Ethics Trade-Off Between Hazards Prevention and the Safeguard of Death Dignity During COVID-19

To the Editor

On March 24, 2020, the World Health Organization (WHO) released its guideline on “Infection Prevention and Control for the safe management of a dead body in the context of COVID-19” (WHO, 2020).

The document offers relevant recommendations on the safe and dignified burial procedures of deceased persons with suspected or confirmed COVID-19.

Biological hazard posed by COVID-19-infected bodies remain unclear. However, a certain level of risk does still exist from the aerosolization of fluids during the post-mortem examination or the cleaning of the mortuary area.

Italy passed the Prime Minister’s Decree n. 648 (Ufficiale, 2020), establishing urgent measures to contain the transmission of COVID-19 and prevent biological hazards, including very restrictive interventions on public Holy Masses and funerals. The law introduced the controversial decision to ban burial procedures based i) on the doubts about the virus environmental stability (Kampf et al., 2020) as well as ii) according to Italian national civil contingency plan and the unprecedented death toll (34,708 deaths, June 27, 2020).

The visit to the body was forbidden by the Health Authority across the whole ceremony cycle. Therefore, in addition to the funeral ceremonies, any prayer at the closing of the coffin was suspended as well.

The dead could not be buried in their personal clothes nor receive any thanato-cosmetics.

Funeral gatherings were not permitted and family members of SARS-CoV-2 victims were either denied to participate at the burial. All the Masses in suffrage of the deceased with the family were postponed after the emergency.

The measure hardly hit not only Christians but also the Muslim community in Italy (approx. 3 million).

According to Islamic tradition, the burial of a deceased person is a collective obligation by the Muslim community, consisting of ghusl, ritual washing of dead bodies, kafan, or shrouding the body with pieces of cloth and finally salat al-janazah, a funeral prayer.

None of the above was permitted by the Italian health authorities. As such, burials have been performed through the taymom, a technique used for example in the desert due to the lack of water, consisting in passing hands on the stone and on the earth to symbolically wash the deceased.

Since all the funeral cerimonies were banned, absentee funeral prayers (salat al-ghā’ib) were performed on COVID-19 victims.

In Islamic law and Muslim cultures, cremation is prohibited because it is considered a violation of the dignity of the human body. Cremation of the remains of individuals that have died from COVID-19 has therefore been a great concern for Muslim communities.

A number of Muslims who died during the outbreak in Italy who would have requested to be buried in their or their families' countries of origin could not be repatriated, and their families have struggled to with funeral management because of the short supply of Muslim burial spots in the Country (Aljazeera, 2020).

In traditional bioethics, much emphasis is placed on the freedom of the individual. The central ethical dilemma, therefore, in public health, is to balance respect for individual freedom and liberty with the responsibility of governments to provide their citizens with some degree of protection in relation to health.

The foundations of value-based decisions in public health during COVID-19 pandemics should lie in moral philosophical conceptions of combination of acceptability on the one hand and the potential for helpful challenge on the other.

The level of coerciveness and intrusiveness of the Italian Decree Law appears, therefore, to be insufficiently justifiable, considering that the current scientific evidences suggest a low risk level for COVID-19 the post-mortem contamination. This risk could be anyhow addressed with appropriate risk mitigation measures, as recommended by the Centre for Disease and Control (2020; USA), for example 1) taking precautions with rituals that involved touching the deceased person’s body, like the mandatory use of personal protective equipment, 2) limiting the attendees to a small number of immediate family and close friends and 3) practicing of social distancing. In practice, the Italian measure appears to be in contrast with the proportionality principle, demanding that in weighing and balancing individual freedom against wider social goods, considerations will be made in a proportionate way.

Furthermore, the Decree had also a very limited impact on the principle of non-maleficence – do no harm; which in public health asserts the ethical imperative to produce benefit in a wider sense and to talk of the obligation to social beneficence (WHO, 2007).

The dignity of the dead, their cultural and religious traditions, and their families should be always respected and protected. Ethics poses new challenges in times of epidemics due to the shortcomings of existing models in bioethics for dealing with such issues.