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Letter to the editor
DOI: 10.1016/j.gaceta.2020.09.009
Open Access
Disponible online el 23 de Noviembre de 2020
Pandemic, public policy and ethics
Pandemia, politica pública y ética
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Fernando-Miguel Gamboa-Antiñolo
Internal Medicine, Hospital Universitario de Valme, Universidad de Sevilla, Sevilla, Spain
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Dear Editor:

The reality has been overwhelmed by the pandemic: tensions between the different national and regional authorities, high costs (still unknown), constantly changing and contradictory protocols, infection of large numbers of health workers and consequences on individual health and rights not always justifiable. This event do not occur in isolation but linked to economic, political and social processes.1 Define a public policy is making a judgment in a context where the results and probabilities are simply unknown. Decisions must be based on the best scientific evidence available, but often there is no evidence. A public health emergency disrupts the normal processes of patient care. An ethically sound framework must balance the duty of care that requires patient loyalty, the alleviation of suffering and respect for the rights and preferences of patients with the duties of promoting equity, public safety, and protecting the health of the community and fairly allocate limited resources. Health care leaders have a duty to plan for the foreseeable ethical challenges. Classification decisions need to be made regarding the level of care, decisions regarding the shortage of personal, space and supplies, safeguard workers and protect vulnerable populations.2

Actions on the population, although they are intended to guarantee a benefit for the aggregate health of the community, do not necessarily do so for each person, who must assume limitations on their freedom and personal losses. Public health introduces tensions in people's autonomy. The concern caused by the imposition of obligations or restrictions on the group of still healthy citizens in name of possible additional improvements, of doubtful benefits or of an uncertain balance between their damages and benefits requires more justification than has been provided, since it leads to interference in elections and personal lives.3 What offers a lot of good to the community can be catastrophic for the individual. It has had a tremendous cost: the victims, those affected by the virus with its morbidity and mortality, and their families, with the consequent economic and social repercussions, the suspension of educational activities and restriction of our personal liberties. So are those who have not received enough attention from the health system due to the amount of resources dedicated to the prevention and control of the epidemic.4

Clinical medicine has an ethical contract to care for patients, maximizing beneficence and minimizing maleficence, respecting autonomy and equity. However, public health lacks that consensus. The objectives of caring for the entire population lead the goods of society (the health of citizens) to prevail over the right of people to make their decisions autonomously. Better training and more transparent information can help us.

In this context uncoordinated and unusual responses are not surprising, with contradictory interventions that demonstrate the lack of coherence. Coordination mechanisms must be established that do not depend solely on the good understanding of the parties involved. Crises are challenges from which we must learn, with mistakes and successes, since they serve to adjust the devices and refine our response to other future, unavoidable and unthinkable crises.1,5 Crises are anything but unexpected.

Funding

None.

Conflicts of interest

None.

References
[1]
A.I. Mushlin.
Covid-19: an imperative to bridge the gap between medicine and public health.
J Gen Intern Med., 35 (2020), pp. 2445-2446
[2]
N. Berlinger, M. Wynia, T. Powell, et al.
Ethical framework for health care institutions and guidelines for institutional ethics services responding to the coronavirus pandemic. Managing Uncertainty, Safeguarding Communities, Guiding Practice.
The Hastings Center;, (2020),
[3]
P. Skrabanek.
Why is preventive medicine exempted from ethical constraints?.
J Med Ethics., 16 (1990), pp. 187-190
[4]
A. Segura.
What can be learned from the management of pandemic influenza?.
Gac Sanit, 24 (2010), pp. 269-271
[5]
J. Gervas, I. Hernandez Aguado.
Crisis Situations Conference Group. Successes and errors in the management of public health crises in Spain.
Gac Sanit., 23 (2009), pp. 67-71
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