Clinical Care During the COVID-19 Outbreak Presents Ethical Challenges in Pakistan

Muheebur Rehman¹*, Faheem Ullah jan², Zala³, Asma nabi⁴, Shagufta Bibi⁵, Sarosh Gohar⁶, Shawkat Ali⁷

¹ Abasyn University, Peshawar, Pakistan

² Khyber Medical University, Peshawar, Pakistan

^3,4 Iqra National University, Peshawar, Pakistan

^5,6 Khyber Girls Medical College Peshawar, Pakistan

⁷ Institue-Khyber Teaching Hospital, Peshawar, Pakistan

Email: muheebjan291@yahoo.com

KEYWORDS	ABSTRACT
Coronavirus Disease-19, Ethical Challenges, Guidelines, Healthcare, Research Resource Allocation.	The COVID-19 pandemic has posed unprecedented bioethical challenges across the global healthcare industry, necessitating a comprehensive examination of ethical dilemmas in medical care and research. This study aims to identify, analyze, and address these challenges, focusing on the pandemic's impact on healthcare systems in Pakistan. A systematic literature review was conducted, analyzing fifteen full-text articles, five ethical guidelines, and one workshop report. The review examined key ethical concerns, including global responses to the pandemic, equitable resource distribution, ethical considerations in clinical trials, fair vaccine allocation, and personalized patient care. The findings reveal significant ethical gaps, particularly in resource-constrained settings like Pakistan, where healthcare systems face challenges such as inequitable resource allocation and inadequate security for healthcare workers. Practical solutions and recommendations are proposed to guide healthcare professionals and policymakers in ethical decision-making during crises. This research underscores the importance of proactive measures by provincial authorities and governments to safeguard healthcare professionals and enhance public awareness. The implications of this study highlight the need for ethical frameworks to strengthen healthcare systems, ensuring equitable access to care and fostering resilience in future pandemics.
DOI: 10.58860/ijsh.v3i11.265

Corresponding Author: Muheebur Rehman*

Email: muheebjan291@yahoo.com

INTRODUCTION

COVID-19 is the designation for the novel coronavirus strain that initiated the current global pandemic. Initially identified by Chinese authorities on January 7, 2020, this virus rapidly spread beyond borders, with cases escalating daily worldwide (Sohrabi et al., 2020). By June 2020, there was no specific medication or effective vaccination available to combat the virus. Although convalescent plasma transfusion has been considered a potential treatment option, it remains in the experimental stages. While preventive measures have proven effective in controlling the virus's spread, their success largely depends on policies that ensure public awareness and health education to foster compliance (Tambo et al., 2021).

To further contextualize the urgency, it is essential to consider Pakistan's healthcare situation before the pandemic (Siddiqui & Smith-Morris, 2022). Pakistan's healthcare system has already faced significant resource constraints and infrastructure limitations. The COVID-19 pandemic intensified these challenges, overwhelming hospitals and straining limited resources. A detailed exploration of Pakistan's case statistics, healthcare responses, and resource limitations provides critical insight into the pandemic’s compounded impact on an already vulnerable healthcare system (Chandir et al., 2020).

Some nations have been severely impacted by this pandemic, and their healthcare systems are at breaking point. In numerous severely affected countries, healthcare systems are facing fragmentation and decentralization as instability rises alongside the mounting death toll (Djalante, Nurhidayah, et al., 2020). This crisis disproportionately impacts vulnerable populations. The pandemic’s relentless progression has exposed significant vulnerabilities within global capitalist frameworks, particularly exacerbated by delayed responses to the crisis, underscoring systemic weaknesses in a world already fraught with challenges (Hampton, 2020).

The surge in COVID-19-positive cases intensified the strain on Pakistan’s already vulnerable healthcare system, which suffered from inadequate infrastructure and a lack of standardized protocols for pandemic management (Lai et al., 2020). In response, the government collaborated with the Corona Experts Advisory Group (CEAG) to formulate region-specific guidelines aimed at bolstering the healthcare system and safeguarding healthcare workers in public institutions. Training was provided to healthcare professionals in pandemic management, and proper handling protocols for personal protective equipment (PPE) were established. Healthcare workers deployed in high-risk zones, such as COVID-19 wards and intensive care units, were isolated for two weeks after each week of duty, and staffing was minimized by scheduling only essential personnel on alternate days in other specialties to reduce exposure (Luo et al., 2020). Despite these measures, the government overlooked the concerns of healthcare professionals, failing to provide necessary facilities and, instead, intervened strictly to prevent potential strikes.

Based on the above background, this research aims to analyze the challenges and responses of Pakistan's healthcare system during the COVID-19 pandemic, focusing on identifying critical gaps and evaluating the effectiveness of the measures implemented. By examining the case of Pakistan in detail, this research seeks to provide actionable insights into how resource-constrained healthcare systems can better prepare for and respond to future pandemics. The findings of this research are expected to benefit policymakers, healthcare administrators, and global health organizations by providing evidence-based recommendations to strengthen healthcare systems in developing countries. In addition, this research contributes to a broader understanding of public health crisis management in resource-constrained environments, emphasizing the importance of equitable resource allocation, effective health education and adaptive healthcare protocols in mitigating the impact of a global pandemic.

METHOD

The research employs a systematic literature review (SLR) to explore and analyze existing research on ethical challenges in healthcare, particularly during pandemics, with a focus on the COVID-19 outbreak in Pakistan. The methodology includes detailed sourcing, reviewing, and synthesizing of relevant studies to gain insights into ethical dilemmas in clinical care settings. To enhance rigor, the research method involves clearly defined inclusion and exclusion criteria for sample selection, as well as a structured thematic analysis approach to systematically examine and interpret the data from the reviewed literature, providing a comprehensive understanding of the ethical frameworks applied in pandemic healthcare.

Population

The research population includes published studies, articles, and guidelines related to the ethical concerns that arose in clinical healthcare settings during the COVID-19 pandemic. These studies focus on healthcare providers, policymakers, patients, and ethical implications within Pakistan, as well as globally relevant frameworks. Literature published between 2019 and 2021 was considered, ensuring that the sample reflects recent and relevant ethical challenges.

Sample Selection

From this population, a specific sample of articles, guidelines, and research reports was selected based on relevance to the research's objectives. This sample includes works from recognized journals, reports by international health organizations, and guidelines issued by local health authorities. Key search terms included “COVID-19 ethical challenges,” “healthcare resource allocation,” “vaccine distribution ethics,” and “bioethics in clinical care.” Electronic databases such as PubMed, Google Scholar, and ScienceDirect were used to locate articles that discussed ethical dilemmas in healthcare during pandemics. Fifteen full-text articles, five health guidelines, and a workshop report were selected, providing a robust foundation for analysis (Pigott & Polanin, 2020).

Data Analysis

Data analysis involved a thematic synthesis of the literature, focusing on common ethical concerns highlighted in each source. This synthesis was designed to identify recurring themes, such as resource allocation, clinical trials, vaccine equity, and the psychological impact on healthcare providers. Each theme was analyzed based on ethical theories, practical implications in clinical settings, and policies suggested to address these dilemmas. The results are discussed in relation to the ethical challenges experienced in Pakistan's healthcare system during the COVID-19 crisis, drawing parallels with international experiences.

RESULT AND DISCUSSION

Pakistan Outbreak

The decentralization and fragmentation of healthcare services have exacerbated the impact of the COVID-19 pandemic in many severely affected countries, intensifying the global crisis (Berardi et al., 2024). While the entire world has felt the consequences, countries with inadequate healthcare policies and systems have faced even more severe challenges. The rapid transmission of the pandemic across regions has turned it into an unprecedented calamity (Djalante, Shaw, et al., 2020). Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, emphasized the urgent need for nations to prioritize healthcare system preparedness over reactionary measures, stating, "we cannot continue to rush to fund panic but let preparedness go by the wayside." Despite the global health expenditure reaching $7.5 trillion annually, substantial investments in healthcare infrastructure remain critically needed.

Pakistani Response to The Outbreak

The contagiousness of the virus worried every research participant, not only for themselves but also for those in their immediate vicinity (Chen et al., 2020). They felt that they were in the middle of a crisis and would not be able to handle it because of the virus's aggressive behavior, which resulted in the unexpected deaths of even very young physicians. The majority of married participants expressed great worry for their parents and kids because caring for COVID-19 patients might have made them virus carriers. For HCPs who were also parents, this was a critical situation because they had to go back home every day to find their kids waiting for them. A concern shared by a subset of research participants (n = 7) was post-duty isolation. This is demonstrated in a It felt a lot like a morgue, dealing with COVID-19 patients in intensive care units. Death is all around you. You work during duty hours somehow, but it's difficult to gather your broken pieces when you're by yourself. You have no one to encourage you or a shoulder to weep on.

Quarantining was more difficult than the duty itself because of this sense of helplessness and loneliness (Goldblatt et al., 2022). While some respondents bemoaned the lack of emotional and social support for female HCPs, others stated they were having trouble finding assistance to provide them with necessities (food, supplies, etc.) during post-duty quarantine. One of them continued, saying:

The largest issue I encountered while isolating myself in an apartment was a dearth of assistance. I had to go get items on my own if I needed supplies or groceries because no one was available to give them to me. I've always been concerned about this: what if I'm the one spreading the virus? Individuals whose partners did not work in medicine distanced themselves from them (while performing their COVID-19 duties), both mentally and physically. The respondents claimed that their spouses believed they put their work ahead of the well-being and safety of their own families. Because they were worried about being held responsible for having the illness, some respondents without children said they would rather not be at home when performing their COVID-19 duties (Bezak et al., 2022).

Who Risk Assessment?

Following the COVID-19 pandemic announcement, governments all over the world established advisory groups to help create ethical frameworks and statutory branches to make sure that ethical standards were followed (Hamza & Kulkarni, 2022). The need for these organizations to provide ethical guidance has, understandably, increased dramatically in light of the pandemic's urgent and quickly evolving context (Organization, 2022). According to this perspective, the GHET aims to assist the NECs by establishing guidelines in response to requirements, facilitating networks of communication, and encouraging collaboration and sharing amongst NECs worldwide in order to assist nations in addressing the moral dilemmas brought on by COVID-19. Additionally, a network of institutions across the globe has been established by the GHET in association with the Global Network of WHO working with Centers for In these pursuits, the GHET seeks to improve cooperation, communication, and teamwork (Lewis & Usher, 2016). In line with this, the Public Health Emergency Preparedness and Response Ethics Network, in collaboration with the World Health Organization (WHO) and a few significant partners, including the Fogarty International Center, the Global Forum on Bioethics in Research, the Global Health Network, and the Global Network of WHO Collaborating Centers, developed pre-existing expertise and resources to offer communities, decision-makers, researchers, and responders timely, reliable, contextual support regarding the ethical issues arising out of global health emergencies.

Social Impact of Lockdown Measures

All facets of society have been affected by the COVID-19 pandemic, leading to the implementation of lockdown protocols. Particular people or groups have been particularly vulnerable, including those who are extremely old, members of Indigenous tribes, those with low incomes, and people with socioeconomic disabilities.

Early research showed that socioeconomically disadvantaged groups suffered the most from lockdown for a variety of reasons, including lost jobs, physical separation being impossible due to crowding, poor sanitation and unsafe water sources affecting personal hygiene, the homeless being left unprotected, and without a place to stay, and the high cost of healthcare facilities. These effects were far more detrimental to migrants, refugees, and other displaced people. In order to address issues of inequality, exclusion, discrimination, and unemployment in the medium and long term, policies are necessary to ameliorate the social crisis that has been created (Sahin et al., 2020). It is imperative that we implement a comprehensive, universal social protection system that provides basic income security both during and after emergencies in order to protect workers, keep them out of poverty, and give them the tools they need to manage and overcome the crisis (Adams, 2020). Leonard and Lo state that in order to prevent the rapid spread of infection, mortality, quarantine, and physical distancing measures were advised. However, these measures have resulted in the loss of 11.6 million jobs, increasing unemployment in 2020 compared to 2019. The loss of employment and revenue has had a major impact on those who are already.

Need for Optimization of Healthcare Resources

The COVID-19 pandemic caused a worldwide rise in hospital admissions, particularly to intensive care units (ICUs), placing an unprecedented demand on the healthcare system's resources (Tyrrell et al., 2021). It is the responsibility of governments, international organizations, and health systems to do everything within their power to guarantee that everyone has access to sufficient healthcare (also known as healthcare for all) (Adams, 2020). Therefore, in order to maximize the limited resources available, the relevant authorities must make difficult decisions, some of which may be morally acceptable while others may raise ethical questions for all parties involved, including patients, healthcare professionals, the general public, and policymakers.

CONCLUSION

The conclusions in this study make it imperative for provincial authorities and government representatives to guarantee better security for healthcare professionals and launch awareness of all expenses before the pandemic causes deaths and infections that will devastate the healthcare system. The government has a responsibility to educate the public and ensure that the message is conveyed that there is no guarantee that the Pakistani population will continue to be smaller than the Western population. Following the positive COVID-19 test results, social distancing and quarantine measures must be put in place immediately. The unorganized public health sector needs to be given the resources and attention it deserves. To limit the rate of local transmission of infection, testing, tracing and lockdown procedures should be concentrated on areas where clusters have been identified. Trace all people who may have come into contact with the virus.

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© 2024 by the authors. It was submitted for possible open-access publication under the terms and conditions of the Creative Commons Attribution (CC BY SA) license (https://creativecommons.org/licenses/by-sa/4.0/).