Artikel 8 - Vonderschmitt (2023)

Vonderschmitt et al.
BMC Public Health (2023) 23:2492 BMC Public Health

https://doi.org/10.1186/s12889-023-17249-4
RESEARCH Open Access
Scarce resources, public health

and professional care: the COVID‑19 pandemic
exacerbating bioethical conflicts — findings
from global qualitative expert interviews
Jane Vonderschmitt1*, Sabine Wöhlke2† and Silke Schicktanz1†
Abstract
Background Since spring 2020, the SARS-CoV-2 virus has spread worldwide, causing dramatic global consequences
in terms of medical, care, economic, cultural and bioethical dimensions. Although the resulting conflicts initially
appeared to be quite similar in most countries, a closer look reveals a country-specific intensification and differentia-
tion of issues. Our study focused on understanding and highlighting bioethical conflicts that were triggered, exposed
or intensified by the COVID-19 pandemic in low and middle-income countries (LMICs) and high-income countries
(HICs).
Methods We conducted qualitative interviews with 39 ethics experts from 34 countries (Argentina, Australia, Austria,
Brazil, Canada, Colombia, Denmark, Ecuador, Ethiopia, France, Germany, India, Italy, Israel, Japan, Kyrgyzstan, Mexico,
Nigeria, Oman, Pakistan, Paraguay, Poland, Romania, Russia, Singapore, South Korea, Spain, Sweden, South Africa, Tuni-
sia, Türkiye, United-Kingdom, United States of America, Zambia) from November 2020 to March 2021. We analysed
the interviews using qualitative content analysis.
Results The scale of the bioethical challenges between countries differed, as did coping strategies for meeting these
challenges. Data analysis focused on:
a) Resource scarcity in clinical contexts: Scarcity of medical resources led to the need to prioritize the care of some
COVID-19 patients in clinical settings globally. Because this entails the postponement of treatment for other
patients, the possibility of serious present or future harm to deprioritized patients was identified as a relevant
issue.
b) Health literacy: The pandemic demonstrated the significance of health literacy and its influence on the effective
implementation of health measures.
c) Inequality and vulnerable groups: The pandemic highlighted the context-sensitivity and intersectionality
of the vulnerabilities of women and children in LMICs and the aged in HICs.
d) Conflicts surrounding healthcare professionals: The COVID-19 outbreak underscored the tough working condi-
tions for nurses and other health professionals, raising awareness of the need for reform.
†
Sabine Wöhlke and Silke Schicktanz shared last authorship.
*Correspondence:
Jane Vonderschmitt
[email protected]
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Vonderschmitt et al. BMC Public Health (2023) 23:2492 Page 2 of 15
Conclusion The pandemic exposed pre-existing structural problems in LMICs and HICs. Without neglecting indi-
vidual contextual factors in the observed countries, we created a mosaic of different voices of experts in bioethics
across the globe, drawing attention to the need for international solidarity in the context of a global crisis.
Keywords COVID-19, Pandemic, Bioethics, Vulnerability, Global Comparison, Experts, Qualitative Interviews
Introduction While this situation has been widely discussed in HICs

Severe acute respiratory syndrome coronavirus 2 (SARS- especially as ‘triage’ in the clinical setting [9–12], in
CoV-2), the virus causing COVID-19, was first detected other countries, particularly in LMICs, prioritization
in December 2019 in Wuhan, China. Its rapid spread to decisions entailed also excluding individuals from basic
many other countries led the World Health Organization healthcare access completely [13]. Under conditions of
(WHO) to declare the international developments sur- resource scarcity in clinical settings, some countries
rounding the virus to be a pandemic on March 11, 2020 formalized priorities in the allocation of life-saving
[1]. Worldwide, the COVID-19 outbreak had serious resources, such as ventilators and ICU beds, favouring
health consequences including long hospitalizations and certain populations [11, 14]. In this context, the pri-
high mortality rates [2, 3]. Many countries responded by oritization of COVID-19-related cases also led to the
implementing public health (PH) strategies to control postponement of other treatments [15], for example
COVID-19 outbreaks, using policies that included iden- tuberculosis (TB) and human immunodeficiency virus
tifying and quarantining infected individuals, mandating (HIV) in Congo [16]. This raises potential bioethical
the wearing of protective masks, social distancing and conflicts of resource allocation.
restrictions on international travel [4, 5]. PH strategies PH ethical dilemmas principally derive from the ten-
gave rise to a multitude of bioethical conflicts and chal- sions between the public good and restrictions on per-
lenges across the globe, and this study investigated their sonal freedom [17]. Infection-control measures like
similarities and differences drawing on expert interviews. masks and contact restrictions, for example, were
“Bioethics” is used in the study as an umbrella term for imposed to protect population health but were often
ethical issues, problems and dilemmas arising in the criticized as an unjustifiable curtailment of individual
fields of biology, research, medicine, PH and healthcare freedom. While the intensity of contact tracing in coun-
[6]. Depending on the context, we differentiate between tries such as Israel and South Korea led to discussions
medical ethics (all clinical settings), PH ethics (collec- about data protection and protests against interventions
tive issues) and nursing ethics specifically. To answer our intended to reduce virus spread [18, 19], debates about
research question of how, in cross-national comparison, vaccines ranged from possible vaccination mandates [20]
bioethical conflicts were triggered or exacerbated by the to global equitable distribution and national prioritiza-
COVID-19 pandemic, we categorized our findings into tion [14, 21]. Health literacy – the skills to understand
four main topics including A) resource scarcity in medi- and to use relevant health information – has been identi-
cal contexts, B) health literacy, C) inequality and vulner- fied as an essential determinant of public acceptance of
able groups and D) conflicts surrounding health-care measures [22]. Yet, the promotion of health literacy has
professionals [5, 7]. These ethical categories were estab- become increasingly complicated in the twenty-first cen-
lished deductively from empirical findings; their theoreti- tury due to the spread of disinformation and conspiracy
cal foundations had been outlined previously, between theories in social media, leading to a decrease in the
June and November 2020. We distinguished between acceptance of important PH interventions [22, 23].
low and middle-income countries (LMICs) and high- Vulnerability is understood as a state of being at
income countries (HICs) by using the World Bank clas- increased risk of harm with reduced capacity to protect
sification of countries based on Gross National Income: oneself [24] and is also a component of ethical debate. In
lower-income (< $1,085), lower-middle income ($1,085— the context of COVID-19, social and medical inequalities
$4,256), upper-middle income ($4,256—$13,205) and in the discriminatory attitudes towards older people in
high-income (> $13,205) [8]. HICs have become apparent, giving rise to further ethical
issues [25, 26]. Meanwhile, in Latin American countries
the protection of women and children was discussed dur-
Background ing the first wave of the pandemic [27]. Other literature
COVID-19 created or exposed various conflicts of identifies conflicts around additional vulnerable groups,
resource scarcity in clinical settings as decisions about such as people with disabilities and ethnical minorities,
the allocation of scarce resources had to be made. as a pressing global issue [28].
Finally, health-care professionals1 gloablly experi- Ethics Committee of the University Medical Center Göt-
enced specific ‘frontline’ stressors [29], including, for tingen (32/10/20).
example, high workloads under scarcity of staff, time
and protective equipment [12, 30–32]. These added Sampling, data collection, consent
tensions strained the integrity of professional stand- Recruitment of experts took place from November 2020
ards, particularly in nursing, that are already at risk due through January 2021 and was based on the department’s
to permanently difficult working conditions [31]. They exiting international network of scientists, a targeted
created sometimes contradictory political demands internet search and an emergent snowball system using
and high societal expectations [12]. Additionally, vari- recommendations from third parties and interviewed
ous challenging situations, such as patient mortal- experts. Participants were selected regarding their
ity and the safety of colleagues and families, further involvement in public discourses concerning COVID-19,
increased mental stress. Moral dilemmas were more such as published papers and participation in interna-
frequent, resulting in ‘moral distress’ [33] for many tional online sessions on COVID-19, their spectrum of
health professionals. research and country of residence. Some were represent-
Through our study of expert opinion, we provide an atives on ethics committees, some were lecturers on the
exploratory contribution that takes a global perspec- pandemic and others were involved in clinical practice
tive. It complements existing studies, which focus as physicians and spoke of their ‘front-line’ experience.
predominantly on single countries. We conducted To ensure confidentiality, we give no details regarding
interviews with 39 experts in bioethics (including the professional status of interviewees, but some have
clinical ethics) or PH ethics. A third of these experts more clinical expertise and others a more theoretical
are addtionally involved in medical research or policy- background.
making related to COVID-19. Their expertise in rele- In total, we conducted 39 interviews with experts of
vant topics provides valuable insights into the realities different ethical fields, reporting from 34 different coun-
of different countries and cannot be adequately cap- tries. The differentiation of the countries studied into
tured quantitatively. By comparing their appraisals of LMICs and HICs was based on the World Bank’s clas-
the bioethical issues of COVID-19, we hope to open sification.3 Table 1 provides an overview of the experts
a globalised perspective on ethical issues for future interviewed.
pandemics. We collected the data in form of semi-structured
expert interviews. With reference to a literature review
Methods and materials of publications up to November 2020 regarding poten-
Study design tial ethical conflicts worldwide in context of COVID-19,
For this exploratory study we used qualitative research a standardized semi-structured interview guide was for-
methods to identify bioethical conflicts created or mulated, aiming to structure the content by means of 13
revealed by the COVID-19 pandemic. We conducted 39 open-ended questions regarding scarce resources, PH
semi-structured expert interviews. The aim of our quali- and professional care (including further sub-topics, see
tative study was to fill the gap of a global perspective by Additional file 1: Interview guideline). The guide was
classifying commonalities and differences perceived in pretested in three interviews to ensure its validity and
bioethical conflicts in context of the COVID-19-pan- comprehensibility and sent to participants prior to the
demic in 34 countries. The study is part of a larger project interviews.
at the Department of Medical Ethics of the University of Data collection took place online via Zoom4 between
Göttingen that has presented the experts’ assessments in November 2020 and March 2021. All interviews were
an internet-based virtual exhibition since May 2022. It is conducted by J.V. with the majority in English (35), but
publicly accessable in the form of podcasts and interac- also in German (3) and Spanish (1). The average inter-
tive teaching material.2 The study was approved by the view lasted about 50 min. Prior to data collection, written
1 3
The nursing profession diverges internationally. By ‘health-care profes- https://data.worldbank.org/countr y/XO (01/06/2023). For clarity, we have
sionals’ we mean all staff working in health institutions (doctors, nurses, combined the groups of low income, low-middle income and upper middle-
etc.), whereas when specifically using the term ‘nurses’ we mean trained income countries into LMICs.
nurses in outpatient and clinical contexts. LMICs: Argentina, Brazil, Colombia, Ecuador, Ethiopia, India, Kyrgyzstan,
2
Medicine and ethics go viral, https://www.ethicsgoviral.com/ (01/06/2023). Mexico, Nigeria, Pakistan, Paraguay, Tunisia, Türkiye, Zambia, South Africa.
The project also produced a physical exhibition in the Forum Wissen in Göt- HICs: Australia, Austria, Canada, France, Germany, Italy, Israel, Japan,
tingen from June to October 2022. For the virtual exhibition additional and Oman, Poland, Russia, Romania, Singapore, South Korea, Spain, Sweden,
new podcasts were produced based on preliminary data analysis. United-Kingdom (UK), United States of America (USA).
4
https://zoom.us/ (01/06/2023).
Table 1 Participant characteristics (n = 39)

Characteristics % (n)
Gender
Male 53.8 (21)
Female 46.2 (18)
Field of ethical expertise
Bioethics (including clinical ethics) 78.0 (29)
Public health ethics 22.0 (11)
Parallel working: Research ethics (6), physicians (8), politics (5) 31.6 (19)
Experts stemming from the following continents
Europe Austria, Denmark, Germany, France, Italy, Spain, Sweden, Poland, Romania, UK 28.2 (11)
Asia India, Israel, Japan, Kyrgyzstan, Oman, Pakistan, Russia, Singapore, South Korea, Türkiye 25.6 (10)
Africa Congo, Ethiopia, Nigeria, South Africa, Tunisia, Zambia 15.4 (6)
America Argentina, Brazil, Canada, Colombia, Ecuador, Mexico, Paraguay, USA 25.6 (10)
Oceania Australia 5.2 (2)
and verbal informed consent for data recording and created and added to the coding guideline. Subsequently,
storage was obtained from all participants. For the next a reduction and abstraction of the coded text passages
analytical step, recordings and transcripts were then was performed to finalize the category system. Coded
pseudonymized and anonymized for publication. text passages were then thematically interpreted, sup-
ported with anchor examples and summarized in text
Data analysis form, always identifying the countries.
Data was analysed by means of qualitative content anal-
ysis [34]. The material was reproduced verbatim and, if Results
necessary, translated into English. Analysis of the mate- Our data analysis identified a wide range of bioethical
rial involved the language-condensation and coding of conflicts. For analysis, we structured this range using
the transcripts. The coding guideline (see Additional three main topics: scarce resources, public health and
file 2: Code overview), had been created deductively fol- professional care. Each main theme includes more than
lowing a literature review. Additionally, inductive codes one subtheme as summarized in Table 2. For transpar-
were added during the coding process and further com- ency and contextual comprehensibility, we mention the
pared with existing research. The coding guideline was countries related to the experts’ statements. For simpli-
pretested by peer-coding before application. Further- fication, we grouped the countries into HICs and LMICs,
more, 25% of the collected material was peer-coded by as national income impacts national healthcare systems.
the co-authors and one external colleague. These findings are described below (see also Additional
Atlas.ti™.5 In a first run of the material review, 16 so-

The coding process was performed using the software file 3: Results summary):
called main codes were created (see Additional file 2:

Code overview), which already represented general terms
for selected quotations or context units taken from the
text. In several condensing steps, irrelevant information Table 2 Overview themes and subthemes
and repetitions were deleted and a transformation of the A) Effects of scarcity for the clinical context
text on a uniform language level took place. Condens- A1) Different dimensions of resource scarcity between LMICs and HICs
ing steps were always carried out with consideration of A2) Prioritization of COVID-19 patients
the theoretical background. For more detailed access to B) Health literacy
the text, these main codes were subsequently expanded, C) Inequality and vulnerable groups
specified and revised, always in light of the research ques- C1) Poverty as a specific challenge for LMICs
tion. Hence, in addition to the main codes, 43 sub-codes C2) Children and women as a specific vulnerable group in LMICs
(see Additional file 2: Code overview) were inductively C3) Older people as a specific vulnerable group in HICS
D) Conflicts surrounding health-care professionals
D1) Frontline burdens
5
D2) Psychological and moral distress
https://atlasti.com/ (01/06/2023).
Effects of scarcity for the clinical context Interviewees from Pakistan, Kyrgyzstan, Paraguay,
Concerning the scarcity of resources and the conse- Romania and Japan accentuated deficits of resources
quences of prioritization in the medical-clinical con- especially in rural health facilities. Compared to urban
text during the COVID-19 pandemic, ethical problems clinics, small provincial ones were not as well supplied
of global, national and regional scope became appar- during the pandemic, which resulted in a national and
ent. We present them in the following. inter-clinical inequality of providing medical care.
Different dimensions of resource scarcity between LMICs Prioritization of COVID‑19 patients

and HICs The severe shortage of material but also of person-
According to all interviewed experts, there was a pro- nel resources in clinics resulted in the prioritization of
nounced lack of material resources in the clinical set- COVID-19 patients over other patients who, conse-
ting, especially at the beginning of the pandemic. This quently, were harmed. The majority of experts reported
included COVID-19 tests and personal protective a focus of medical care on COVID-19 and emergency
equipment (PPE). In the context of international dis- medicine, especially during the initial period. Though
crepancies between LMICs and HICs, experts from shortage of medical material was mentioned by every
Ecuador, Ethiopia and Türkiye emphasized the une- interview partner, reported resource allocation and con-
qual conditions in terms of access to the international sequences of priority-setting varied across the countries.
market. Especially in HICs, such as Austria, the United Kingdom
From a national perspective, regardless of the inter- and Canada, the main strategy was to postpone surgery
viewed experts’ origin, the majority identified the lack interventions and non-essential treatments. Meanwhile,
of PPE in clinics and nursing homes as one of the big- in India, Brazil, Argentina and Italy entire hospitals were
gest problems. Experts from Russia, Oman, Zambia transformed into exclusive COVID-19 facilities or even
and Argentina, among others, mentioned the result- totally closed to redistribute available resources:
ing serious COVID-19 infections and COVID-related
‘Many hospitals have been completely closed
deaths among healthcare personnel themselves. Fur-
because of the pandemic and the patient, who usu-
thermore, interview partners from the African LMICs
ally went to this hospital, hadn’t the possibility to be
Zambia, Ethiopia and Tunisia reported that the severe
treated as usual. This was a big problem’. (Italy)
lack of PPE resulted in extreme re-usage of used mate-
rials which can be problematic for hygienic reasons. The transformation of hospitals into COVID-19 facili-
ties led to conflicts worldwide regarding equal access to
‘PPE has been a huge issue here. [...] I didn’t have
treatment options during the pandemic. An expert from
any disposable PPE, so I had to use my regular one
Sweden concluded that ‘prioritizing one group means
[...]. I had people with COVID, so I put it [PPE] in
making another one suffer’.
plastic, took it home and washed it and I will use
Most experts considered two sides. On the one hand,
it again’. (Zambia)
there has been a prioritization of emergencies and
Emphasizing that long-existing financial deficiencies COVID-19 cases by policy and/or by the healthcare
in healthcare systems became more apparent, experts facilities themselves, aiming to minimize infections and
from the LMICs Ethiopia, Paraguay, Ecuador, Pakistan to prevent a collapse of the entire system. On the other
and Kyrgyzstan reported serious scarcities in terms hand, patients themselves refused to visit potential infec-
of basic resources. Additionally, other experts from tious institutions, such as clinics. Interview partners from
LMICs like Mexico, Kyrgyzstan, Paraguay, Ecuador and HICs such as Austria, France and Sweden, also reported
South Africa emphasized a fundamental lack of health a general mobilization of resources towards COVID-19,
infrastructure and ICU equipment in local hospitals which resulted in an unequal distribution of available
that had already existed before the crisis: resources on different wards in hospitals. By limiting
elective procedures, screenings and the overall number
‘From the beginning it was clear that the pub-
of patients in general, an attempt was made to prevent
lic clinics wouldn’t cope, that there were no near
the system from becoming overburdened. Many experts
enough ICU beds in the country based on the pro-
reported that this ‘Covidization’ (EC17) of healthcare sys-
jections that we had at that time. I think South
tems resulted in a global treatment deficit, especially for
Africa has about 3000 ICU beds in total and most
oncological patients all over the world. Delayed diagnosis
of those are in the private healthcare system which
of malignant tumours due to reduced screening, diagno-
most people can’t access’. (South Africa)
sis and control examinations, potentially has led to an
increase in undetected tumours, as an expert from Oman Health literacy

with clinical experience stated: The high risk of population infection in a pandemic cre-
ates ethical conflicts for PH policy. In the context of
‘We had [oncological] patients who were delayed
health-influencing factors such as living space, educa-
three months because their previous appointment
tion, nutrition and social environment, various experts
was cancelled because it was thought to be an elec-
mentioned the decisive influence of health literacy.
tive procedure, [but] it turned out to be much more
Regarding the implementation of pandemic protection
[of ] a malignant diagnosis. […] That’s really a con-
measures, the ability of the public to comprehend medi-
cern because some elective procedures actually end
cal information seemed essential. Experts from LMICs
up as non-elective emergencies’.
such as Ecuador, Nigeria and India noted a health lit-
Regarding the postponement of elective surgical inter- eracy gap between rich and poor. In countries without
ventions and therapies, the concept of selectivity was a functioning healthcare system, health literacy in the
often described as problematic, as it was mostly equated predominantly poor population was considered very
with non-essential. Experts from Türkiye, Oman, Canada, low. This was not only seen due to the lack of educa-
Singapore and the USA emphasized that the designation tion, but also due to dissatisfaction with the government
of a procedure as elective does not automatically exclude and the daily struggle for survival, regardless of the
the existing necessity or (potential) urgency of this proce- SARS-CoV2-virus:
dure. On the contrary: especially in the case of oncologi-
‘Sixty percent of the population has no access to
cal diagnostics and therapies, delayed detection can have
money,...to health [or] education. I would say [...]
grave consequences.
the culture of health is not good in my country […].
Furthermore, numerous experts, especially from
Some people from the media to the rich [classes] can
LMICs such as India, Zambia, Nigeria, Ecuador and
understand, can be aware of taking care.’ (Mexico)
Mexico, elucidated the negative effects on essential diag-
nostic examinations in the field of infectious diseases, Our results showed that also in HICs, including the
such as HIV and TB: United States, Canada, Poland, Sweden and Israel, health
literacy was seen as more deficient in marginalized and
‘We are losing more people from HIV, from TB, from
often financially weaker groups, such as migrants and
malaria [than from] COVID. But COVID, it has cre-
ethnic minorities. Thus, education and social background
ated this huge public health, global public health
has been identified as relevant factor in the context of
emergency and all the attention is on it […] Now we
health literacy:
have to reallocate some of the wards … from HIV
into COVID. So, but what will happen then to these ‘It’s not exactly shocking that someone who grows up
programs of HIV and TB?’ (Zambia) in an environment like that is not getting access to
the same resources than someone who’s living in a
As the statement shows, international standards were
[…] wealthy neighbourhood.’ (USA)
often used as a guide in a global crisis. This, in a number
of cases, led to a lack of contextualizing national situations Experts from many countries, including the UK, Aus-
and needs of healthcare systems of respective countries. tralia, Sweden, Ecuador and Paraguay, explained that
Finally, the analysis of interviews with interview part- being linguistically, socially and culturally separated from
ners from South Africa, India, Argentina and Nigeria the majority society led to the lack of access to relevant
indicated that the pandemic might also undermine years information for minorities in general. In addition, some
of public work and education, for example, in the fields of interview partners emphasized the key role of religious
vaccination or reproductive medicine. For example, the rites and gatherings, which showed a diminishing effect
number of registered abortions and of pregnant women on the establishment of health competence and thus on
seeking care in hospitals reportedly dropped significantly the implementation of necessary pandemic protection
during the first and second waves of the pandemic: measures. For example, experts from Singapore, Israel,
South Korea, but also from Colombia and India stated
‘In the southern part of the world where [there
that the realization of rituals and customs often out-
are] campaigns of vaccination and campaigns for
weighed compliance with restrictions in their impor-
the children, and campaigns for letting the young
tance, also pointing to a specific influence of cultural
women to go and to check their pregnancies, we have
attitudes regarding health literacy.
achieved so much in sexual and reproductive health
Especially Latin American interview partners (from
during the last ten to fifteen years. It was all lost […]
Ecuador, Paraguay, Mexico and Argentina) ranked
because of COVID.’ (Argentina)
interpersonal relationships and physical proximity as Furthermore, interview partners from Tunisia and
a significant influence on the acceptance of protective India stressed that the state had imposed restrictions
measures. This indicated a cultural influence on the rep- without offering support to affected citizens. This kind
resentation of conflicts: of reciprocity and fairness regarding pandemic measures
should be indispensable, experts said:
‘The masks and the isolation of the patient in the
hospital […] is also something that for our culture is ‘People were also starving because they had no
terribly heavy […] so we are anything but puritan, income, because the entire economic activity had
we like human contact and for us that thing has come to standstill. And the government did it with-
been a very important issue’. (Argentina) out having an ethical obligation of caring for them.
[… But] if you take measures [restricting] peoples’
rights […] then you must reciprocate it by providing
Inequality and vulnerable groups
them support so that they can survive.’ (India)
The COVID-19 pandemic disproportionately affected
vulnerable groups, both highlighting and exacerbating Data collection from December 2020 until March 2021
existing social and economic inequalities. This section with experts from Türkiye, Brazil, Paraguay and Ethiopia
presents experts’ perspectives on ethical challenges in showed also their concern with the lack of global solidar-
LMICs stemming from high poverty. Below, we look at ity regarding the distribution of COVID-19-vaccines.
the rationale for and consequences of public safety meas- Since vaccine distribution only began in mid-December
ures with a focus on the vulnerability of women and chil- 2020 [35], interviews conducted in November 2020 did
dren affected by lockdowns. not address this topic.
A lack of global solidarity heightened inequalities
Poverty as a specific challenge for LMICs between LMICs and HICs. Exclusively experts from
Higher poverty rates in LMICs were identified as the underserved countries such as Nigeria, Pakistan, Para-
root of many difficulties. To minimize infections, coun- guay and Ethiopia, among others, reported the unequal
tries mandated protective measures including masks distribution and thus contextualized an expression of
and social distancing mandates as well as restrictions unfair conditions:
on mobility. Numerous experts, primarily from Latin ‘I think for developing countries that’s another ethi-
American and African LMICs such as Ecuador, Mexico, cal concern […] the vaccines are expensive [and there
Zambia and Tunisia, noted that lockdowns in particular is some] scepticism about vaccines [but] assuming
created existential problems for the poor because, for they work, and they are effective then the next ques-
example, street vending is the only source of income for tion is: who can afford them? [In] poor countries like
many. Because many families’ food choices often depend Ethiopia […] the government has other priorities,
on their daily earnings, some experts talked of ‘hunger like infectious diseases’. (Ethiopia)
vs. COVID’. An expert from Argentina reported in that
context:
‘Because of the high poverty levels – we live from Children and women as a specific vulnerable group in LMICs
hand to mouth, people have to wake up every day In terms of specific vulnerabilities, the pandemic caused
and they get daily wages from selling, [...] so you eat different effects globally. Although we identified several
what you can make in one day and, the next day different vulnerable groups, in this paper we will present
you die. So now the ethical issue is … can we have the results on children and women as a vulnerable group
even say a one week shutdown? [...] the consequences in LMICs and on elderly people in HICs.
would actually be worse’. Interviewees from LMICs of Latin America and Africa,
such as Mexico, Argentina, Paraguay, Tunisia and Ethio-
Moreover, experts from India, Zambia, Argentina pia, explicitly named children as a vulnerable group
and Colombia, among others, concurred that infor- during the pandemic. This was mainly related to school
mal employment relationships presented difficulties in closures and nationwide lockdowns with their complex
the context of any lockdown. Those employees working socio-economic consequences. Experts from Argentina,
in, for example, informal street vending were not only Brazil and Tunisia explained that lockdowns often con-
restricted in selling goods, but also lost customers. Given tributed to increased domestic violence against children
the absence of the laws protecting employees, numerous and women:
experts from LMICs reported an increase of unemploy-
ment, resulting in a sharp rise of poverty and hunger. ‘Domestic violence against the wife, against the child
[…] many problems increased […] the lockdown is
good perhaps for the epidem[ic] but it is not good for hidden low esteem for old age became more transpar-
all the other aspects’. (Tunisia) ent and explicit. They agreed that social inequality led to
general health inequality for the elderly:
Additionally, experts from Argentina and Paraguay
noted that kids’ suddenly no longer having access to a ‘We had, especially when there was the first wave of
free lunch in educational institutions as another negative COVID-19, a very sad situation with the triage, with
consequence of school closures. Especially poorer fami- the choice of who should have the possibility to have
lies in LMICs cannot ensure sufficient nutrition for the this emergency intervention. And there was a sort of
children, thus lockdowns entailed grave consequences discrimination against the older people and that is
for health. Experts agreed that the pandemic also took people like me’. (Italy)
away school as a safe daycare option and as a component
Experts from Sweden, Canada, Oman and Türkiye
of a stable daily routine and social environment. Moreo-
especially concluded that the combination of medical
ver, as children could not play much with each other, nor
vulnerability and so-called ‘ageism’ resulted in structural
interact with new children, their socio-emotional devel-
disadvantages for older people that were ethically unac-
opment was severely impaired. Consequently, socio-
ceptable in their view. Having been made from a utilitar-
emotional skills may have developed less well, according
ian perspective, COVID-19-policies aimed at protecting
to experts from South Korea and Ethiopia.
this vulnerable group from infection and at preventing a
Women were identified as another vulnerable group
collapse of the healthcare system. However, especially in
by several interview partners from America, Asia,
nursing homes in many countries such as Canada, Swe-
Europe and Africa. On the one hand, women’s and espe-
den and Türkiye, this planning often led to extreme social
cially mothers’ traditional gender role –housework and
isolation:
the upbringing of children – meant that the pandemic
increased their workload: ‘What I mean is that discriminatory stigmatizing
attitude towards the elderly, [not] all of the elderly
‘Most of the nurses that we have, seventy percent of
people were [treated] like this [but even now] there
nurses [are women]. On one hand, we have nurses
is a ban for the elderly people not to go out after
[…] working extra hours, [being] most exposed to the
four o’clock. [...] We have to think of how can we help
virus and […] sometimes they are mothers that take
them.’ (Türkiye)
care of [their own] children. [Also] domestic violence
increases’. (Ecuador) Additionally, nursing homes and long-term care facili-
ties as place of older people have proved to be places cre-
Interviewees also mentioned increased domestic vio-
ating immense vulnerability for their inhabitants during
lence, particularly against women and children. They
the COVID-19-pandemic. According to many experts,
saw the reasons mainly in the intensification of tensions
the combination of the vulnerability of older people, the
within households during the prolonged confinement of
fragility of long-term care facilities as unpopular places
families at home, economic insecurity and lower social
and already deficient supply structures within the nurs-
interaction. On the other hand, experts from LMICs such
ing profession have emerged as significant challenges in
as Ecuador and Argentina stressed the very high propor-
HICs in America, Oceania and Europe. In this context, a
tion of females in care-associated professions. Hence,
bioethicist from Austria summarized the profound struc-
women had a higher workload while also bearing an
tural discrimination of age on a multidimensional level as
increased risk of exposure both COVID-19 and domestic
follows:
violence.
‘In the German-speaking countries we have pro-
Older people as a specific vulnerable group in HICS found age discrimination.... That means not only the
Experts from HICs stressed above all the vulner- old person goes into a spiral of grievance, but being
ability of the aging population. As shown in the follow- old triggers grievance and that affects [also] the rela-
ing, this relates mainly to the cultural bias against the tives. And the third path is the discrimination of
elderly in Western countries as well as to the vulnerabil- elder-care workers’.
ity of residents in nursing homes, especially regarding Experts from HICs such as Canada, Austria, Israel,
SARS-CoV-2. Sweden and Australia, but also from Argentina, saw one
Most of the interviewees from HICs identified older driver for immense infection and mortality rates in nurs-
people as a vulnerable group in terms of pandemic ing facilities in the need of nurses being employed in
effects. Experts from Israel, the USA, Australia and Italy, several facilities at the same time, which already was a
among others, emphasized that an already existing but practice before the pandemic. This unfortunate situation
then led to the spread of the SARS-CoV2-virus between psychological stressors, moral and legal challenges as
different facilities during the crisis. In addition, experts well as societal expectations, were identified by the inter-
from Austria, France and the United Kingdom identified viewed experts across the globe.
national inequalities in the distribution of materials such
as PPE and tests between hospitals and nursing homes, ‘Front‑line’ burdens
accentuating the vulnerability of these facilities on the Healthcare professionals, both in clinics and in outpa-
supply level: tient services, faced specific professional ethics con-
flicts. Most experts called this a ‘front-line’ burden,
‘It was difficult to get enough personal protective
speaking, among other factors, of an exacerbation of
equipment, [it] was bought by the government and
already existing deficits in the healthcare system gen-
primarily went to the healthcare system [...] which
erally and in nursing care specifically. Experts from
made it difficult for nursing homes to protect their
France and Austria mentioned funding cuts, ongoing
staff and their residents adequately’. (UK)
for years:
The management of nursing homes was often criti-
‘We’ve been chipping away at the public health
cized. Here, interviewees found it problematic that
system for about twenty years now and it’s really
the economic motivation of institutions was of prior-
starting to show, and for the last five to ten years
ity instead of the protection of residents. Moreover, a
there’s been systematic protests about the lack of
few experts, including those from Canada and Austria,
pay and the stress on healthcare workers’. (France)
pointed out that hospitals and care homes increasingly
tended to work against each other during the crisis, for In this context, the majority of interview partners
example, by hospitals refusing to admit residents of the emphasized that nurses in particular are generally
homes. In the end, considering all aspects mentioned, underpaid. Experts from Poland, USA, Mexico, India,
dramatic deficits in the care of nursing home residents – Zambia and Türkiye, among others, also agreed that
both, medically and emotionally – emerged. According to this results primarily from understaffing. This does not
most experts from HICs, visiting restrictions in nursing only increase staff workload but also leads to extra
homes, which were primarily intended for protection this hours and shifts, which are associated with a reduction
group, resulted in undignified treatment. in the quality of care.
Contrary to the conflicts outlined in HICs, various Several experts, including those from the US, Canada
experts from Latin America and Africa stated that vul- and Spain, noted temporary policies implemented in
nerability of the older people did not exist to the same reaction to acute staff shortages. These included, for
extent as in HICs. As a reason for that difference, they example, appealing to retired nurses and physicians for
named their countries’ different demographic structures support or activating military personnel.
and the self-reliance of caring for family members at About half of the interviewees emphasized that at
home: the time of data collection there had been no official
measurable or significant changes, for example, regard-
‘I don’t see that as a major problem in Pakistan
ing working schedules or payment. Hence, numerous
because we don’t have many people living by them-
experts agreed that the working conditions needed rad-
selves. […] Most people live with their children with
ical improvements:
families, I think there is the concept that you protect
your elderly’. (Pakistan) ‘This is actually also necessary - I believe that the
caregivers are to be supported and that the COVID
Still, interview partners from Argentina, Colombia and
care has shown because they are not only to be
India spoke of vulnerability of the older people in terms
supported on the individual level but also on the
of medical care, primarily due to of a lack of financial
organisational and societal level’. (Austria)
resources and insufficient pensions. Where healthcare
systems rely heavily on private supplementary benefits,
universal, fair access cannot be guaranteed, which is lead-
Psychological and moral distress
ing to insufficient healthcare.
In addition to the structural deficits outlined above, the
analysis of the interviews accentuates psychological and
emotional burdens faced by healthcare professionals.
Conflicts surrounding healthcare professionals
All interviewees agreed that psychological stress in
The analysis of the results revealed specific conflicts for
particular was a major challenge for health profession-
health professionals, especially nurses, during the pan-
als during the pandemic. Experts, including those from
demic. Several levels of burden, including physical and
Ethiopia, Pakistan, Canada and Poland, described the Paraguay and Argentina described the treatment of dying
fundamental moral difficulties arising from the clash patients during the pandemic as often undignified. In
between the duty to help infected patients and the dan- South Korea, Austria and Mexico, for example, it was not
ger of infecting oneself through contact with COVID- possible to say goodbye to close relatives. This resulted in
19. An expert from Japan focused on the perspective of a sense of injustice for relatives and patients, also creating
the caregivers involved: feelings of helplessness for caregivers.
In addition to their personal sense of responsibil-
‘Many of the health professionals providing care for
ity towards patients, healthcare professionals also felt
COVID-19 patients are in an ethical dilemma: they
responsible towards their colleagues and their loved ones.
wish to provide care but their situation is very hard
This blurred the boundary between the professional and
so they may not be able to continue their job’.
the private sphere even more, as they distanced them-
A bioethicist from Poland commented on this from the selves from family members and friends to protect them
perspective of the general public, also considering the from potential infection. Not only did this cut them off
challenges for doctors in this context: from emotional respite after work, it also caused fatigue
and feelings of frustration, helplessness, victimhood and
‘Bioethical debates basically revolve around the
vulnerability:
degree to which medical professionals have to
respond to patients’ needs. What level of risk they ‘They [doctors and nurses] are tired […] emotionally
are expected to take […]. A number of people say and spiritually and physically tired because some of
this is just a job like any job […]. So you should not them cannot see their own family. In order to [pro-
expect that doctors to be heroes. [Others say] the tect] them […] they have decided to go into the hotel
duty of the doctor is much stronger’. facilities paid for by donors, and they don’t go home’.
(Mexico)
Several interview partners from HICs such as France,
Israel, Italy and Denmark and from LMICs like Pakistan Finally, interview partners from Ecuador, Israel, Par-
and South Africa emphasized the possibility of these con- aguay and France explained that it was common for
flicts turning into moral distress. Primarily fuelled by a healthcare professionals and notably nurses to ulti-
feeling of loss of control in everyday clinical life regard- mately flee their jobs in the sense of refusing to work.
ing adequate care for patients, distress was increased by Moreover, numerous protests, in which medical staff
precarious working conditions due to missing PPE and publicly pleaded for stricter PH measures, have taken
additionally exacerbated by social expectations. Moreo- place, as experts from the UK and Canada, among oth-
ver, experts from Romania, Argentina, Türkiye and Can- ers, stressed:
ada, among others, explicitly noted that being assigned to
‘Professions are constantly throwing out they’re
intensive care units or other areas outside a worker’s pro-
exhausted [...]. Nurses have in fact come online and
fessional expertise without prior adequate training was a
said patients are suffering and what we need is bet-
major stressor in the hospital environment:
ter conditions for our work’. (Canada)
‘In some other cities because of the lack of the medi-
cal staff [doctors and teams of ] surgeons, neurosur- Discussion
geons, dermatologists were involved...and those indi- Our findings illustrate the complexity of bioethical issues
viduals were really against it because they said...we arising from the COVID-19 pandemic. We identified var-
are not really trained for this situation’. (Romania) ious political, economic and societal problems that have
Several experts also reported the specific challenges of existed for years but were spotlighted and amplified by
nurses mediating between political constraints and clini- the pandemic. Although these challenges are known, our
cal reality. During the pandemic, due to their profession, material reveals significant disparities between LMICs
nurses were not only contact persons for patients and rel- and HICs, a critical aspect often underrepresented in
atives and thus responsible for helping them address their the bioethical discourse. By highlighting existing gaps in
needs, they also functioned as an executor of state deci- the current bioethical debate, our analysis contributes
sions, as interview partners from Romania, Austria and to critical-constructive rethinking of a more globalised
the UK noted. perspective for bioethics. In the following discussion,
According to numerous experts, the daily, intense we focus on three topics of high relevance for advanc-
confrontation with patients dying in one’s care and han- ing discussions on global bioethics: vulnerability, the role
dling grieving relatives had also become drivers for psy- of organisational ethics in the clinical setting and global
chological overload. Experts from Japan, Spain, Sweden, inequalities.
The concept of vulnerability as a relevant issue socially vulnerable. When social isolation occurred due
The analysis of our results highlights the complexity of to social-distancing policies [39], social and biomedical
vulnerability in the context of the pandemic and shows dimensions necessarily intersected.
that the concept of vulnerability was used in a highly Our results highlight the lack of a consideration of
context-specific manner. Our results say nothing about pandemic-related vulnerability in the public bioethics
which groups in the countries studied are genuinely vul- discourse. As the immediate focus is either on the con-
nerable but rather reflect discourse priorities generated sideration of only medically vulnerable groups or on only
in the media or in the professional environment of the socially vulnerable groups, their intersection is less often
experts at the time of the interview. Currently, although an issue. However, since biomedical and social vulner-
vulnerability is an acknowledged part of the field of PH ability are directly and indirectly related, PH ethics must
ethics [24], our interviews showed that in practice, PH discuss both separately and in their intersection. Further-
ethics does not sufficiently discuss the general impor- more, it is necessary to consider context-specific vulner-
tance of vulnerability, its contextual complexity and all its ability: every country and every region has its own kinds
implications. The vulnerability of specific groups creates of vulnerable groups requiring special attention [40].
a fundamental dilemma for PH ethics and thus deserves The phenomenon of vulnerability also demonstrates the
more attention. transnational connections of national conflicts [37].
Context‑sensitive vulnerability Reducing vulnerabilities

Generally, being vulnerable means to be at an increased The discourse cited here may still sound abstract, but
risk of harm with reduced capacity to protect oneself Marckmann et al. (2015) stress the necessity of providing
[24], entailing that any person can be vulnerable in in a practice-oriented analyses that use a structured method-
specific situation [36]. The concept of vulnerability is too ology for applying normative criteria to PH issues [41].
abstract and broad to be used without further differen- As PH interventions in a pandemic are meant to protect
tiation. Regarding COVID-19, different kinds of vulner- population health, they should also be designed to avoid
ability have been discussed globally including medical exacerbating vulnerabilities and inequalities [41]. We
vulnerabilities like age (as in ‘the elderly’) or pre-existing showed that this was not always the case. In a pandemic
conditions and socially defined vulnerabilities including that required a public and global health ethical focus,
those of ethnic minorities and refugees [7, 37]. We dif- reflection of and protection of vulnerable groups should
ferentiate the levels of vulnerability into the risk of high be elevated to an explicit PH ethical objective.
infection (biomedical vulnerability) and by the degree to
which pandemic protection measures disproportionately Organisational ethics needed
affect specific groups (social vulnerability).6 The negative Our results indicate the COVID-19-pandemic exacer-
consequences of PH interventions designed to protect bated already-existing precarious circumstances and the
the general populations or specific groups can lead to multifaceted physical and psychological challenges faced
vulnerabilities in highly biomedically vulnerable groups by health professionals globally. While the interview
such as older people. Additionally, these interventions analysis reveals that all healthcare workers were under
may also create vulnerabilities in non-biomedically vul- increased stress, our discussion will centre on the role of
nerable groups, as in the example of children being indi- nurses. They occupied a special position in the pandemic
rectly harmed by school closures (see Additional file 4: linking the medical profession, patients and society and,
Overview vulnerabilities). in our opinion, are still underappreciated. Additionally,
with the steadily growing world population and increased
Intersectional vulnerability life expectancy worldwide, nursing care in particular is
The focus of discussions about vulnerability was mainly playing an increasingly important role [42, 43].
on biomedically vulnerable groups during the first wave Understanding the impact of the pandemic on nurs-
of the pandemic [25, 38] and broadened over time. Later, ing means understanding norms of internal profes-
social inequalities like the disproportionate impact of sional collaboration, hierarchies within health services
lockdowns on women and children in LMICs became and the distribution of professional responsibilities. All
an issue. Although those are two fundamentally differ- of these touch on organisational ethics, which involve
ent perspectives, we still speak of vulnerability in both behaviour-guiding moral principles like individual rights,
contexts. Older people are not only biomedically but also self-interest and social responsibility and norms like hon-
esty, fairness and compliance with legal and social obli-
gations [44]. The ethical obligation of professional care
6 is conventionally thought of as based on the principle of
Also including cultural influences.
beneficence and thus recognizes a special moral obliga- of organisational and nursing ethics would be key for
tion of nurses to advance patients’ well-being [45]. Yet defining the ethical environment [55]. This would not
the additional burdens of societal medical emergencies only benefit nurses but also contribute to their ability to
cannot be borne by nurses alone, especially given their act ethically, fairly and with dignity towards patients and
precarious working conditions [46–48]. thus to meet the goals of PH ethics.
What can we conclude from these results for future
bioethical debates? Overall, it is of great relevance to Global inequalities and global solidarity
establish concepts of organisational ethics regarding Achieving equality at the level of global health is one of
nursing in order to reflect actual professional routines the greatest challenges in contemporary times. Most
in different settings and organisations [45, 49]. The com- global health conflicts are subject to structural, cultural,
plexity of the organisation of nursing should be respected. social, political, historical and economic determinants
Nursing practice is affected by a broad range of organisa- within individual countries [56]. The COVID-19 pan-
tional differences, including for example, those between demic has brought into focus the importance of consid-
community and in-home settings or between long-term ering national circumstances and contextual factors in
and short-term care [45]. formulating effective pandemic strategies [57]. Hence,
global inequalities call for global solidarity as a collective
Essential reflection on responsibilities response to address pressing social and economic dispar-
Professional responsibility involves individual responsi- ities across the world.
bility within the caregiver-patient relationship, but it also
entails responsibilities within organizations and other Increasing awareness of global inequalities in HICs
collectives. The latter highlights the need for nurses to Global ethics is of enormous significance in a pandemic.
work collectively within the healthcare system to fulfil The challenges national governments are likely to face,
their professional obligations [50]. In essence, in nurs- such as vaccine distribution, the protection of vulnerable
ing, ‘responsibility’ involves determining the cause of groups or resource scarcity all have global dimensions
problems, assigning accountability for outcomes and [58, 59]. For instance, significant disparities exist between
distributing accountability among involved parties. It LMICs and HICs in terms of their access to goods traded
also encompasses the commitment to the whole setting, on international markets. This leads both to shortages
the duty to accomplish nursing tasks with empathy and and surpluses of medical care resources and technolo-
awareness for moral decision-making [50]. For this to gies. While various interviewed experts from HICs took
happen and to empower nurses to recognize and fulfil issue with the postponement of elective measures, the
their responsibilities, however, a fundamental restructur- shortages mentioned in LMICs resulted in supply-chain
ing of nurses’ roles must take place at the macro (health breakdowns for truly essential goods such as primary
policy), meso (clinic) and micro (ward) levels. healthcare or even food. Hence, global inequalities in the
On the macro level, the general inclusion of adminis- starting conditions hindered the handling of the novel
trative and specific nursing ethics is needed to sharpen virus [57, 60]. Increasing awareness of these disparities,
professionalization and actualise the assumption of pro- especially among the perspective of the more powerful
fessional responsibility by considering the expertise of HICs, is the necessary first step to pave the way towards
nurses in the design of all care processes [45, 51]. Nurses’ greater equality between LMICs and HICs.
own reflection on the ethical dimensions of their work
should lead to their involvement in all significant deci- Reliable global governance and international cooperation
sions related to patient care. In addition to professionaliz- Global health inequality is a well-known problem. Ruger
ing the field of nursing, the development of a framework (2009), for example, argues that global health justice
for nursing ethics would also contribute to broader dis- requires prioritizing responsibilities through shared
cussions on equity and justice in healthcare [49, 52]. health governance to reduce inequalities in healthcare
On the meso and micro levels, many of our interviewed capacity. This points to the importance of governance
experts concurred with several studies regarding the structures and political power on national and interna-
numerous already-existing problems that were exacer- tional levels [61]. Precisely this international competence
bated by the COVID-19 crisis [29, 53, 54]. The pandemic was lacking in the Corona pandemic, as the WHO was
showed how conflicts arose when the overlap of respon- quickly marginalized by the more powerful states such as
sibility was not fully defined and thus often rested with the USA and China. Its 2005 International Health Regu-
nurses, whose authority was increased by their daily lations [62] once designed to regulate such a situation,
patient contact and by their mediating role between were quickly dismissed [63, 64].
patients and the doctors. A fundamental change in terms
Any pandemic must be understood as global crisis, but constant self-reflection and communication within the
interviewees from LMICs criticized the lack of interna- research group, we tried to minimize this potential bias.
tional cooperation. As we have seen during COVID-19,
the global contribution of vaccines suffered from national Conclusion
politics, despite indications that public opinion in HICs, We conducted a qualitative study on the opinions of bio-
such as the USA and Germany, would support more ethics experts regarding bioethical issues arising from
utilitarian and egalitarian allocation rules [65]. Many the COVID-19 pandemic in international comparison.
countries prioritized their own interests, such as secur- We found that perceived ethical challenges were similar
ing their own PPE and vaccines, rather than develop- across the globe but that their perceived consequences
ing equitable distribution strategies for sharing scarce and causes show country-specific cultural, infrastruc-
resources. This behaviour was understandable in the tural and economic differences. In summary, the pur-
initial period [59], but a global crisis requires a global pose of seeking a deeper understanding of a globalised
ethical, solidarity-based response. Active cooperation perspective on ethical issues related to pandemics is
between countries is necessary to control pandemics in essential for crafting more effective and equitable pre-
future scenarios [66, 67]. If only those countries with the paredness and responses to future global health crises.
means to stockpile supplies and buy vaccines can protect It might help policy organisations and health policymak-
their populations, discrepancies and asymmetrical power ers to identify potential ethical problems and develop
structures between HICs and LMICs will widen [59, 68]. ethical frameworks and related strategies at early crisis
The COVAX-Initiative [69] for global equitable distribu- stages – regarding human rights, fair allocation of scarce
tion of COVID-19 vaccines was a sensible idea in theory resources, the need for more contextualized health lit-
but fell short due to insufficient support. As of January eracy, among others, to address them in advance. Lastly,
2021, 90 million doses had been administered worldwide the connections linking countries and populations dur-
but only 25 in sub-Saharan Africa outside of vaccination ing a pandemic situation were highlighted, underscoring
trials [67]. From a global ethical perspective, developing the importance of international collaboration. Identifying
detailed strategies for fair allocation is necessary, but so specific needs can promote cooperation among nations
too is a consideration of national and international gov- and organisations to collectively address the bioethi-
ernance structures including their political impact and cal challenges of pandemics. Although no single study
the role of expertise in policy making. of expert opinion can capture the full complexity of the
pandemic and its global impact, our findings open a win-
Limitations dow onto the pandemic’s ethical ramifications and should
A first limitation of this study is that we identified experts motivate empirical bioethicists, in collaboration with PH
online and via publications; thus the definition of expertise experts, to continue the analysis of experts’ insights so as
may be biased by our language abilities and by the experts’ to be better prepared for the next pandemic.
international visibility. To overcome this limitation, we
also used a snowball-recruitment system which extended
Abbreviations
our contacts with experts less visible in those international COVID-19 Coronavirus disease 2019
bioethical discourses we are familiar with. Another selec- HIC High-income country
tion bias may have been introduced because some experts HIV Human immunodeficiency virus
LMIC Low and Middle-income country
declined participation due to fear of political retribution. PH Public health
That some interview partners requested anonymity indi- PPE Personal protective equipment
cates this may have been an issue. TB Tuberculosis
SARS-CoV-2 Severe acute respiratory syndrome coronavirus type 2
Second, we interviewed in the rule only one expert UK United Kingdom
per country. Therefore our study cannot claim quantita- USA United States of America
tive representativity; rather, our focus was on taking an
explorative snapshot of various experts’ opinions during
one critical episode of the pandemic [70–72]. Our primary
Supplementary Information
The online version contains supplementary material available at https://doi.
objective was to make a broadly comparative and explora- org/10.1186/s12889-023-17249-4.
tory contribution to the bioethical discourse related to the
pandemic under the constraints of time and uncertainty. Additional file 1. Interview Guideline.
Finally, we tried to overcome the European perspec- Additional file 2. Code overview.
tive on the pandemic through comparison across global Additional file 3. Summary results.
regions. However, our approach may still introduce Euro- Additional file 4. Overview vulnerabilities.
centric bias through in the study design itself. Through
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of Diary Entries to Document their Experiences during the First Wave of

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BMC Public Health (2023) 23:2492 BMC Public Health

RESEARCH Open Access

Scarce resources, public health

Introduction While this situation has been widely discussed in HICs

Table 1 Participant characteristics (n = 39)

Atlas.ti™.5 In a first run of the material review, 16 so-

called main codes were created (see Additional file 2:

Different dimensions of resource scarcity between LMICs Prioritization of COVID‑19 patients

increase in undetected tumours, as an expert from Oman Health literacy

Context‑sensitive vulnerability Reducing vulnerabilities

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