Tanuj Sharma, Medha Mathur, Simran Jiwani, Navgeet Mathur, Pranati Vyas, Anjana Verma, Ashish Patyal
Rajasthan Hospital, Jaipur; Community Medicine, Geetanjali Medical College & Hospital, Udaipur; Department of Oncology, Geetanjali Medical College & Hospital, Udaipur; General Medicine, Geetanjali Medical College & Hospital, Udaipur; Undergraduate Student, Pacific Institute of Medical Sciences, Udaipur; Anaesthesiology, Geetanjali Medical College & Hospital, Udaipur
The epidemic of corona virus disease 2019 (COVID19) started from Wuhan, China, December, 2019and have become a major challenging public health problem. (1) On January 30, 2020, the World Health Organization (WHO) announced that this outbreak had constituted a public health emergency of international concern. Since the outbreak of the COVID-19, in order to race against time to treat patients, many medical workers from all over the country joined battle against virus. The COVID-19 pandemic poses numerous and substantialethical challenges to health and healthcare including adequate protective equipment, testing and monitoring, violence and about when a vaccine might become available and social restrictions might be lifted.
In these trying times the debatable professionalism and ethical issues are surging and posing a challenge to integrity of medical profession. Doctors are bided by the Hippocratic Oath (5th century B.C.), which to this day is pledged (often in modiﬁed form) at medical school initiation and graduation ceremonies which came after the Code of Hammurabi (2,000 B.C.), the ﬁrst known code of medical ethics which ensures integrity of the individual doctor. (2) Principles of bioethics including the cardinal pillars of ethics i.e. autonomy, beneﬁcence, non-maleﬁcence and justice abides the doctors to maintain conﬁdentiality, profess to cause no harm to patients and should make sure to producing net beneﬁt over harm. (3) The doctor should act fair to the patient on the basis of resource distribution, rights and legal issues. (2)
The thorny dilemmas posed by triage and resource allocation and violence against the doctor also attracted considerable attention. And the debate continues around professionalism and ethics such as declining of treatment, due to the fear of infection from the virus; diﬃcult conversations are being held in suboptimal. Healthcare personnel, meanwhile, are facing moral distress and post-traumatic stress, for some, diﬃculties arising from undertaking new roles in unfamiliar settings. Whilst patients and public require support, health and social care professionals also need guidance to help navigate the ethical challenges.
Professionalism instils a commitment to peers who join together on the frontlines of medicine. In this way, health professionals resemble soldiers who sacriﬁce for their comrades in the trenches. And like the military, they accept collective responsibility for their behaviour. We should also recognize that in times of crisis like this, professionalism reinforces the sense of duty, the courage, and even the heroism of millions of clinicians who feel its pull. We would certainly be worse oﬀ without it. That is why it is important to be aware of signiﬁcant forces that threaten professionalism both in the midst of this crisis and beyond it. Protecting health care workers is a sign that society values and respects them for the professionalism they show every day. The global research community must act now to meet needs of patients and health care professionals both in the short term, and when this public health emergency subsides.
Covid-19 pandemic has raised numerous challenges all around the world. The health care system is at breaking point in many developed countries. Several studies suggested a need to design research for health policy, making the laws and practice grounded simultaneously in rigorous, ethical evidence, the highest standards of professionalism, and the experiences of health care professionals (4-6). The current study was designed to assess the ethical dilemma faced by the health care workers while serving the patients during COVID-19 pandemic.
MATERIALS AND METHOD
The study was conducted for 8 weeks of duration in a tertiary care hospital of southern Rajasthan from 15th April 2021 to 15th June 2021. The health care workers serving in COVID-19 wards, intensive care units and outpatient departments were included in the study after availing consent. Based on the previous study prevalence of COVID-19 stress among health care workers was found to be nearly 13% and considering 5% allowable error the sample size calculated was 175. Taking 15% non-response rate, nearly 201 sample size was estimated.
A pre tested and pre validated questionnaire was used for the data collection which included demographic details of study subjects and their knowledge, perception and ethical dilemmas regarding the COVID-19 situation. Questionnaire was administered to the study participants by one-to-one interview technique.
Ethical approval was obtained by the principal investigator and collected data was entered in MS excel and analysed using SPSS-16 software. Statistical analysis was done and appropriate test of signiﬁcance were applied. P value of <0.05 were considered to be signiﬁcant.
Total of 201 study subjects were included in the study, out of them 65.2% (131) participants were male while 34.8% (70) were females. The average age of study participants was 29.23±2.45 years. Out of total 201 subjects, 89.1% (179) were involved in COVID-19 direct patient care services, while 10.9% (22) were not involved in direct patient care. The health care
protective providers included in the study were doctors (35.3%), nursing staﬀ (32.8%), Postgraduate students (22.8%), interns (4.9%) and other staﬀ (3.98%) of hospital.
The knowledge assessment of study subjects about the causative agent, common signs and symptoms, diagnostic tests, precautionary measures revealed that health care workers had adequate knowledge (89.5%) about the subject. The ethical dilemmas were assessed based on various factors and their responses are depicted in the table 1.
The measures of prevention of mental health issues like post-traumaticstress disorders in health care workers can be prevented using following measures like support and encouragement (170; 84.6%), providing good and safe working environment (153; 76.1%), providing adequate rest, nutrition and rotatory duties (162; 80.6%), by sharing their concern and grief (127; 63.2%), by providing counselling (125; 62.2%) while few stated that it is not needed (4; 2%). Respondents selected multiple responses for this item. (Figure 1)
In the study gender based distributionwas 65.17% (131) males while 34.83% (70) were females where as another study by Limbuet.al. reported 60.2%females (8). In current study the nursing staﬀ was 32.8% which wasin consensus with the ﬁndings of another study conducted in Nepal where 39.8% were the nursing staﬀ. (8)
The ethical dilemmas faced by health care workers as discussed in the current study were in consensus with the issues discovered and discussed by Menon et al (9) in their work. The issue of non-availability of personal protective equipment (PPE), revelation of COVID-19 positive status of patient and self were discussed in detail by the author who were having similarities with our study. Another study by Jose et al (10) from one of the north Indian tertiary care centres revealed similarities with the current study.
Mental health issues like post-traumatic stress disorder were reported in current study and have also been mentioned by Ayanian (11) and Verma et al (12) in the work on mental health needs of health care workers on front line in COVID 19 care. Study by Vizheh et al (13) also reported that insomnia, distress, depression and anxiety were commonly reported issues among health care workers in various studies analysed by them in their systematic review.
The modes for prevention of mental ailments were support and encouragement (170; 84.6%), providing good and safe working environment (153; 76.1%), providing adequate rest, nutrition and rotatory duties (162; 80.6%), by sharing their concern and grief (127; 63.2%), by providing counselling (125; 62.2%). The measures stated by Greenberg et.al. (14) were similar to the one came out in our study like early support and care of health care workers, proactive actions by health care managers in taking care of mental health of health care workers, arrangement of counselling sessions for health care professionals and their family members.
Study limitations: The study was conducted at single centre with limited number of subjects.
This study concluded thatthe pandemic triggered a situation that unwinds the fact that ethical and professional dilemmas are prevalent among medical health care professionals and they are equally struggling with the issues which is in addition to the responsibility of treating and caring for patients. The healers should be healed ﬁrst in order to serve the community.
Conﬂict Of Interest
Source Of Funding
Ethical conduct of research
The authors declare that this review article does not require Institutional Review Board/Ethics review or approval.
1. Mahalmani VM, Mahendru D, Semwal A, Kaur S, Kaur H, Sarma P et al. COVID-19 pandemic: A review based on current evidence. Indian J Pharmacol. 2020;52(2):117-29.
2. MacKenzie CR. Professionalism and medicine. HSS J. 2007;3(2):222-7.
3. Medical Council of India, Attitude, Ethics and Communication (AETCOM) Competencies for the Indian Medical Graduate, 2018. [Last accessed on December 18 2021] Available from https:// www.nmc.org.in/wp-content/ uploads/2020/01 /AETCOM_ book.pdf
4. Vyas H, Goyal R, Meena JK, Mathur M, Yadav A. Knowledge, attitude, and practices in response to COVID-19 pandemic in Indian population. Int J Res Med Sci 2020;8:4038-46.
5. Brennan MD. The role of professionalism in clinical practice, medical education, biomedical research and health care administration. J Transl Int Med. 2016;4(2):64-5.
6. World Health Organisation. International working group on Ethics & COVID-19. [Last accessed on November 18 2021 Available from https:// www.who.int/news-room/detail/20-03-2020-who-hasestablished-an-international-working-group-on-ethicscovid-19.
7. Sahu AK, Amrithanand VT, Mathew R, Aggarwal P, Nayer J, Bhoi S. COVID-19 in health care workers – A systematic review and meta-analysis. Am J Emerg Med. 2020;38(9):1727-31.
8. Limbu DK, Piryani RM, Sunny AK. Healthcare workers’ knowledge, attitude and practices during the COVID-19 pandemic response in a tertiary care hospital of Nepal. PLoS One. 2020;15(11):e0242126.
9. Menon V, Padhy SK. Ethical dilemmas faced by health care workers during COVID-19 pandemic: Issues, implications and suggestions. Asian J Psychiatr. 2020;51:102116.
10. Ayanian JZ. Mental health needs of health care workers providing frontline COVID-19 care. In JAMA Health Forum 2020;1(4):e200397.
11. Jose S, Dhandapani M, Cyriac MC. Burnout and Resilience among Frontline Nurses during COVID-19 Pandemic: A Cross-sectional Study in the Emergency Department of a Tertiary Care Center, North India. Indian J Crit Care Med. 2020;24(11):1081-88.
12. Verma A, Meena JK, Choudhary S, Patyal A. Nurses’ mental health and work place safety during COVID 19 Pandemic in tertiary care hospitals of North India. Indian Journal of Applied Research. 2020;10(10) :2249-52.
13. Vizheh M, Qorbani M, Arzaghi SM, Muhidin S, Javanmard Z, Esmaeili M. The mental health of healthcare workers in the COVID-19 pandemic: A systematic review. J Diabetes Metab Disord. 2020.26;19(2):1-12.
14. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ.2020;368:m1211.