In 2020, with the outbreak of the COVID-19 pandemic, academics and scientists began to question the triage criteria for allocating insufficient healthcare resources, trying to ethically justify the answer to the question, Who should receive medical care first? In this article, I will argue that even if we apply triage criteria, we won't be able to avoid the violation of human dignity or of the right to life and to health care. I will then suggest that, maybe, the real ethical (...) triage dilemma lies not in the question, Who should receive medical care first? but in the question, How are we to decide who should receive medical care first? (shrink)

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We report on the (...) difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

The paper discusses the problem of triaging the elderly in the period of the COVID-19 pandemic crisis by analyzing the triage process, caused by lack of resources, in Germany, Holland, the Czech Republic, and Slovakia. We apply inductive, deductive, and normative bioethical methods, comment on various recommendations for the indication of intensive care during a crisis, and discuss the utilitarianism of benefit maximization. As it follows from the evaluation of the elderly by the frailty parameter, medically inappropriate treatment, as a (...) result of limited resources, is characterized by clinical and bioethical uncertainty. If the main bioethical objective of general bioethics for the COVID-19 pandemic is, in the case of limited resources, based on the non-utilitarian consequentialism paradigm, from the perspective of medical ethics, we face a borderline situation closely related to the topic of dying and death. Such a situation requires social, ethical, and professional reflection. An algorithm for intensive care indication in the situation of crisis and limited resources in the period of the pandemic requires a definition of criteria that identify an acceptable reason for abandoning the treatment in the context of the autonomy of the elderly and by respecting their human dignity and humanity. A global objective of general bioethics in the situation of the pandemic crisis should be based on the paradigm of social justice. (shrink)

The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. Since most (...) of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis. (shrink)

Introduction: Public health ethics addresses moral dilemmas arising from balancing individual healthcare needs with societal interests. Ethical considerations in public health during pandemics and disasters aim to reduce mortality rates and minimize social injustice through fair principles. Objective: This paper analyzes public health ethics and ethical values in allocating resources during mass casualty incidents. The intersection of public health ethics, applied bioethics, and ethics of social consequences (through non-utilitarian consequentialism) guides addressing serious public health challenges in catastrophic scenarios. The application (...) of the given interaction is significant for professional medical ethics. Methodology: The paper employs inductive, deductive, and normative methods of bioethics and the methodology of ethics of social consequences. Conclusion: The paradigmatic disparity between the bioethics of pandemics and disaster bioethics lies in the fluid application of bioethical principles and the accentuation of utilitarian demands depending on the severity and scale of mass casualty incidents. Applied bioethics in crisis situations respects the approaches of public health ethics and attempts to increase positive social outcomes. The application of (scarce) resource allocation criteria and triage of patients is derived from ethical decisions beneficial to public health and lege artis approaches of medical bioethics. The paper presents professional and ethical criteria for medically inappropriate treatment within the framework of patient triage; we approach crisis ethics from the perspective of maximization of benefit. Age is not an exclusion criterion of acute healthcare provision in crisis situations. Ethics of social consequences as a form of non-utilitarian consequentialism allowing for social consequences bridges public health ethics and applied bioethics. (shrink)

Zusammenfassung Die Einführung von Impfprogrammen bei einer immun-naiven Bevölkerung in Europa spielte eine wesentliche Rolle für den Verlauf der COVID-19 Pandemie. Vor allem zu Beginn waren Impfprogramme jedoch durch einen Mangel an Impfdosen gekennzeichnet. Bei einer Zuteilung geringer Dosen an Krankenhäuser in der Initialphase, waren Krankenhausleitungen durch eine möglichst faire Verteilung dieser Impfdosen unter dem Krankenhauspersonal gefordert. Der Beitrag dokumentiert das Vorgehen im ersten Quartal 2021 an fünf deutschen Krankenhäusern in einem Klinikverbund. Wir berichten über einen regel-konsequentialistischen Ansatz auf der (...) strategischen Ebene, der durch einen egalitären Ansatz auf der taktischen Ebene ergänzt wurde. Es erfolgte die ethisch begleitete Entwicklung eines hybriden Schemas unter Verzicht auf klassische Verteilungsmuster, wie dem First-Come-First-Served Schema. Die Kombination des strategischen regel-konsequentialistischen Schemas mit egalitärer Verteilung auf der taktischen Ebene war vollständig funktional und unter den Mitarbeitenden des Klinikverbundes gut akzeptiert. In Zeiten von Pandemien und knappen Ressourcen spielt die Verteilung von medizinischen Gütern für die Funktionalität medizinischer Einrichtungen eine wichtige Rolle. Die Verteilung von Gütern, die durch den Staat bereitgestellt werden, bedarf jedoch einer Anpassung an die jeweiligen Gegebenheiten der Institutionen. Dieser Bericht zeigt eine mögliche Option für die Verteilung knapper Impfdosen auf, die nicht nur unter Personen der Zielgruppe verteilt wurden, sondern die auch die Funktionalität der medizinischen Versorgung in einer Region sicherte. (shrink)

BackgroundUnder COVID-19 pandemic, many organizations developed guidelines to deal with the ethical aspects of resources allocation. This study describes the results of an argument-based review of ethical guidelines developed at the European level. It aims to increase knowledge and awareness about the moral relevance of the outbreak, especially as regards the balance of equity and dignity in clinical practice and patient’s care. MethodAccording to the argument-based review framework, we started our research from the following two questions: what are the ethical (...) principles adopted by the ethical guidelines produced at the beginning of the COVID-19 outbreak related to resource allocation? And what are the practical consequences in terms of 'priority' of access, access criteria, management of the decision-making process and patient care?ResultsTwenty-two ethical guidelines met our inclusion criteria and the results of our analysis are organized into 4 ethical concepts and related arguments: the equity principle and emerging ethical theories; triage criteria; respecting patient’s dignity, and decision making and quality of care.ConclusionFurther studies can investigate the practical consequences of the application of the guidelines described, in terms of quality of care and health care professionals’ moral distress. (shrink)

The ever-debated question of triage and allocating the life-saving ventilator during the COVID-19 pandemic has been repeatedly raised and challenged within the ethical community after shortages propelled doctors before life and death decisions. The British Medical Association’s ethical guidance highlighted the possibility of an initial surge of patients that would outstrip the health system’s ability to deliver care “to existing standards,” where utilitarian measures have to be applied, and triage decisions need to maximize “overall benefit” In these emergency circumstances, triage (...) that “grades according to their needs and the probable outcomes of intervention” will prioritize or eliminate patients for treatment, and health professionals may be faced with obligations to withhold or withdraw treatments to some patients in favour of others. This piece is a response and extension to articles published on the manner of involvement for ethics and ethicists in pandemic triage decisions, particularly examining the ability and necessity of establishing triage committees to ameliorate scarce allocation decisions for physicians. (shrink)

BackgroundThe Covid-19 pandemic caused situations where, in some hospitals, there were more patients in need of urgent treatment in intensive care units (ICU) than were available. In particular, there were not sufficient ventilators or critical care resources for all patients in danger of dying from respiratory failure or other organ failures.DiscussionAs the “first come, first served” criterion was not considered adequate, more nuanced and fairer clinical criteria were proposed to assess whom to treat first. One type of patients that has (...) not been considered in the literature so far is that of “important patients”, individuals that many people might consider worthy of priority treatment for the contribution they made or might make to society as a whole.SummaryIn this article, we discuss the moral insights behind the possible treatment of “important patients” and suggest a supererogatory solution of voluntary renunciation/withdrawal. Details of the proposal are explained, and potential objections are addressed. (shrink)

Following the Second Summit on Human Gene Editing in Hong Kong in 2018, where the birth of two girls with germline genome editing was revealed, the need for a responsible pathway to the clinical application of human germline genome editing has been repeatedly emphasised. This paper aims to contribute to the ongoing discussion on research ethics issues in germline genome editing by exploring key issues related to the initial applications of CRISPR in reproductive medicine. Following an overview of the current (...) discussion on bringing germline genome editing into clinical practice, we outline the specific challenges associated with such interventions and the features that distinguish them from conventional clinical testing of new medical treatments. We then review proposed ethical requirements for initial heritable genome editing, such as the absence of reasonable alternatives, the existence of sufficient and reliable preclinical data, appropriate informed consent, requirements related to safety, and long-term follow-up. (shrink)