Introduction
The COVID-19 outbreak caused an unknown global health crisis and compelled governments and health systems worldwide to take strict measures to avoid the spread of the virus. These measures were necessary to protect public health, but at the same time caused ethical and functional problems, particularly for patients unrelated to COVID-19 virus but needing emergency care. This article, using narrative review methodology, examines the ethical and practical consequences of restrictive public health policies during the emergence of COVID-19 and emphasizes the need for a balanced approach to ensure that non-COVID-19 patients receive appropriate and acceptable emergency services in time.
The urgency to address these challenges is highlighted in cases where pandemic control measures have adversely affected non-COVID-19 cases. For example, ambulances are denied access to restricted areas, emergency services are closed, and urgent care is denied, resulting in preventable disease and mortality. Similar scenarios illustrate the crucial need for public health policy that is both effective in controlling pandemics and adapts to the immediate medical needs of all cases. Even though in the current literature we can find research paying attention to the situation of non-COVID-19 patients,1 there is no study addressing the problems that this study addresses, namely restriction of ambulance access and closure or refusal of emergency department.
The aim of this article is to contribute to public health ethics by proposing useful recommendations to improve the delivery of healthcare in the event of public health emergencies. It advocates ensuring ambulance access in restricted areas, strengthening emergency service capabilities, maintaining a balancing relationship between pandemic control measures and respect for patient rights. Through these recommendations, it attempts to promote a more equitable approach to healthcare in times of crisis, ensuring necessary care for non-COVID-19 patients in need of emergency services.
Measures Against the COVID-19 Outbreak: Raising Concerns
The outbreak of the COVID-19 pandemic presented an unprecedented challenge for governments worldwide, necessitating swift and decisive actions to control the spread of the virus and protect public health. Nonetheless, it is not the first severe acute respiratory syndrome (SARS) occurring in our history. The first emergence of SARS can be traced back to February 2003, when it broke out in China and spread to four other countries.2 Although with the first experience against SARS, humanity was as helpless against COVID-19 as it was when it experienced SARS for the first time.
Given the lack of medication, the most effective way against the COVID-19 virus was halting its transmission.3 The measures taken by countries worldwide to prevent the virus’s spread and lessen its effects on the populace included, but not limited to, quarantine, temporary closing of outbound routes and public areas, travel restrictions, social distancing, personal protective equipment, cleaning and disinfection, set-up of fever clinics, enhancement of testing capacity, expansion of healthcare infrastructure, use of digital technology for contact tracing. For instance, the Chinese government’s first step against the COVID-19 outbreak was a temporary closing of outbound routes and public areas, including various outbound routes at airports and railway stations and non-essential public spaces, such as cinemas, theatres, gyms, and other entertainment venues. This policy successfully limited social interactions to a certain extent and prevented large gatherings, thereby slowing down the spread of the virus and placing people’s lives above economic growth.4 In addition, the measures taken by the Chinese government embraced mass quarantine and travel restrictions,5–7 expansion of healthcare infrastructure,8 use of digital technology for contact tracing,9 and enhancement of testing capacity.10 Similar policy was taken by many other countries to protect public health.
However, this study intends to raise concerns relating to the measures that can affect health and endanger the lives of patients not related to COVID-19 but needing emergency treatments. The following two situations are emphasized in this study: (1) restriction of ambulance access; (2) closure or refusal of emergency department.
Restriction of Ambulance Access
The restriction of ambulance access was one of the main worries during the COVID-19 outbreak. While measures such as lockdown and blockade were put in place to stop the virus’ spread and safeguard the public’s health, there were instances during which ambulances could not get to patients who were in urgent or life-threatening circumstances. For instance, delivered in an ambulance on route to the closest hospital in Mangaluru, India, was a 25-year-old migrant worker from the border area of Kasaragod, Kerala. Since the entire country was under lockdown, the police in Karnataka prevented the ambulance from entering the state.11 The restriction of ambulance access occurred also in China, especially in Zibo city of Shandong Province,12 in Jingzhou city of Hubei Province,13 and in Lanzhou city of Gansu Province.14
Closure or Refusal of Emergency Department
To safeguard the health and lives of non-COVID-19 patients in need of emergency care, further consideration should be given to the closure or refusal of an emergency department. Even though the public health policies of countries worldwide were implemented to control the massive influx of COVID-19 patients and stop the virus from spreading, they presented difficulties for those who needed emergency medical attention for reasons unrelated to COVID-19. This situation occurred, for example, in Kazakhstan where local clinics refused to accept two critically ill patients, causing them to die while waiting in the ambulance.15 A similar situation also occurred in India, where a public hospital in Moga was shut when a woman reached it and two private hospitals refused to accept her.16 The closure or refusal of an emergency department also took place in some Chinese cities, such as in Xi’an city of Shaanxi Province,17 in Shanghai city18 and in Suining City of Jiangsu Province.19
In summary, certain measures against the COVID-19 pandemic, especially the ones that can restrict ambulance access and cause closure or refusal of emergency department, can affect the health and lives of non-COVID-19 patients in need of emergency care.
Public Health and Individual Rights
Individual rights, such as freedom of movement, right to health and well-being, free speech, right to work, etc, are regarded as natural rights and not created by the constitution, but states have responsibility to safeguard and defend through the constitution and other legal mechanisms at both local and international levels, ensuring the prevention of any violations of fundamental human rights.20 Nonetheless, the protection of individual rights is not absolute as they need to be compromised when colliding with public interests, such as public health. Public health is based on the social contract, wherein individuals abandon the state of nature to become members of society, relinquishing specific individual rights for the collective benefit, and in return, they receive the safeguarding of social order and laws, which are deemed more advantageous than the state of nature.21 However, the protection of public interests should not be based on the complete harm to individual interests given that states are required by their constitutions to comply with the principle of proportionality (or prohibition of excess). To be more precise, measures against pandemics should be proportionally taken against specific individual rights. For instance, the Constitution of the Portuguese Republic,22 Article 18/n 2, requires that the law, when restricting individual rights, should be limited to what is necessary to protect other rights and interests, such as collective interests. Within the Portuguese framework of the rule of law, the concept of proportion or prohibition of excess essentially refers to the necessity of a balanced relationship between means and purposes: state actions cannot, in pursuit of their purposes, use means that, due to their weight, result in excessive (and therefore unbalanced) burdens for the individuals for whom they are intended.23
This study does not intend to jeopardize the value or status of public health or even defend that individual rights can prevail over public health. It intends to find a better healthcare policy during the pandemic to protect proportionally public health and simultaneously guarantee the health and lives of non-COVID-19 patients needing emergency care. There is no doubt that measures against pandemics are fundamental to protecting public health, namely the collective interest that can prevail over specific individual rights. Even so, the balance between the measures and the purpose of protecting public health can be questioned, especially when the measures can affect ambulance access and cause closure or refusal of emergency services. If the defensive measures are well implemented, they can protect public health and simultaneously allow ambulances access and emergency rooms to be open 24 hours a day, guaranteeing the health and lives of non-COVID-19 patients in need of emergency service.
If this argument is correct, it is ethically or even legally questionable to restrain ambulance access and to close emergency departments or refuse urgent cases during a pandemic, even though these measures aim at protecting public health. They can endanger the well-being and possibly the lives of non-COVID-19 patients who need emergency medical care. There are significant concerns about patient rights and access to prompt and efficient medical care. People with medical emergencies unrelated to COVID-19, such as heart attacks, strokes, or severe traumas, may face potentially fatal situations if they do not receive early medical attention. Furthermore, people with chronic medical conditions or more likely to experience medical emergencies are disproportionately affected when urgent cases are rejected due to over-protection of public health. For these people, delaying or refusing care can worsen existing diseases, raise morbidity, and potentially increase death.
Emergency medical services (EMS) must be accessed quickly in a public health emergency to guarantee patient life and successful treatment, either for COVID-19 or for non-COVID-19 patients. If it is a common understanding that the right to health includes the right to prevention, treatment and control of diseases and equal and timely access to basic health services,24 its violation may have serious repercussions. The situation becomes even more urgent when a patient’s health is time-sensitive, regardless of whether it relates to COVID-19 or not. For that reason, ambulance access and emergency care should be guaranteed to all patients needing emergency services, not only the ones related to a pandemic. To manage the pandemic while ensuring that all patients, regardless of their COVID-19 status, have fair access to emergency medical care, a balance must be struck. In public health emergencies, especially when the medical resources are limited, the right to health of non-COVID-19 but critically ill patients always conflicts with that of COVID-19 patients. If it is not possible to guarantee EMS to all, the priority shall be given based on the patient’s clinical urgency. It means science decides the priority, not the policymaker. In this sense, non-COVID-19 but critically ill patients should be given priority if their clinical status is more critical than those of COVID-19 patients.
Suggestions for a Better Healthcare Policy in Public Health Emergency
Ensuring Ambulance Access to Confined Areas
One of the crucial challenges encountered during the COVID-19 pandemic was ensuring unimpeded access to EMS for patients residing within containment zones. However, many countries’ constitutions require that no one should be denied access to emergency medical care at a healthcare facility, such as the ones of Ecuador, the Arab Republic of Egypt, the Republic of Fiji, the Republic of Kenya and the Federal Democratic Republic of Nepal.25 To effectively address this issue and safeguard patients’ rights during public health emergency, it is recommended that healthcare policies be revised, if any, to guarantee unrestricted EMS access for all patients regardless of their location within containment zones.
For achieving this purpose, clear EMS access protocols shall be established. Healthcare policies shall establish unambiguous protocols and guidelines governing EMS access to confined zones. These protocols can provide explicit instructions on how EMS providers can enter and exit these areas, ensuring their timely reach to patients with urgent and critical conditions. Collaboration between healthcare authorities, EMS, and local governments is essential in developing these protocols, striking a balance between infection control measures, and ensuring timely care.
Additionally, coordinated communication channels should be set up. Effective communication between healthcare authorities, EMS, and local governments is vital in facilitating ambulance access during public health emergencies. Regular updates and communication channels shall be established to keep EMS providers informed about restricted access areas, changes in access requirements, and necessary precautions. Such coordinated communication channels enable EMS providers to navigate confined zones while complying with infection control measures.
Moreover, dedicated transportation corridors shall be created within restricted zones to streamline EMS access. These corridors allow EMS vehicles to bypass checkpoints efficiently and reach patients needing urgent care. By assigning specific routes for EMS providers, healthcare policies ensure that time-sensitive emergencies are not hindered by logistical challenges or delays due to restricted access.
Finally, training and preparedness are needed. EMS providers should receive specialized training to handle public health emergencies effectively.26 Healthcare policies should emphasize the importance of ongoing training programs to enhance the skills and knowledge of EMS personnel in infection control, patient management, and effective communication in high-stress situations. This training ensures that EMS providers can navigate restricted zones and provide safe and effective care for needy patients.
Strengthening Emergency Department Capabilities
During the COVID-19 pandemic, emergency department closure or rejection of urgent cases presented significant challenges concerning patients’ rights and ability to receive timely care. To address these concerns and maintain accessible emergency care during public health emergencies, it is necessary to revise, if any, healthcare policies to strengthen the capabilities and protocols of emergency departments. Changes that can enhance emergency department operations, prioritize urgent cases and guarantee patient’s rights in an emergency shall be made.
Therefore, it is necessary to sustain at least the operation of emergency departments. Healthcare policies should emphasize the importance of keeping emergency departments operational throughout public health emergencies. Clear guidelines shall be established to prevent the closure or rejection of urgent cases from emergency departments. For instance, states can be inspired by the steps in health service continuity planning proposed by WHO that are built on the basic principles of emergency and service continuity planning.27 When a public health emergency poses exceptional difficulties, it is critical to ensure that emergency departments continue to provide essential care to patients with acute medical conditions, even though they are unrelated to COVID-19. For achieving this purpose, the separation of patients in different areas in emergency departments is needed to avoid trans infection of the virus.
On the other hand, it is suggested an optimization of patient flow in emergency departments. Healthcare policies shall incorporate strategies to streamline patient flow within emergency departments during public health emergencies. This can be achieved by implementing triage systems that rapidly identify and prioritize patients based on the severity of their conditions.28 Emergency departments can optimize patient care by efficiently assessing patients, allocating resources, and ensuring that urgent cases receive timely attention. Clear protocols and guidelines shall be established for the triage process to ensure consistency and fairness.
Further, sufficient staffing and resources shall be guaranteed. Emergency departments should have adequate staff and resources to meet the increased demand during public health emergencies.29 Healthcare regulations shall encompass provisions for maintaining optimal staffing levels within emergency departments. This entails ensuring the availability of adequate doctors, nurses, and support personnel to manage the influx of patients effectively. In addition, allocating essential resources to ensure secure and efficient patient care is paramount. This encompasses the provision of vital medical supplies, medications, and personal protective equipment indispensable for safeguarding the well-being and safety of healthcare providers and patients. If the staffing and resources in an emergency department cannot deal with the increased number of patients, communication and coordination among healthcare facilities are needed to transfer the ones who cannot be treated in time to other hospitals with enough staffing and resources or, alternatively, transfer healthcare professionals to facilities facing insufficient staff. For the former purpose, the concept of a Collective Critical Care Ambulance can be used to transfer a large number of COVID-19 patients from the hospitals with overwhelming demand to the ones with less demand.30 Besides, a system that in real-time displays the emergency department capacity of healthcare facilities nearby can avoid useless communication, facilitating the immediate transfer of needy patients between facilities.
Finding a Balance Between Pandemic Control and Respect for Patient Rights
In pursuing a harmonious compromise between pandemic control measures and preserving patients’ rights, it becomes imperative to explore inventive strategies that alleviate the impact on patient rights while effectively combat the spread of the virus. This study intends to emphasize the need for a patient-centric approach to managing pandemics.
Transparency and communication emerge as a guiding light, illuminating decision-making processes involving healthcare professionals, policymakers, and patient representatives. Listening to the voices of patient representatives and not only of healthcare professionals while managing public health emergencies can be a key step towards transparency. From our perspective, this transformative approach can ensure that patients’ rights occupy a central place while implementing pandemic control measures, given that it considers patients’ needs during the pandemic without affecting the existing value or status of public interest. A lack of transparency and communication can cause people to misunderstand the reasons behind healthcare policy during public health emergencies. The worst situation is that receiving disinformation in a pandemic may cause patients to lose trust, feel worried, or even be encouraged to carry out harmful behavior.31 Therefore, transparency and communication play important roles in finding a balance between pandemic control and respect for patient rights.
To strike a balance between pandemic management and patient rights, it is important to embrace the transformative potential of individualized risk assessment. By accounting for individual circumstances, vulnerabilities, access to healthcare, and socio-economic factors, tailored measures emerge to minimize the impact on patient rights while addressing the exigencies of public health concerns. The importance of individualized risk assessment highlights the need for pandemic control measures to be precisely tailored to individuals’ and communities’ diverse risks. For example, countries worldwide can develop a dynamic system, such as COVIRA, that uses the most recent data available to estimate individual and regional COVID-19 risk,32 which can protect public health and, at the same time, guarantee individual rights of patients, whether related to COVID-19 or not.
Besides, flexibility becomes central, giving control measures new vitality and encouraging a compromise that upholds patient rights. Rapid responses, formed by changing epidemiological data, enable adjustments that strike a careful balance between reducing the impact on human rights and preventing the virus’s spread. Some studies demonstrate the important role of flexibility in public health emergencies. For example, some authors highlight the role of flexibility for capacity management and demand management in a hospital to effectively balance COVID-19 and non-COVID-19 hospitalizations of patients.33
A harmonious compromise is reached by cooperative efforts that incorporate the knowledge and perceptions of significant stakeholders from various backgrounds,34 such as medical experts, policymakers, and patient advocate organizations. Engaging multiple perspectives becomes a transformative catalyst, resolving potential conflicts and shaping solutions that strike a balance between competing priorities. Involving diverse stakeholders in ethical deliberations and decision-making processes can ensure an inclusive and comprehensive approach that acknowledges the interests of public health and individual rights.
Ethical frameworks are also important for balancing pandemic control and respect for shared values.35 By employing ethical principles and frameworks, policymakers and healthcare professionals can handle the complexities of the pandemic, making informed decisions that safeguard patient rights while effectively restraining the virus.
Finally, two important points should be emphasized. First, comparative analysis of healthcare systems or regions that maintained emergency services versus those that restricted them can validate the abovementioned recommendations. Taking the Portuguese health system as reference, there was neither policy restraining the ambulance access to the ones who needed emergency services nor closure or refusal of emergency departments in public hospitals, even though this closure or refusal occurred in private hospitals at the beginning of the COVID-19 pandemic.36 The comparison between the Portuguese situation and the ones we analyzed above (such as China, India, Kazakhstan and Moga) demonstrates the importance of the three suggestions above. Second, policymakers shall, based on the suggestions above, create actional strategies to help healthcare systems balance emergency care and pandemic control in future crises. These strategies can guarantee the feasibility of the mentioned suggestions.
Conclusion
In conclusion, the COVID-19 pandemic illuminated substantial gaps and ethical dilemmas within existing healthcare policies, particularly concerning the treatment of non-COVID-19 cases in emergency situations. The restrictive measures adopted to control the virus’s spread, while effective in some respects, compromised the health and well-being of individuals needing critical medical attention for conditions unconnected to COVID-19. This paper underscores the necessity of revising current healthcare policies to guarantee a more balanced and ethical approach during public health emergencies.
The recommendations provided herein, namely ensuring unimpeded ambulance access, enhancing the functional capabilities of emergency departments, and striking a proportional balance between pandemic control and patient rights, are pivotal ways towards achieving the purpose. By applying these measures, health systems can better navigate the complexity of public health emergencies and ensure public health and individual rights of patients unrelated to pandemic but needing emergency care.
Future public health crises are inevitable, and we must learn from the challenges faced during the COVID-19 pandemic. All potential stakeholders, such as policymakers, health care providers and legal experts, must collaborate to establish a flexible health system that can provide equitable healthcare under all circumstances. This visionary approach will not only improve our preparedness for future emergencies but also establish the ethical principles of public health and medical practice. By placing public health and individual rights at the forefront of attention, we can create a more just and effective health system for all.
Abbreviations
SARS, severe acute respiratory syndrome; EMS, emergency medical services.
Funding
This research is supported by funding from the University of Macau under research Grant No. SRG2024-00038-FLL.
Disclosure
The author(s) report no conflicts of interest in this work.
References
1. Hassan B, Arawi T. The Care for Non-COVID-19 Patients: a Matter of Choice or Moral Obligation? Front Med. 2020;7:564038. doi:10.3389/fmed.2020.564038
2. World Health Organization. Severe Acute Respiratory Syndrome (SARS). Available from:
3. Güner R, Hasanoğlu İ, Aktaş F. COVID-19: prevention and control measures in community. Turkey J Me Scie 2020;50:571–577. doi:10.3906/sag-2004-146
4. The State Council Information Office of the People’s Republic of China. Fighting Covid-19. Available from:
5. Ding D, Zhang R. China’s COVID-19 Control Strategy and Its Impact on the Global Pandemic. Front Public Health. 2022;14(10):857003. doi:10.3389/fpubh.2022.857003
6. Cheng S, Zhao Y, Kaminga AC, et al. China’s Fight Against COVID-19: what We Have Done and What We Should Do Next? Front Public Health. 2022;10:548056. doi:10.3389/fpubh.2022.548056
7. Zhang X. Study on Prevention and Control Measures and Experience of Village and Road Closures during Covid-19 Epidemic Prevention – Illustrated with the Case of Henan Province. J Zhangjia Vocatio Tech Co. 2020;33:3–9.
8. Cai Y, Chen Y, Xiao L, et al. The health and economic impact of constructing temporary field hospitals to meet the COVID-19 pandemic surge: Wuhan Leishenshan Hospital in China as a case study. Journal of Global Health. 2021;11:05023. doi:10.7189/jogh.11.05023
9. Yu X LN, Dong Y, Dong Y. Observation on China’s Strategies to Prevent the Resurgence of the COVID-19 Epidemic. Risk Manag Healthcare Poli. 2021;14:2011–2019. doi:10.2147/RMHP.S305413
10. Xu J SL, Cao B, Cao B. Guarding a city from the COVID-19 pandemic. Lancet Digital Health. 2020;2(6):E275–E276. doi:10.1016/S2589-7500(20)30111-4
11. Bisht R SJ, Saharia R COVID-19 Lockdown: guidelines Are Not Enough to Ensure Pregnant Women Receive Care. The WIRE.
12. Are cancer-stricken elderly people asked for a ‘certificate of awaiting death’ when seeking medical treatment? Official notification. The Guancha.
13. The road was closed, and the ambulance could not enter, the police used sheets to carry out the patient. The Paper.
14. China’s epidemic prevention has reached a point of outrage and resentment. The Liberty Time Net. Available from:
15. Kumenov A. Kazakhstan pivoting back to robust lockdown. The eurasianet. Available from:
16. Bisht R, Sarma J, Saharia R COVID-19 Lockdown: guidelines Are Not Enough to Ensure Pregnant Women Receive Care. The WIRE. Available from:
17. Xi’an lockdown: many pregnant women and critically ill patients were refused treatment by hospitals, sparking public outrage. BBC News. 2022 Available from:
18. She used her life to adjust the scale of epidemic prevention and control, and patients must ensure normal medical treatment. China Medical Tribune. Available from:
19. A one-and-A-half-year-old baby in Suining, Jiangsu died after being stuck in his throat and being refused diagnosis because he had no nucleic acid certificate? Official: verifying. The Guancha.
20. Chime SC. Individual Rights and Public Interest. African J Enviro Law. 2024;9(1):219–228.
21. Leonard EW. The Public’s Right to Health: when Patient Rights Threaten the Commons. Washington University Law Review. 2008;86:1335–1396.
22. Public Ministry. Constitution of the Portuguese Republic. Available from:
23. Constitutional Court of Portugal, Judgement No. 632/2008, Case No. 977/2008, Available from
24. Office of the United Nations High Commissioner for Human Rights. The Right to Health (Fact Sheet No. 31), in Human Rights Fact Sheet; 2008. Available from:
25. Burkholder TW, Ross M, Vartanyan L, et al. A Global Review of Provisions on Emergency Care in National Constitutions. Heal Hun RigJ. 2021;23(2):187–200.
26. Pan American Health Organization. Prehospital Emergency Medical Services (EMS) COVID-19 Recommendations. Available from:
27. World Health Organization. Health service continuity planning for public health emergencies: a handbook for health facilities. Interim version for field testing. Availabe from:
28. Yancey CC, MC O. Emergency Department Triage. StatPearls. Available from:
29. World Health Organization. Strengthening health emergency prevention, preparedness, response and resilience; 2023. Available from:
30. Lentz T, Groizard C, Colomes A, et al. Collective Critical Care Ambulance: an innovative transportation of critical care patients by bus in COVID-19 pandemic response. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2021;29:78. doi:10.1186/s13049-021-00896-0
31. Secretary-General of the Organisation for Economic Co-operation and Development. Transparency, communication and trust: the role of public communication in responding to the wave of disinformation about the new Coronavirus. Available from:
32. Parajuli RR, Mishra B, Banstola A, et al. Multidisciplinary approach to COVID-19 risk communication: a framework and tool for individual and regional risk assessment. Sci Rep. 2020;10:21650. doi:10.1038/s41598-020-78779-0
33. Troisi R, Simone SD, Vargas M, et al. The other side of the crisis: organizational flexibility in balancing Covid-19 and non-Covid-19 health-care services. BMC Health Serv Res. 2022;22:1096. doi:10.1186/s12913-022-08486-1
34. Mohamadian M, Nasiri T, Bahadori M, et al. Stakeholders analysis of COVID-19 management and control: a case of Iran. BMC Public Health. 2022;22:1090. doi:10.1186/s12889-022-14219-0
35. Sláinte AR. Ethical Framework for Decision-Making in a Pandemic. Available from:
36. Varanda J GL, Craveiro I, Craveiro I. The Unlikely Saviour: portugal’s National Health System and the Initial Impact of the COVID-19 Pandemic? Development. 2020;63:291–297. doi:10.1057/s41301-020-00268-8
link
.jpg "New Stroke Prevention Guidelines Emphasize Power Of Lifestyle Changes")
