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Dying individuals and suffering populations: applying a population-level bioethics lens to palliative care in humanitarian contexts: before, during and after the COVID-19 pandemic
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  1. Keona Jeane Wynne1,2,
  2. Mila Petrova3,
  3. Rachel Coghlan4
  1. 1 Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
  2. 2 Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Cambridge Palliative and End of Life Care Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  4. 4 Centre for Humanitarian Leadership, Deakin University, Burwood, Victoria, Australia
  1. Correspondence to Keona Jeane Wynne, Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, MA 02115, USA; kjwynne{at}g.harvard.edu

Abstract

Background Humanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care—a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, the WHO released a guide on Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises’—the first guidance on the topic by an international body.

Aims This paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.

Implications In parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance.

  • palliative care
  • public health ethics

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Footnotes

  • Twitter @KeonaWynne

  • Contributors All authors contributed equally to this work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed in this paper are RC's and MP's views as an academic researchers and not a formal position of PalCHASE.

  • Competing interests MP reports that she is a Steering Group member of Palliative Care in Humanitarian Aid Situations and Emergencies network. RC reports that she is a member of the Palliative Care in Humanitarian Aid Situations and Emergencies network.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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