct, indirect (contaminated surfaces or objects), or close (at a distance of one meter) contact with infected people, when secretions such as saliva or infectious respiratory droplets – expelled by coughing, sneezing, talking or singing – come into contact with a non-infected person’s mouth, nose, or eyes⁶. Although it was not possible to determine the impact of each individual measure, a study observed that the combination of interventions (diagnostic tests, clinical management, rapid isolation of suspected cases, confirmed cases and contacts, and, most notably, restrictions on mobility) was clearly successful in reducing the local transmission of covid-19⁷.

The overloading of human and material resources is one of the conditions for a public health crisis⁸. In this sense, outbreak control measures help to mitigate disease transmission in order to delay the pandemic’s peak and reduce its timescale⁵. On the other hand, if these restrictions are prematurely and suddenly removed, new peaks may occur.⁸

In healthcare, bioethics has been an important resource for decision-making and mediation of ethical problems⁹. In the current context, one of these dilemmas has been the conflict between maintaining social-distancing recommendations as a way to control the pandemic (collective consciousness) and individual freedoms (personal consciousness). In other words, in view of social distancing, autonomy to organize individual and social life according to one’s own choices and beliefs becomes limited.

In this study, bioethics is approached not as a model of philosophical ethics, but as a form of applied ethics that has human action as its starting point¹⁰– concrete actions related to life, health, and the environment. Thus, we must discuss the relation between bioethics and public health in its social, subjective, contextual, and environmental determinants⁹.

In a pandemic, the rapprochement between bioethics and public health may contribute to decision-making by encouraging reflection on how to ensure values such as responsibility, transparency, and trust – which need to be carefully considered by government officials. In this sense, this study proposes a reflection on social distancing as a measure for the covid-19 scenario under the prism of public-health bioethics.

Method

This study aims to answer the following research question: is it reasonable to impose social distancing, at the expense of individual freedom, as a way to control the covid-19 pandemic? This text was based on personal reflections and dialogues with authors in the field of public health and bioethics, and also reports available online to obtain examples and contributions.

These reports were found on Google in September 2020, by searching for the following phrase: “ morador que testou positivo para covid-19 é preso ao sair de casa ” (resident who tested positive for covid-19 is arrested while leaving home). Among numerous reports that circulated in the media regarding this event, we selected three¹¹ - ¹³ for being representative of our object of study: the imposition of restrictions on the freedom of those tested positive for covid-19. The reports selected were analyzed according to the bioethical principles proposed by Beauchamp and Childress¹⁴and social bioethics¹⁵.

Bioethical conflicts: social distancing and individual freedoms

Even though they have been used for centuries, due to their ability to restrict the spread of diseases, social-distancing measures remain the main instrument of public-health intervention in the 21st century. To maximize their benefits, these measures must be planned and implemented right at the beginning of the epidemic¹⁶. In situations where social distancing is required, society adopts a mode of exceptionality, and political measures that would never ordinarily be accepted come into consideration¹⁵.

Since covid-19’s transmission via respiratory droplets needs a certain proximity between people, social-distancing decreases the interaction between individuals to slow down the spread of the virus¹⁷. These procedures are usually adopted when the community transmission stage has already been reached, that is, when inter-case connections can no longer be traced and isolating those who have been initially exposed is no longer sufficient to stop further transmission¹⁸. Moreover, social distancing allows governments to structure and expand the healthcare network’s response capacity.

A study found that the early adoption of social distancing and the suspension of face-to-face school classes influenced the course of transmissibility, resulting in fewer covid-19 deaths in certain countries¹⁹. In Singapore, South Korea and Japan, the immediate implementation of social distancing, together with strict case management and mass testing have helped to contain the virus spread¹⁹.

Until now, March 2021, the pandemic has already killed more than two million people worldwide⁶and, according to data from the Ministry of Health²⁰more than 260,000 Brazilians have died. Thus, to contain the pandemic, non-pharmacological public health measures must be implemented at all costs.

In Brazil, the Ministry of Health¹⁸presented a few social distancing strategies. The first was total lockdown, which provides the highest level of safety by interrupting a wide range of activities for a short period of time. During what is effectively a blockade, all entrances to the isolated perimeter are closed by security workers, and no one is allowed to enter or leave¹⁸.

Generalized social distancing, on the other hand, requires people to stay at home¹⁸. The strategy aims to restrict contact between people, maintaining only essential services, a more rigorous hygiene, and avoiding crowds. Increased distance is essential to avoid uncontrolled acceleration of contagion levels, which may result in the collapse of the healthcare system, with more demand for beds and respirators than hospitals are able to supply¹⁸.

In selective social distancing, only a few groups are isolated: symptomatic people and their home contacts, as well as groups at greater risk of developing the disease or those who may have more severe symptoms, such as older adults and people with chronic diseases¹⁸. With this strategy, people under 60 years of age are allowed to circulate freely, albeit maintaining social distancing and increased hygienic care, as long as they are asymptomatic. This measure can be adopted as a transitory model to avoid an abrupt transition from a more restrictive situation to a less restrictive one¹⁸.

When regarded as a public-health instrument, bioethics may help us to reflect on and confront the covid-19 pandemic, allowing for a rational development of strategies founded on human rights, collective responsibility, precautionary principles and intergenerational solidarity, aiming to avoid further harm to human health²¹. In the covid-19 pandemic, any health-related ethical decision must fulfill the human-rights premises of international agreements, be considered in light of bioethics, and remain respectful of each country’s laws¹⁵.

In Brazil, warning messages about the importance of social distancing were disseminated immediately after the first cases of covid-19 appeared. However, newspaper reports pointed to conflicts between freedom, individual rights and the need for State intervention: “Homeless people with coronavirus flee from shelter isolation and are arrested in MT”¹¹; “Young man with covid-19 leaves quarantine, goes to party and soccer match and is arrested in Rio Grande do Sul”¹²; “Public Prosecutor’s Office to investigate man with covid-19 who disrespected social distancing rules and visited restaurant in Santa Catarina”¹³.

Similar news reports have been circulating on the internet since the end of March 2020, when the pandemic began to spread throughout the Brazilian territory. They present cases of people who refused to comply with the social distancing measures recommended by health professionals, and ended up suffering government sanctions. The issue of whether it is reasonable to impose social distancing at the expense of individual freedom to control the covid-19 pandemic is not circumscribed to the field of bioethics, also having implications for public health. Thus, this article points out some possible avenues for decision-making, which may be approached in a more in-depth manner in future research.

Concepts such as “individual freedoms,” “autonomy,” “self-determination” and “collective interest” are important for this discussion. Here, individual freedom is regarded as the fundamental principle of adulthood. Its basis lies on the fact that, as Mill²²argues, power can only be rightfully exercised against the will of any member of a civilized community in the interest of preventing harm to others. In other words, individuals must be free to decide their own destinies, as long as their actions do not cause harm to others.

The term “autonomy” refers to self- -governance. For individuals to be autonomous, that is, able to make their own choices, they must be capable and free to act intentionally²³. Personal autonomy consists of self-regulation without interference or control by others. People who exercise autonomy can make decisions on matters that affect their life, health, physical and mental integrity as well as their social relationships, according to their expectations, needs, priorities, beliefs and values²⁴.

Self-determination, on the other hand, represents a set of behaviors and skills that endow a person with the ability to act intentionally in regards to their future. For this, individuals must rely on four basic premises: to be able to act autonomously, to have self-regulating behavior, to respond to events in a psychologically empowered manner, and act in a self-realizing manner²⁵. Social distancing also has ethical implications, considering the conflicts of interest that lie between the individual right of self- -determination and the collective demands towards “flattening” the covid-19 curve.

The principle of collective interest is difficult to define, even though it is expressed in the Brazilian Constitution²⁶. Such concept rests on the pursuit of the common good and on respect for the dignity of the human person. It is the foundation, criterion and limit of all public administration actions. In other words, it is an abstract but constitutionally grounded notion that refers to the ideal of a “common good”²⁷. When this notion is at stake, collective interest takes precedence over individual interest²⁸, as in pandemic situations. Under these circumstances, the strict restriction of individual freedoms may be legitimate, since there are laws that enable measures for protecting the community – in the current context, such actions are established by Law 13,979/2020²⁹. Thus, it is understood that autonomy should not be respected in an excessively individualistic conception, as it denies people’s social nature, disregarding the influence of the collective on individual choices and attitudes²⁴.

Thus, “collective public-health actions” are aimed at improving the health of the population³⁰, achieving general, global and impersonal effects. In most cases, these actions have preventive characteristics to avoid future health issues³¹. In health professionals’ everyday practices, bioethics involves a non-coercive reflection on decision-making based on the exercise of freedom, with no prejudices and respecting divergences³². Bioethics is the foundation of the relationship between health professionals and the community, and its actions is aimed not at causing harm or damage, but rather at ensuring the autonomy and well-being of each and every person.

A document published in 2002 by Sociedade de Liderança em Saúde Pública (Public Health Leadership Society)³³upholds the idea that public health practices can only be ethical when they respect the rights of individuals and the community. In this sense, one possible assumption is that social distancing measures to protect the health of the population enter into conflict with individual freedom and self-determination³⁴.

Healthcare practices cannot be thought in dissociation from bioethics, as this field has a prominent role in contributing to decision-making in a pandemic situation. After all, in such a situation the principles, values and rights of people and society in general confront each other³⁵. Since the application of ethics to the public health area is meant to tackle social challenges in the health-disease process, it is certainly possible to speak of ethical problems within the context of the public health. These dilemmas disturb the conscience of health professionals; as sources of conflict between values and duties, these challenges have several possible solutions, and finding the best one requires careful consideration and deliberation³⁶.

Albeit often present in everyday practice, the ethical problems of primary healthcare are sometimes difficult to identify for being more subtle than issues that emerge in extreme situations³⁷. This exacerbates the complexity of ethical issues in public health, expanding the range of implicated values. Moreover, ethical decision-making is related to the ethical competence and autonomy of health professionals³⁶.

In this context, an approach to the Covid-19 scenario from the standpoint of public health poses conflicting values: on the one hand, social distancing measures must be respected so that the demands of collective responsibility are met; on the other, individual freedoms and mobility must also be observed. Understanding these conflicting values allows us to comprehend that there is no “pre-defined” solution; on the contrary, we should continually and creatively re-evaluate and propose strategies to discover far-reaching alternatives. Likewise, it is important to consider that each value in conflict has intrinsic importance and, therefore, ethical decision-making is necessarily challenging. Therefore, an ethical problem entails tensions involving one or more values, and since there is no clear answer as to which one should be privileged, this creates the need for further reflection.

In this sense, bioethics emerged to address moral and ethical conflicts that arise within the scope of health actions and biomedical sciences²⁸. This field of knowledge should be considered a legitimate and efficient tool for the critical analysis of social distancing measures, and also an aid to ethically justified decision-making²⁸. To this end, this study briefly presents some bioethical questions that motivated a reflection based on principlism and social bioethics.

Principlist bioethics encompasses four widely publicized precepts – autonomy, beneficence, non-maleficence and justice¹⁴–, used to approach problems in human relations. In the public health sphere, these precepts cannot be applied blindly and in a close-minded manner, for this would nullify their collective and social specificity³⁸. While respecting these principles is essential, in pandemic situations these concepts acquire new aspects³⁹. Their application can be thought of as a prima facie obligation²⁶, that is, an obligation that must be fulfilled unless it conflicts with another of equal or greater strength²⁴.

These principles come into conflict mainly in the context of collective actions, as in social distancing measures. For example, if a person with covid-19 autonomously chooses to go out into the street – threatening public health, causing damage to third parties and putting pressure on scarce resources such as intensive care unit beds –, their autonomy enters into conflict with the interests of collective protection, since, in this case, the maintenance of individual autonomy puts the whole community at risk²⁸. In these situations, where the common good is at stake, collective interests take precedence over individual interests. Thus, in the pandemic, for instance, the restriction of individual freedoms may be legitimate⁴⁰considering the benefit it provides to individuals themselves or to the community as a whole²⁸.

Treating individual freedom as the only relevant value would call into question the principle of non-maleficence, which imposes an obligation to minimize risks to the population³⁹. Causing harm or damage to another person is morally reprehensible, meaning that this principle is applicable to all people⁴¹. To attribute the decision on whether to adhere to social distancing measures entirely to the individual would be completely opposed to this precept, because this would put the entire community at risk. In this case, there is a tension between individual interest and collective good, in which individual freedom (autonomy) must be subjected to the interests of the collective (common good)⁴². Therefore, one cannot be afraid to apply emergency measures in pandemic situations, nor to remove them if the context changes.

Likewise, the principle of beneficence entails a duty to treat the sick and aid society. This precept establishes a moral obligation to help others, promoting their interests as legitimate and important, even if its application is conditional or situation-dependent⁴¹. Beauchamp and Childress¹⁴consider that the principle of beneficence needs more than non-maleficence: agents must carry out positive action to help others, instead of merely abstaining from committing harmful acts.

In the case under analysis, the principle of justice also limits autonomy by forcing people to comply with social distancing, hampering the right to come and go¹⁵. This principle deals with the fair distribution of social benefits, and in a pandemic context, resources are limited on a global scale³⁹. The concept of equity is commonly aggregated to it – meaning to give each person what they are due, according to their needs⁴³. According to Schramm⁴⁴, helping those who do not have the means to survive with dignity is essential for the concrete observance of the principle of justice, since applying the value of equity as a means of achieving equality is a sine qua non condition for the effectiveness of this principle. Thus, justice presupposes positive government intervention in health.

To this end, decision-making must surpass the perspective of individual ethics, as personal will may have maleficent consequences for the community. This is a difficult position, because it involves depriving people of individual freedoms in the name of collective health. Social distancing exposes the tension between society’s interests in protecting the health of its citizens and their civil liberties, such as privacy and free movement¹⁶, putting their autonomy in check.

Although civil liberties are protected by the Universal Declaration of Human Rights ⁴⁵, large-scale threats to public health may need extraordinary governmental measures. For prudent actions, the benefits to the collective must outweigh the potential burdens or harms to individuals¹⁴. Thus, social distancing should be voluntary whenever possible and employ the least invasive means available.

As part of a different school of thought, Schramm and Kottow⁴⁶argue that the ethical problems of collective health practices cannot be satisfactorily understood using the principlist model, which is more suitable for discussing conflicts of clinical bioethics. On the other hand, social bioethics, a field that emerged in Latin America during the 1990s, discusses themes related to socioeconomic vulnerability, such as lack of access to healthcare, social exclusion, hunger and violence¹⁵.

Thus, social bioethics is a legitimate and efficient tool for the critical analysis of social distancing measures. Its main contribution in the current pandemic context lies in its focus on socially fragile groups, promoting public policies that prioritize protecting the most vulnerable segments¹⁵. This bioethics approach encourages ethically justified actions within the scope of public health.

The main issues evidenced in the selected news reports¹¹ - ¹³ can also be assessed on the basis of social bioethics, as they pose a conflict between collective and individual interests. Brazil has a significant housing deficit, with millions of homeless people as well as people living in precarious conditions, including lack of access to drinking water and basic sanitation. These factors favor the spread of various diseases, including covid-19⁴⁷.

Government measures must consider the territory’s various vulnerabilities. Differences and inequalities between various population groups need to be duly examined, both to understand the difficult context people are going through as well as to collectively find ways to cope with the epidemic⁴⁷. Healthcare organizations that participate in Frente pela Vida ⁴⁷point out actions that can be taken by governments, such as accommodating homeless people who need isolation in appropriate spaces and the provision of hand sanitizer and hygiene products for people in situations of vulnerability.

According to social bioethics, decision-making parameters – both regarding clinical context and definition of protocols, rules and public policies – must prioritize vulnerable and excluded social groups. In this sense, studies such as the one by Bezerra and collaborators⁴⁸can also aid in planning. The authors identified factors that interfere in social distancing, including differences in living conditions between people with higher and lower incomes.

Campos⁴⁹argues for preventive actions that do not subject users, but rather include them, emphasizing that it is not enough to improve the reported data, as we must also ensure that the various sectors involved in the project have capacity for decision-making. Coping with the covid-19 pandemic requires participation by society in social distancing measures. But genuine adherence and effective participation in government initiatives on the part of society at large can only be achieved if people can understand that prevention is an individual responsibility⁴⁹.

Research carried out after the Sars epidemic shows that people comprehend and accept the need for restrictive measures. Many perceive them as a civic duties, and may sacrifice their right to freedom of movement⁴⁰. State measures must be implemented in an open, fair and legitimate manner; society has the right to know the reasons why the public health field has decided to restrict freedoms³⁴.

The British Columbia Ministry of Health⁵⁰released an ethical analysis of care in times of covid-19, stating that society has the right to protect itself from immediate harms or future threats. Thus, the government can intervene in the rights of individuals, protecting the community from harm. But authorities must impose the least burden on personal self-determination necessary to achieve the objective of containing the pandemic, that is, one cannot exchange all freedom for security¹⁶. The principle of proportionality requires that restrictions on individual freedom and measures to protect the public from contamination do not go beyond what is necessary to address the concrete risk level or the community’s demands⁸.

The Joint Centre for Bioethics at the University of Toronto⁴⁰has developed a guide identifying important ethical issues to be addressed in planning against the pandemic, among which is the application of measures such as quarantine to restrict freedoms in the interest of public health. To this end, the government and the healthcare sector must ensure that the community is aware of the reasons for these restrictive measures, explaining the benefits of complying with them and the consequences of neglecting them⁴⁰.

As previously stated, public health authorities must clearly and honestly disclose the reasons for implementing social distancing measures, allowing the community to participate in the decision¹⁶. In this sense, governments must ensure transparency in the decision-making process, since this increases the public’s confidence and acceptance of the pandemic control measures¹⁶ , ³⁵ . Society’s involvement in these measures requires behavioral changes in both the individual and collective domains. Only with the collaborative effort of all (public authorities and citizens) will the impact of this pandemic in Brazil be able to be mitigated¹⁹.

In this context, individual fear and community panic associated with infectious diseases generally lead to hasty and emotionally charged decisions about public health policies, leading to conflicts between individual freedoms and self-determination³⁴. Thus, health professionals play a key role in gaining the trust of citizens, facilitating the understanding of restrictions on individual autonomy brought about by social distancing measures. They also collaborate to promote individual hygiene behaviors, helping to reduce covid-19’s propagation.

Health professionals are central in planning responses to pandemic situations, acting as health-decision agents alongside patients, families, and the community. Providing comprehensive and humanized care, they play a vital role in the fight against the pandemic, since the plurality of their training and the leadership position they occupy make them protagonists in the fight against the disease.

As we have argued, it is essential to promote adherence to social distancing measures, explaining their reasons and benefits, as well as the personal and social risks involved in not complying with them. In a society characterized by a pluralism of moral values, the authorities’ deliberative processes must be made transparent and open to public debate, generating clearly articulated and justified decisions so that people may trust the services and professionals that stand in the frontline⁵¹.

Careful attention to the bioethical values involved in public-health decision-making can promote voluntary cooperation and community trust³⁴. A pandemic requires solidarity between nations and collaborative approaches that leave aside traditional values centered on self-interest, turning to the collective.

Final considerations

The questions presented here point to an important issue: what actions should be taken during a pandemic? We do not expect to make suggestions or try to provide a definitive answer, but rather to instigate reflections about bioethics and public health in the current context. As insufficient as it may be, principlist bioethics is present in any decision involving ethical healthcare problems. Social bioethics, in turn, seems to be complementary, as its discourse is based on community and social values.

The conflict between values associated with collective benefits (through the adoption of social distancing measures) or with the restriction of individual freedoms opens space for bioethical reflection and creates a favorable environment for discussing and improving care practices. Risks, mistakes and successes are part of decision-making processes during pandemic periods; there is no absolutely correct answer to the problem, and the most viable approach is to seek a solution that is understood and accepted by the population.

Finally, we present some bioethical considerations that might be relevant for all players involved in health production processes typical of a pandemic:

• Users need to assess the extent to which their choices can harm others or society, as freedom presupposes responsible citizens who are aware of the results and consequences of their choices and actions, both individually and collectively. A well-informed population is vital for the success of any action to confront the pandemic, which ultimately depends on the mobilization and protagonism of civil society.

• Health professionals’ decision-making must rely on scientific facts, in the interest of providing good-quality care to everyone. Primary health care professionals should guide people suspected of infection in regards to social distancing and recognition of warning signs, monitoring the clinical evolution of such cases. It is important not to make reductionist bioethical interpretations that induce deliberations based on a single principle.

• The government has a moral and constitutional obligation to propose policies and coordinate appropriate emergency actions to control, overcome and reduce the impacts of covid-19. Likewise, administrators must implement sanitary and epidemiological measures and propose social protection strategies to improve the healthcare system, since their actions are capable not only of saving lives, but also causing deaths. There is also an urgent need to strengthen cooperation between municipalities, states and the Union.

Thus, our understanding is that social distancing measures are viable and successful insofar as users, professionals and administrators are mobilized under firm and solidary cohesion.

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Publication Dates

• Publication in this collection
  21 May 2021
• Date of issue
  Jan-Mar 2021

History

• Received
  9 June 2020
• Reviewed
  24 Sept 2020
• Accepted
  26 Nov 2020