Ethical dilemmas during the COVID-19 pandemic

This article aims to reflect on the ethical dilemmas faced by health professionals, patients and family members during the COVID-19 pandemic. The pandemic raised ethical issues in health caused by the lack of material and human resources and the fear of the unknown. Patients and family members were also affected by social distancing in hospitalization and mourning. Health profissionals faced ethical dilemmas that raise questions about the duty to assist patients and the guarantee of personal safety, dealing with the challenge of acting ethically amid work overload and insecurity of the context. The family and patients face a scenario of adaptation of health care with the lack of technologies that allow feelings of care in the face of the need for distancing, including in the process of farewell rituals of the late. Investments in health can thus drive changes in care, in compliance with social justice and respect for human dignity.


Update
The pandemic triggered by the new Coronavirus (SARS-CoV-2), or COVID-19, as it became better known, forced several areas to face challenges, adaptations, and changes. The virus, the cause of an outbreak of respiratory disease, was first detected in Wuhan, China, which led the World Health Organization (WHO) to declare an international public health emergency on January 30, 2020 1 .
The disease had one of the most devastating impacts in the history of humanity and was considered even more aggressive than the swine flu, whose pandemic took place years ago. This is due to the poor knowledge about prevention, pathogenesis, and treatment of COVID-19, as well as its high transmission capability. Coronavirus continues to plague society and cause an exorbitant number of deaths worldwide 1 . Affected by the pandemic, Brazil also faces great social inequality, with people living in precarious housing, hygiene, and sanitation conditions in often crowded areas due to the high number of family members, and with chronic problems of access to water 2 .
Such a complex situation produces ethical dilemmas since it tests values, principles, and priorities, generating doubts that involve all social actors' decision-making, such as: Should we save the economy or lives? Who should we choose to save in an overloaded public system? Should we prioritize individuals' protection and rights or infringe them for the collective interest? These ethical impasses are difficult to solve or even insoluble 3 .
Thus, it is evident that ethical dilemmas, especially in a pandemic, refer to the conflict of more than one moral reference regarding health and its agents: healthcare providers, patients, and family members. The delicateness and complexity of the situation is evident due to its object: human life. On the other hand, these subjects encourage us to think about resolutions for conflicting situations and evaluate whether the decision was acceptable for the situation faced 3 .
It is neither simple nor fair to deliberate on individuals' lives based on social values. Thus, this article is justified in view of the relevance of the theme for healthcare providers, who, even based on laws and codes of ethics and endowed with principles, still encounter several challenges in their professional practice given the pandemic and the atypical situation in which they perform their activities. This context also presents the dilemmas experienced by patients who, in most cases, face social isolation since hospitalization forbids the presence of companions. Thus, families face distancing and anguish for information about patients' conditions.
The following questions arose in this context: what are the ethical dilemmas faced by healthcare providers during the pandemic? And what are the ethical dilemmas faced by patients and family members? This article aims to reflect on the ethical issues faced by healthcare providers, patients, and family members during the COVID-19 pandemic.

Ethical dilemmas faced by healthcare providers
In health, ethical dilemmas are intensified since decisions directly impact human lives. Considering this peculiarity facilitates our understanding of the challenge of facing an ethical dilemma during a pandemic which caused public calamity, with insufficient personal protective equipment, medicines and structure; limited access due to overcrowding; and increased absence of professionals due to infection 3,4 .
This scenario affects healthcare providers since they deal directly with human vulnerability, and, due to the pandemic, still face the new or unknown, which can generate fear in them. Thus, healthcare providers should aim to maintain their physical and mental well-being to deal with the imposed situation, assist patients well, and protect themselves 4 . It is important, thus, to understand some aspects in the daily life of healthcare providers to understand their routine and what influences their decision-making which triggers ethical dilemmas. Thus, to better understand the theme, we divided it into the following topics: i) fear and mental health; ii) lack of personal protective equipment; and iii) lack of resources and equipment.

Fear and mental health
Health care requires a professional diversity that includes health workers and support services, such as servants, food service worker, security guards, among others 4 . Physical and mental http://dx.doi.org/10.1590/1983-80422022301502EN Ethical dilemmas during the COVID-19 pandemic Update exhaustion is even greater among these workers, conflicting with their ethics and responsibility amidst work overload. Treating critically ill patients infected with a relatively unknown virus requires accurate and cautious care, especially due to stress and the possibility of death. Moreover, healthcare providers face the lack of protocols guaranteeing humanization and reception -necessary changes in the practice of care -, fear, and insecurity 5 .
This scenario intensifies feelings, such as fear, anguish, concern, anger, and helplessness, among others. They stem from the front line in the fight against a disease whose orientations and treatment arise concomitantly with its accelerated spread in the world 4 . Social isolation, imposed on family members to ensure greater safety, caused many healthcare providers to leave their homes to temporarily live in hotels, inns or other real estate to avoid endangering their families, an act of love involving loneliness, longing, and the uncertainty of a reunion 5 .
Researchers have focused on mental health, another problem of the pandemic, manifest in increased symptoms of anxiety, depression, insomnia, sleep disorders, indiscriminate use of drugs, psychosomatic symptoms, post-traumatic stress disorder (PTSD), low job satisfaction, and fear of infection and transmission 6,7 .
A study in China, the first country to face the consequences of COVID-19, conducted with nurses, doctors, respiratory therapists, auxiliary staff, and other health workers, showed that those in the front line were more prone to emotional tension and physical exhaustion when caring for diverse audiences with greater potential for complications. Caring for co-workers whose situation worsened with the disease or who died also left them at a high level of stress. The scarcity of personal protective equipment, concerns about infecting family members, shortage of ventilators and other medical equipment, anxiety about taking on new or unknown functions, work overload, and limited access to mental health services affect healthcare providers not only in China but also in all countries plagued by the disease. Moreover, women were more likely to report such symptoms than men 8 .
Ethical impasses are also present and latent for those not on the front line or on temporary leave since they may show psychological distress in health emergencies. Thus, "vicarious" or "secondary traumatization," which occurs when a person, even distant from the traumatic situations of the pandemic, starts to show psychological symptoms due to their empathy for those who suffered from them or, still, show guilt, anger, frustration, and sadness for being unable to care for patients, making it necessary and important to develop psychological care strategies for healthcare providers during the pandemic 9 .
Though difficult to solve, ethical dilemmas arising from mental health issues can be controlled or minimized if health services provide adequate support to their healthcare providers, including training strategies aimed at managing anxiety and stress 10 . Mental health care, such as telemedicine, remote care with mental health professionals, mobile applications, online resources, and virtual support can be very positive for healthcare providers 8 .
Other guidelines from the WHO include reducing the consumption of news which can generate anxiety or stress, prioritizing news from reliable sources; maintaining healthy eating, regular sleep, and physical exercises or meditation; keeping contact with family members, even if via virtual meetings; and taking breaks at work, especially for those who are in home office 10 .

Lack of personal protective equipment
Healthcare providers manufactured or purchased their own personal protective equipment (PPE) since they feared that their work environment would adequately unable to adequately provide them. This was a part of healthcare providers' daily lives, a situation which increases exhaustion regarding the risk of infection and transmission, making the work for health teams unsafe and frightening 4 .
Many healthcare providers experience ethical and moral hesitation when assisting patients without adequate PPE as they put their, patients, health teams, and their families' lives at risk. This situation is a conflict of values since healthcare providers are subjected by law to the Brazilian Penal Code 11 and to their professional bodies if they fail to offer aid. This context, however, offers personal risks, raising a dilemma for healthcare providers since working conditions hinder proper assistance 12 .
Regarding nursing professionals, ethical aspects guarantee their right to individually or collectively http://dx.doi.org/10.1590/1983-80422022301502EN Ethical dilemmas during the COVID-19 pandemic Update suspend their activities if workplaces fail to offer adequate and safe conditions for professional practice and/or disrespect the legislation in force, except in urgent and emergency situations. It is up to these professionals to formalize their decision in writing or electronically to their institutions and Regional Nursing Councils 4 .
Moreover, nursing professionals are forbidden to deny care in urgent situations, emergencies, epidemics, disasters, and catastrophes unless it endangers their physical integrity. Thus, nursing professionals can deny care to patients with COVID-19 due to inadequate PPE or unsafe working conditions. However, this situation configures an ethical and moral impasse for these professionals who daily risk their lives for their patients. Thus, nursing professionals' lives and civil liability enter in conflict, which may have consequences for their health and safety in performing their work activities 4 .
The Code of Medical Ethics, chapter II, ensures physicians' right to refuse to practice in institutions, whether public or private, whose conditions are undignified or may harm their health or that of their patients and other professionals, justifying their decision to their technical director, Regional Council and ethics committee, if applicable. However, this item conflicts with the subsequent one, which mentions the right to suspend activities, except for urgent and emergency situations 12 .
Moreover, physical therapists should protect client/patient/users, as well as the institution/programs in which they work from the damages which malpractice, negligence or recklessness may incur. These professionals must also assume technical responsibility to offer their services in urgencies or in cases in which they are the only professionals in the sector, individually and collectively unable to deny assistance in urgencies 13 .
Thus, it is worth reflecting that pandemics, as a public health problem, are characterized by a constant state of alertness, in which urgent and emergency situations take place at all times. Thus, should care and procedures be maintained even if they bring risks to all involved? Should one life be maintained at the expense of another? As an ethical dilemma, one must choose between two paths, but the principle which should prevail is protecting and promoting life on both sides by providing health workers with adequate and sufficient PPE, thus offering a quality service for the population that may need it.
Thus, the 1988 Federal Constitution inaugurated an environment of renewal and challenges by occupying the core of the judicial system within the system of rules and principles, controlling and validating the entire infraconstitutional norm. It established a framework grounded in democratic pillars, which the entire social, political and legal system must follow 14 .

Lack of resources and equipment
We see the discussions on health investments and the impasse of saving the economy during a pandemic in principles such as equity, which is based on granting more to those who need it most, considering the needs of the most vulnerable groups. Thus, this should be the focus of concern and priority of government actions. In practical terms, equity is a benchmark for comparing, for example, the extent of financial aid packages in relation to other resources making up the public budget 15 .
The pandemic has highlighted chronic problems in health, such as physicians' arduous task of enabling patients to access scarce resources, such as intensive care unit beds (ICU), supplies, and hospital structure and proper functioning. Moreover, we also highlight the lack of decent remuneration for healthcare providers. COVID-19 worsened all these factors 15 .
Recently, the state of Amazonas suffered from lack of oxygen tanks to treat patients hospitalized for COVID-19 16 . A task force was organized, especially by civil society, to transport oxygen tanks to patients. They arrived too late for those who could not survive the absence of this input. This reflects the need for public managers to plan how to cope with the pandemic. In the press and social media, healthcare providers reported losing patients from an entire sector, patients sharing tanks without a perspective of a next one arriving, and health workers on the limit of their physical and psychic conditions 16 .
In general, what the pandemic has daily shown is that before thinking about offering mechanical ventilators and inputs, such as oxygen tanks, we need to think of a specialized workforce. Though new healthcare providers have been invited to work, they lack sufficient knowledge, http://dx.doi.org/10.1590/1983-80422022301502EN Ethical dilemmas during the COVID-19 pandemic Update training, and experience to manage this equipment in such complex situations 6,15 .
In view of this, it is essential to act to promote training through courses and simulators, enable access to telemedicine, support technological development to manufacture ventilators with more accessible technology, use components and inputs that are independent of the international market, seek alternative ventilatory support offering low risk of contamination to health workers. Moreover, it is necessary to invest in input maintenance, such as individual equipment, mechanical ventilation accessories, sedatives, analgesics, and neuromuscular-blocking drugs. For this, investments should be a priority for universities, industry sectors, and health entities 17 .
The need to prioritize and decide based on a conduct grounded on the criterion of justice was evidenced in the preparation of a protocol by the Brazilian Association of Intensive Care Medicine (Amib) to allocate scarce resources during the COVID-19 pandemic. The protocol includes screening all patients affected by the virus as a criterion of justice so patients with the highest chances of benefitting from treatment and surviving are prioritized 14 .
Healthcare providers should seek better solutions which reflect on assistance, care, and appropriate treatment choice. We should note that the struggle for improvement is the responsibility of other actors in society, especially the State. In the current context, these conditions promote dilemmas. How can one choose the right treatment without equipment and resources? Given this reality, is making arrangements the way to save patients? Would using one equipment for two people save both or put them at risk? We suppose many healthcare providers have found themselves in this situation and, amidst chaos, have sought training in the available courses in partnership with health institutions or universities. There was also a demand for necessary equipment and resources, better wages, and working conditions [14][15][16][17][18] .

Ethical dilemmas faced by patients and family members
In addition to the ethical challenges and dilemmas faced by healthcare providers, it is important to consider another facet: to whom care is provided -i.e., not only patients, but their support network. Patients affected by the Coronavirus are vulnerable, as they face treatment with scarce evidence, fear of the unknown, demotivating news, and social isolation and distancing from their families. It is common to find a patient or family member requesting discharge on request or hospital evasion 9 .
After the discovery of the virus, its spread, and forms of transmission, many countries adopted measures to contain the spread of the virus, especially quarantines and social distancing. One of the greatest health crises of this century has brought a devastating change in human and ethical issues. Those infected experience isolation from their families and society since the virus is extremely aggressive and transmissible 9 .
This change in reality also affected the traditional ways of coping with death and mourning. Visits, wakes, and rituals to bid farewell to the deceased infected by COVID-19 are forbidden to family and friends due to the great risk of contagion, generating anguish and suffering to loved ones. People with COVID-19 experience the process of death alone. Moreover, funeral homes send these people to cemeteries without the respect and dignity such a painful moment requires and without the right to the humanized practice of palliative care. Finitude and death should receive a dignified treatment, treating patients in their integral structure. In this practice, patients' physical, psychological, social, and spiritual pain is treated, humanely reaching patients, family members, and healthcare providers 19 .
The devastating advance of this pandemic hindered the creation of strategies to confront religious and spiritual issues, constituting the ethical and human challenge of producing the technological resources allowing patients and family members to bid their farewell with dignity, including burial. For this, it is necessary to adapt to the conditions imposed by the pandemic 20 .
This reality made the National Congress discuss a bill providing for the right to family members to virtually visit patients via video calls. It aimed to establish a right, safeguarded by law, of visiting hospitalized loved ones, even if by technology (since physical presence is vetoed) 21

Update
The fact that family members are forbidden to visit burial sites, accompany the body on special occasions aimed at the deceased, perform the rituals reconnecting them with the sacred, console themselves with friends, neighbors, and relatives, creates an abyss of pain to be overcome by the families of the deceased. Thus, new ethical and bioethical challenges arise which require new strategies to deal with death and mourning 20 .
Another reality experienced that raises dilemmas is the care of the older adults in ICU, a situation affecting families and patient since the demand of older adults infected by COVID-19 has increased. Older adults show disadvantages for hospitalization eligibility due to their age and comorbidities. At this point, we invite readers to consider placing themselves in patient and families' shoes to better understand a reality experienced by many. An example that expresses this situation well took place in Italy, the first European country to be the focus of the pandemic, in which its government adopted guidelines that highlighted this ethical, such as the allocation of resources in ICUs, limited agerelated screening, comorbidities and functional status of critical patients admitted to ICUs, and of palliative care in worsened outcomes after discharge from intensive care 22 .
This problem is concretely reflected in the ethical challenges and dilemmas raised during the pandemic. Affected patients and families, fearing the unknown, are vulnerable. Moreover, lack of resources and health investments in some places even forces the separation of family members, as happened in Manaus when patients needed to be transferred to other states due to lack of oxygen tanks. In addition to illness and social distancing, these patients faced displacement. This is the drama of families which, often due to precarious financial conditions, are unable to follow-up family members 16 .

Final considerations
The pandemic undoubtedly created a scenario that raised ethical dilemmas for healthcare providers, patients, and families. Health workers experienced impasses such as the lack of adequate PPE due to high demand which generated questions about their duty to assist patients and guarantee their own personal safety. The lack of working conditions and resources is still reflected in doubts and questions that involve choice and priority regarding human lives. Moreover, being on the front line against a little-known virus triggers fear and challenges mental health maintenance. These dilemmas permeate health workers' routines.
Note that one limitation of this study is failing to address other workers who are also part of health care, although indirectly, such as hygiene teams, stretcher operators, ambulance drivers, nutrition service teams, equipment maintenance teams, and workers involved in burial services. They are workers who are exposed daily to the risk of contamination and need to be remembered. The ethical dilemmas experienced by patients and their family permeate distancing, especially when patients need hospital care. In this case, family members wish to be close to loved ones and protect them. Patients have requested discharge, evaded, or even had to be transferred from their municipalities for lack of resources. In this context, many families experienced lack of information, which led them to adopt new approximation and shelter strategies, such as video calls.
Ethical dilemmas arise before this dramatic scenario of marks and challenges generated by COVID-19, which may promote solutions and the drive for changes and improvements. At least they highlight the need for urgent health investments with responsibility, social justice, and respect for human dignity.