FIGO Ethics And Professionalism Guideline 080: Ethical Challenges Of The COVID-19 Pandemic

Background

1. The COVID-19 pandemic has affected almost every country in the world, some more than others and at unpredictable severity levels.  The response to the pandemic in countries and regions has varied, with varying levels of success in containment.  The most successful responses appear to have occurred in countries with equitable healthcare systems, which is an important macro-level consideration.

2. FIGO has provided its members with resources on the scientific and clinical challenges of the pandemic for obstetrician-gynecologists and their patients.

3. The World Health Organization has provided general guidance.

4. National associations of obstetricians and gynecologists have also provided guidance to their members.

5. Pandemics create ethical challenges for physicians in all specialties, and especially for obstetrics and gynecology. Fear and stress in the early stages of the COVID-19 pandemic mirrored other pandemics, in that scientific and clinical information was limited and treatment and prevention were in their infancy; factors that were exacerbated by the shortage of personal protective equipment.

6. Professionally responsible care of a pregnant patient with COVID-19 disease requires a multidisciplinary team, with sustained coordination with infectious disease and epidemiology.

7. There is no evidence that a spouse or other companion assisting in vaginal delivery who follows accepted infection control measures creates an unacceptable risk of horizontal to the patient or healthcare team.

Ethical Framework

1. An essential component of professional ethics in obstetrics and gynecology is the life-long commitment to scientific and clinical competence, as a matter of professional integrity.

2. The ethical principle of beneficence in professional ethics in obstetrics and gynecology creates the prima facie ethical obligation of the obstetrician-gynecologist to identify and provide clinical management of the patient’s condition or diagnosis that, in deliberative (evidence-based, rigorous, transparent, and accountable) clinical judgment is predicted to result in net clinical benefit.  Such clinical management is known as medically reasonable.

3. The ethical principle of respect for autonomy obligates the physician to empower the patient to make informed decisions about the clinical management of her condition by providing her with an unbiased presentation of information about the medically reasonable alternatives for the management of her condition, and the clinical benefits and risks of each alternative, and to support her decision making.

4. The ethical principle of healthcare justice in professional ethics in obstetrics and gynecology creates a prima facie ethical obligation of the obstetrician-gynecologist to make sure that each patient receives medically reasonable clinical management of her condition or diagnosis.

5. The professional virtue of self-sacrifice requires the physician to accept reasonable limits on the physician’s self-interest in order to fulfill the commitment to putting the patient’s interests first, and to accept limits on group self-interest to fulfill the commitment to maintain the profession of medicine as a public trust.

6. All women and men have the fundamental human sexual and reproductive rights.  These rights have been widely agreed on and are laid down in such documents as the Universal Declaration of Human Rights (1948); the twin International Covenants on Civil and Political Rights and on Economic, Social and Cultural Rights (1975); the International Convention on the Elimination of All Forms of Discrimination against Women (1979); and the International Convention on the Rights of the Child (1989). Sexual and Reproductive Human Rights have also been identified by the International Conference on Population and Development, in Cairo (1994), and reaffirmed by the Fourth World Conference on Women, in Beijing (1995), the UNESCO Declaration on Bioethics and Human Rights (article 6) 2005, and the World Health Organization (WHO) (2017).  Many countries have enumerated human rights and provided for their protection and implementation in law.

7. Every patient has a legitimate self-interest in participating in infection control measures, to protect her own health and life. Patients also have a beneficence-based ethical obligation to prevent harm to their obstetricians and other healthcare professionals by participating in infection-control measures, to protect the health and life of team members. This is simply a clinical application of what is known in general ethical theory as the harm principle.

8. The spouse or other companion supporting the patient in a vaginal delivery has a beneficence-based ethical obligation to prevent risk of horizontal transmission to the pregnant patient, neonatal patient, other patients, and the healthcare team.  This is simply a clinical application of what is known in general ethical theory as the harm principle.

9. Obstetricians and all other specialists have both beneficence-based and healthcare-justice-based ethical obligations to protect the life and health of all of the patients served by a healthcare organisation. Fulfilling these ethical obligations may require ‘frame-shifting’ away from meeting the needs of obstetric patients, to meeting the needs of the entire population of patients of a healthcare organisation in the allocation of its resources.

Recommendations

1. Obstetricians and gynecologists have the integrity-based ethical obligation to remain updated on the rapidly evolving information about the COVID-19 pandemic and its implications for obstetric and gynecologic practice. This ethical obligation can be readily fulfilled by consulting resources on COVID-19 and pregnancy such as FIGO, WHO, and national associations of obstetricians and gynecologists.

2. FIGO member societies should advocate against proposed restrictions on human sexual and reproductive rights in public policy responses by governments to the COVID-19 pandemic. 

3. An organisational policy of limiting elective procedures may be justified by healthcare justice as a measure to conserve resources for all patients gravely ill in a hospital with COVID-19.  However, as much as the termination of pregnancy is time-sensitive, it should not be classified as ‘elective’ but as an essential component of patient care.

4. Healthcare organisations have a healthcare-justice-based ethical obligation to make sure that the human and material resources necessary to provide equitable healthcare resources for obstetric services, to ensure that labouring women have access to medically reasonable clinical management, including rapid access to indicated cesarean delivery. These resources should be protected from diversion to other services. This is known as ‘ring-fencing’ of obstetric services. 

5. As necessary to protect pregnant patients, obstetrician-gynecologists should advocate for evidence-based ring-fencing of obstetric resources. Obstetrician-gynecologists should join with other specialists to engage in unified advocacy for ring-fencing all medically reasonable clinical management for essential clinical care, including treatment of cancer and other conditions and diagnoses for which postponement of treatment is not medically reasonable. 

6. Obstetrician-gynecologists have the beneficence-based ethical obligation to be aware of and seek to prevent psychosocial aspects of containment measures, e.g., the risk that a shelter-in-place policy may increase the risk of spousal economic, psychological, or physical abuse.

7. Obstetrician-gynecologists have the beneficence-based ethical obligation to be aware of and seek to prevent mental health aspects of containment measures, e.g., increased risk of onset or exacerbation of anxiety, depression, and other mental disorders, particularly among geriatric female patients who live alone.

8. The fulfillment of the ethical obligation to take reasonable risks to one’s health and life, which originates in the professional virtue of self-sacrifice, creates the correlative right against healthcare organisations and governments of obstetrician-gynecologists to be provided with effective infection control materials, including personal protective equipment. Member societies should advocate for the resources required to implement this right routinely in clinical practice and education.

9. Since at least the middle of the nineteenth century, the ethical obligation not to flee during times of contagion has been recognised, along with the prerogative of physicians to relocate their families to safety. The use of accepted infection control measures reduces personal risk of obstetricians to a minimum, making such risk acceptable from the perspective of the professional virtue of self-sacrifice. Obstetricians should fulfill their ethical obligation to continue to provide obstetric care to their patients, provided that effective infection control measures are feasible. Obstetricians should be compensated for provision of patient care; provision of care to patients with COVID-19 is no exception.

10. Obstetric educators should advocate for the continued clinical instruction of learners when their involvement does not create unreasonable risk to patients and when their use of personal protective equipment does not result in shortages for healthcare team members. When either of these conditions cannot be met, obstetric educators should advocate for non-clinical teaching of learners, to minimise disruption to their progress toward degrees and certification.

11. In extreme circumstances, the needs of a population to patients may threaten to overwhelm an organisation’s resources. When this occurs, obstetricians have beneficence-based and healthcare justice-based ethical obligations to accept the need for frameshifting in decision making about the allocation of organisational resources to meet the needs to the entire population of patients served by a healthcare organisation. At the same time, obstetricians should advocate for the recognition of limits on such resource allocation created by ethically justified ring-fencing of obstetric resources.

Virtual Meeting from New York, July, 2020

Citation:

FIGO Committee on Ethical and Professional Aspects of Human Reproduction and Women’s Health.  FIGO Ethics and Professionalism Guideline 080: Ethical Challenges of the COVID019 pandemic.  https://www.figo.org/figo-ethics-and-professionalism-guideline-080-ethical-challenges-covid-19-pandemic

About FIGO

FIGO is a professional organisation that brings together obstetrical and gynecological associations from all over the world.

FIGO’s vision is that women of the world achieve the highest possible standards of physical, mental, reproductive and sexual health and wellbeing throughout their lives. We lead on global programme activities, with a particular focus on sub-Saharan Africa and South East Asia.

FIGO advocates on a global stage, especially in relation to the Sustainable Development Goals (SDGs) pertaining to reproductive, maternal, newborn, child and adolescent health and non-communicable diseases (SDG3). We also work to raise the status of women and enable their active participation to achieve their reproductive and sexual rights, including addressing FGM and gender based violence (SDG5).

We also provide education and training for our Member Societies and build capacities of those from low-resource countries through strengthening leadership, good practice and promotion of policy dialogues.

FIGO is in official relations with the World Health Organization (WHO) and a consultative status with the United Nations (UN).