Table 4 Emerging meaning of dignity among ethical guidelines
From: Among equity and dignity: an argument-based review of European ethical guidelines under COVID-19
Country | Guidelines’ title | Mention of dignity | Appropriateness and proportionality | Equality | Equity | Emerging meaning of dignity |
|---|---|---|---|---|---|---|
Austria | Management of scarce resources in healthcare in the context of the COVID-19 pandemic | The protection of the individuals and their dignity provided for in these fundamental rights implies the duty to provide healthcare to every person regardless of who they are, in other words, without distinction following non-medical criteria | There is no right to medical treatment that is not or no longer medically indicated | Equality is considered as a binding fundamental right Everyone has a right to life (Article 2 ECHR) and other relevant Fundamental rights in the medical context, such as in particular the right to respect for private life (Article 8 ECHR). (…) There is no justification for excluding a person from treatment based on criteria such as their remaining lifetime or quality of life. At the same time, it needs to be emphasized that there is no right to medical treatment that is not or no longer medically indicated | Equity: Some people are in need of special support to be able to effectively exercise their fundamental right to life and the access to associated medically indicated treatment, e.g. if they have a physical or mental/cognitive impairment. Such cases require not only the same, but possibly more resources to ensure that they have the same chance as people without such impairments | Respecting the intrinsic value of human beings—no discrimination (equality) while differentiate resources among people with different needs (equity) |
Belgium | Ethical principles concerning proportionality of critical care during the COVID-19 pandemic: advice by the Belgian Society of IC medicine | Disproportionate care should be defined on a scientifically funded estimate of the expected outcome, which implies knowledge of an advanced care plan, the medical condition of the patient, the antecedents, the acute evolution of his condition, and a funded estimate of his prognosis with and without intensive care | In addition, non-COVID-19 patients should be evaluated according to the same criteria in order to avoid discrimination between both groups. Although an increased age is associated with worse outcomes in COViD-19, age in isolation cannot be used for triage decisions, but should be integrated with other clinical parameters. Frailty and reduced cognition, more than age, are independent predictors of outcome when elderly patients are admitted to the ICU | Dignity as respect of patient’s autonomy and patient’s choices and respecting the intrinsic value of human beings—no discrimination (equality) | ||
Council of Europe | COMMITTEE ON BIOETHICS (DH-BIO) DH-BIO Statement on human rights considerations relevant to the COVID-19 pandemic | It is essential that decisions and practices meet the fundamental requirement of respect for human dignity and that human rights are upheld | The principle of equity of access to health care laid down in Article 3 of the Oviedo Convention must be upheld, even in a context of scarce resources. It requires that access to existing resources be guided by medical criteria, to ensure namely that vulnerabilities do not lead to discrimination in the access to healthcare. This is certainly relevant for the care of COVID-19 patients, but also for any other type of care potentially made more difficult with confinement measures and the reallocation of medical resources to fight the pandemic. The protection of the most vulnerable people in this context is indeed at stake, such as persons with disabilities, older persons, refugees and migrants. This concerns decisions to allocate scarce resources, to provide necessary assistance to those most in need | Respecting the intrinsic value of human beings—no discrimination (equality) while differentiate resources among people with different needs—vulnerable people (equity) | ||
Estonia | Recommendations on clinical ethics for Estonian hospitals for distribution of limited health care resources during the COVID-19 pandemic | Beneficence, patients’ autonomy (including informed consent) and the principle of human dignity continue to be in effect | Equal treatment. The medicine system treats all patients equally regardless whether they have COVID-19 infection or some other severe illness Earlier arriving for treatment does not give any patient any advantage compared to those who come later | Respecting the intrinsic value of human beings—no discrimination (equality) | ||
EGE | Statement on European Solidarity and the Protection of Fundamental Rights in the COVID-19 Pandemic | The protection of human health is accorded a much higher priority in the system of values of the European Union than economic interests. EU member states should jointly pursue the protection of health of EU citizens | Protection of Human health and human rights | |||
France | COVID-19 Contribution from the French national Consultative Ethics Committee: Ethical issues in the face of a pandemic | A person's dignity does not depend on his or her usefulness. Thus, in a situation of scarcity of resources, medical choices, always difficult, have to be guided by ethical reflection that takes into account respect for the dignity of persons and the principle of fairness | The need for triage of patients raises a major ethical question of distributive justice, which in this case may lead to a differential treatment for patients infected with COVID-19 and those with other diseases. Those choices must always be explained and respect the principles of human dignity and fairness. It will also be necessary to be vigilant about the continuity of care for other patients | Differentiate resources among people with different needs (equity) | ||
Germany | Solidarity and Responsibility during the Coronavirus Crisis | The guaranteeing of human dignity necessitates egalitarian equality and thus provides for corresponding basic protection for all against discrimination | Respecting the intrinsic value of human beings—no discrimination (equality) while differentiate resources among people with different needs (equity) | |||
Ireland | Ethical Framework for Decision-Making in a Pandemic | The principle of fairness means that everyone matters equally, and under normal circumstances all individuals have an equal claim to healthcare | Respecting the intrinsic value of human beings—no discrimination (equality) | |||
Italy | Clinical ethics recommendations for admission to intensive care and for withdrawing treatment in exceptional conditions of imbalance between needs and availble resources | All access to intensive care must be considered and communicated as an “ICU trial” only and therefore undergo daily reassessment of its appropriateness, based on goals of care and proportionality of care | It may be necessary to establish an age limit for admission to the ICU. It is not a question of making choices merely according to worth, but to reserve resources that could become extremely scarce to those who, in the first instance, have a greater likelihood of surviving and who, secondarily, will have more years of life saved, with a view to maximizing the benefits for the greatest number of people | Differentiate resources among people with different needs—vulnerable people (equity) | ||
Republic of San Marino | Statement on ethical issues regarding to the use of invasive assisted ventilation in patient s all age with serious disabilities in relation to Covid-19 pandemic | Respect for human dignity is concretized allowing each person to experience a good death, through the precious tool of Palliative Care, which guarantee the control of pain and suffering, in the deep awareness that a person's life seriously ill and incurable, it never loses its intrinsic value nor the right to be supported and protected, therefore it reiterates that equal dignity must also be guaranteed to "non-treatable" victims, through taking charge and any sedation of pain | The founding principles of the Convention can be briefly indicated in equality and non discrimination and in the equality of opportunity (…) Equality of opportunity concerns the recognition of the right of access to goods and services, primarily health-related services | Respecting the intrinsic value of human beings—no discrimination (equality) Respecting dignity means offer patients good death and no suffer | ||
Portugal | CNECV statement: Covid-19 key consideration | The protection of life, dignity and integrity of citizens is an ethical responsibility that involves political authorities at different levels, namely in the preparation of health and sanitary responses, while planning and organising access to healthcare | Respecting dignity as ethical responsibility to Respecting the intrinsic value of human beings—no discrimination (equality) | |||
Public health emergency situation due to the COVID-19 pandemic- Relevant ethical aspects | Duty to protect human health should be given precedence when confronted with possible economic interests | Care teams are responsible for assessing the clinical needs of each patient, namely their severity and urgency, and weighing the response according to the principle of equitable distribution of available resources, which, in a context of scarcity, is a highly demanding responsibility | Differentiate resources among people with different needs—vulnerable people (equity) | |||
Spain | Report of the Ministry of Health on ethical aspects in pandemic situations: SARS-CoV-2 | The very foundations of our rule of law, in particular our recognition of the equal intrinsic dignity of every human being | Accepting discrimination of this kind would mean giving less value to certain human lives due to their life-cycle stage, contradicting the very foundations of our rule of law, in particular our recognition of the equal intrinsic dignity of every human being | It will be necessary to combine the general framework for such criteria with a thorough reflection on the situation and circumstances of each particular patient, and assessing-within that general framework of guiding principles—the uniqueness and individuality of each person affected | Respecting the intrinsic value of human beings—no discrimination (equality) differentiate resources among people with different needs—vulnerable people (equity) Individualized care | |
Switzerland | Pandemic Covid-19: triage of intensive care treatments in case of scarcity of resources Indications for the implementation of chapter 9.3 of the directives of the ASSM "Measures of intensive care" (2013), updated version of March 24, 2020 | Equity: Available resources are to be allocated without discrimination—i.e. without unjustified unequal treatment on grounds of age, sex, residence, nationality, religious affiliation, social or insurance status, or chronic disability | Respecting the intrinsic value of human beings—no discrimination | |||
The Holy See | Pandemic and Universal Brotherhood | Decisions cannot be based on differences in the value of a human life and the dignity of every person, which are always equal and priceless | The decision concerns rather the use of treatments in the best possible way on the basis of the needs of the patient, that is, the severity of his or her disease and need for care, and the evaluation of the clinical benefits that treatment can produce, based on his or her prognosis. Age cannot be considered the only, and automatic, criterion governing choice. Doing so could lead to a discriminatory attitude toward the elderly and the very weak | Respecting the intrinsic value of human beings—no discrimination | ||
UNESCO International Bioethics Committee (IBC)and theUNESCO World Commission on the Ethics of Scientific Knowledge and Technology (COMEST) | Statement on COVID-19: Ethical considerations from a global perspective | Procedures need to be transparent and should respect human dignity. Ethical principles enshrined in the human rights framework recognize the protection of health as a right of each human being | Respecting the intrinsic value of human beings—no discrimination; human right to health care | |||
UK | Guidance: Responding to COVID-19: the ethical framework for adult social care | Respect This principle is defined as recognising that every person and their human rights, personal choices, safety and dignity matters | (Inclusiveness): consider any disproportionate impacts of a decision on particular people or groups | Inclusiveness This principle is defined as ensuring that people are given a fair opportunity to understand situations, be included in decisions that affect them, and offer their views and challenge. In turn, decisions and actions should aim to minimise inequalities as much as possible | Dignity as respect of patient’s autonomy and patient’s choices and respecting the intrinsic value of human beings—no discrimination (equality) | |
Ethical considerations in responding to the COVID-19 pandemic | People should be treated as moral equals, worthy of respect | Respecting the intrinsic value of human beings—no discrimination | ||||
COVID-19—ethical issues. A guidance note | Equal respect everyone matters and everyone matters equally, but this does not mean that everyone will be treated the same | Fairness everyone matters equally. People with an equal chance of benefiting from a resource should have an equal chance of receiving it—although it is not unfair to ask people to wait if they could get the same benefit later | Respecting the intrinsic value of human beings—no discrimination (equality) while differentiate resources among people with different needs (equity) | |||
Ethical dimension of COVID-19 for front-line staff | Front-line staff, policymakers, management and government have a responsibility to patients to ensure that any system used to assess patients for escalation or de-escalation of care does not disadvantage any one group disproportionately. Treatment should be provided, irrespective of the individual’s background (eg disability), where it is considered that it will help the patient survive and not harm their long-term health and wellbeing | Respecting people while differentiate resources among people with different needs (equity) | ||||
Covid-19 Guidance: Ethical Advice and Support Framework | Respect All patients should be offered good quality and compassionate care Fairness Patients should be treated as individuals, and not discriminated against | Minimising harm Where there is a decision that a treatment is not clinically appropriate there is not an obligation to provide it, but the reasons should be explained to the patient and other options explored8 No active steps should be taken to shorten or end the life of an individual9, however the appropriate clinical decision may be to withdraw life prolonging or life sustaining treatment, or change management to deliver end of life care | It is important that patients are treated independent of suspected or confirmed COVID-19 status, and that any clinical decision guidance applies equally to all patients. The interests of each person are the concern of all of us, and of society ∙ The harm that might be suffered by every person matters, and so minimising the harm that a pandemic might cause is a central concern10 | Respecting the intrinsic value of human beings—no discrimination (equality) while differentiate resources among people with different needs (equity) | ||
Coronavirus: Your frequently asked questions | If a decision is taken not to start or to withdraw some forms of treatment from a patient, doctors should still take all possible steps to alleviate the patient’s symptoms and distress and respect their dignity. The patient’s wishes, preferences and fears in relation to their future treatment and care should be explored as far as possible | Decisions are based on clinical need and the likely effectiveness of treatments, and don’t unfairly discriminate against particular groups | Respecting the intrinsic value of human beings—no discrimination (equality) while differentiate resources among people with different needs (equity). Respecting dignity means to offer patients good death and no suffer. Dignity as respect of patient’s autonomy |