The Covid‐19 pandemic needs to be considered from two perspectives simultaneously. First, there are questions about which policies are most effective and fair in the here and now, as the pandemic unfolds. These polices concern, for example, who should receive priority in being tested, how to implement contact tracing, or how to decide who should get ventilators or vaccines when not all can. Second, it is imperative to anticipate the medium‐ and longer‐term consequences that these policies have. The case of (...) vaccine rationing is particularly instructive. Ethical, epidemiological, and economic reasons demand that rationing approaches give priority to groups who have been structurally and historically disadvantaged, even if this means that overall life years gained may be lower. (shrink)

In this article, we aim to map out the complexities which characterise debates about the ethics of vaccine distribution, particularly those surrounding the distribution of the COVID-19 vaccine. In doing so, we distinguish three general principles which might be used to distribute goods and two ambiguities in how one might wish to spell them out. We then argue that we can understand actual debates around the COVID-19 vaccine – including those over prioritising vaccinating the most vulnerable – as reflecting disagreements (...) over these principles. Finally, we shift our attention away from traditional discussions of distributive justice, highlighting the importance of concerns about risk imposition, special duties, and social roles in explaining debates over the COVID-19 vaccine. We conclude that the normative complexity this article highlights deepens the need for decision-making bodies to be sensitive to public input. (shrink)

Allocating access to unapproved COVID-19 drugs available via Pre-Approval Access pathways or Emergency Use Authorization raises unique challenges at the intersection of clinical care and research....

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)

Much of the sustained attention on pandemic preparedness has focused on the ethical justification for plans for the “crisis” phase of a surge when, despite augmentation efforts, the demand for life...

In late February and early March 2020, Italy became the European epicenter of the COVID-19 pandemic. Despite increasingly stringent containment measures enforced by the government, the health system faced an enormous pressure, and extraordinary efforts were made in order to increase overall hospital beds’ availability and especially ICU capacity. Nevertheless, the hardest-hit hospitals in Northern Italy experienced a shortage of ICU beds and resources that led to hard allocating choices. At the beginning of March 2020, the Italian Society of Anesthesia, (...) Analgesia, Resuscitation, and Intensive Care issued recommendations aimed at supporting physicians in prioritizing patients when the number of critically ill patients overwhelm the capacity of ICUs. One motivating concern for the SIAARTI guidance was that, if no balanced and consistent allocation procedures were applied to prioritize patients, there would be a concrete risk for unfair choices, and that the prevalent “first come, first served” principle would lead to many avoidable deaths. Among the drivers of decision for admission to ICUs, age, comorbidities, and preexisting functional status were included. The recommendations were criticized as ageist and potentially discriminatory against elderly patients. Looking forward to the next steps, the Italian experience can be relevant to other parts of the world that are yet to see a significant surge of COVID-19: the need for transparent triage criteria and commonly shared values give the Italian recommendations even greater legitimacy. (shrink)

The COVID-19 pandemic has both exposed and created deep rifts in society. It has thrust us into deep ethical thinking to help justify the difficult decisions many will be called upon to make and to protect from decisions that lack ethical underpinnings. This paper aims to highlight ethical issues in six different areas of life highlighting the enormity of the task we are faced with globally. In the context of COVID-19, we consider health inequity, dilemmas in triage and allocation of (...) scarce resources, ethical issues associated with research, ethical considerations relating to tracing apps, and exit strategies such as immunity passports and COVID-19 vaccines. Finally, we consider environmental issues in light of COVID-19. The paper also offers some ethical reflection on these areas as many parts of the world contemplate the recovery phase. (shrink)

Ethical issues around triage have been at the forefront of debates during the Covid‐19 pandemic. This essay compares both discussion and guidelines around triage and the reality of what happened in the United States and in Europe, both in anticipation of and during the first wave of the pandemic. Why did the issue generate so many vivid debates in the United States and so few in most European countries, although the latter were also affected by the rationing of health care (...) resources? Are countries with socialized health care systems better equipped to face the hard choices of triaging? Important lessons in transparency, trust, and accountability for policy‐makers can be drawn from this comparison, demonstrating that fostering public involvement and ethical debate remains a critical element for the sustained acceptance of any triage plan. (shrink)

Hastings Center Report, Volume 51, Issue 5, Page 18-29, September‐October 2021.

In the recent literature across philosophy, medicine and public health policy, many influential arguments have been put forward to support the use of randomization procedures to allocate scarce life-saving resources. In this paper, I provide a systematic categorization and a critical evaluation of these arguments. I shall argue that those arguments justify using RAND to allocate SLSR in fewer cases than their proponents maintain and that the relevant decision-makers should typically allocate SLSR directly to the individuals with the strongest claims (...) to these resources rather than use RAND to allocate such resources. (shrink)

Ethics consultants and critical care clinicians reflect on Seattle’s early experience as the United States’ first epicenter of COVID-19. We discuss ethically salient issues confronted at UW Medicin...

This paper introduces the model of Utilitarian Principlism as a framework for crisis healthcare ethics. In modern Western medicine, during non-crisis times, principlism provides the four guiding principles in biomedical ethics—autonomy, nonmaleficence, beneficence, and justice; autonomy typically emerges as the decisive principle. The physician–patient relationship is a deontological construct in which the physician’s primary duty is to the individual patient and the individual patient is paramount. For this reason, we term the non-crisis ethical framework that guides modern medicine Deontological Principlism. (...) During times of crisis, resources become scarce, standards of care become dynamic, and public health ethics move to the forefront. Healthcare providers are forced to work in non-ideal conditions, and interactions with individual patients must be considered in the context of the crisis. The COVID-19 pandemic has forced healthcare to shift to a more utilitarian framework with a greater focus on promoting the health of communities and populations. This paper puts forth the notion of Utilitarian Principlism as a framework for crisis healthcare ethics. We discuss each of the four principles from a utilitarian perspective and use clinical vignettes, based on real cases from the COVID-19 pandemic, for illustrative purposes. We explore how Deontological Principlism and Utilitarian Principlism are two ends of a spectrum, and the implications to healthcare as we emerge from the pandemic. (shrink)

The COVID-19 pandemic put a large burden on many healthcare systems, causing fears about resource scarcity and triage. Several COVID-19 guidelines included age as an explicit factor and practices of both triage and ‘anticipatory triage’ likely limited access to hospital care for elderly patients, especially those in care homes. To ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public’s moral intuitions. Our study aimed to explore general public views in the UK on (...) the role of age, and related factors like frailty and quality of life, in triage during the COVID-19 pandemic. We held online deliberative workshops with members of the general public. Participants were guided through a deliberative process to maximise eliciting informed and considered preferences. Participants generally accepted the need for triage but strongly rejected ‘fair innings’ and ‘life projects’ principles as justifications for age-based allocation. They were also wary of the ‘maximise life-years’ principle, preferring to maximise the number of lives rather than life years saved. Although they did not arrive at a unified recommendation of one principle, a concern for three core principles and values eventually emerged: equality, efficiency and vulnerability. While these remain difficult to fully respect at once, they captured a considered, multifaceted consensus: utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability. This ‘triad’ of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage. (shrink)

At the height of the COVID-19 crisis in the Netherlands a shortness of intensive care beds was looming. Dutch professional medical organizations asked a group of ethicists for assistance in drafting guidelines and criteria for selection of patients for intensive care treatment in case of absolute scarcity, when medical selection criteria would no longer suffice. This article describes the Dutch context, the process of drafting the advice and reflects on the role of ethicists and lessons learned. We argue that timely (...) interaction between clinical and ethical expertise is necessary since the distinction between medical and non-medical considerations is not as clearcut as sometimes assumed. Furthermore, pragmatic considerations related to the specifics of an epidemic are of importance, for example, in relation to prioritizing health care workers. As a consequence, any protocol already present before the pandemic would need alterations to fit the current situation. The ‘fair innings’ criterion we proposed, rephrased as an argument of intergenerational solidarity, was considered reasonable by professionals as well as patient organizations. While it is desirable to draft ethical guidelines in ‘peacetime’ as a matter of pandemic preparedness, the pressure of an actual crisis facilitates decision-making, although it will also complicate a more democratic approach. (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits (...) from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)

The current public health crisis has exposed deep cracks in social equality and justice for marginalised and vulnerable communities around the world. The reported rise in the number of ‘do not resuscitate’ orders being imposed on people with disabilities has caused particular concerns from a human rights perspective. While the evidence of this is contested, this article will consider the human rights implications at stake and the dangers associated with using ‘quality of life’ measures as determinant of care in medical (...) decision-making and triage assessments. (shrink)

Ruth Macklin argued that dignity is nothing more than respect for persons or their autonomy. During the COVID-19 pandemic, difficult decisions are being made about the allocation of scarce resources. Respect for autonomy cannot justify rationing decisions. Justice can be invoked to justify rationing. However, this leaves an uncomfortable tension between the principles. Dignity is not a useless concept because it is able to account for why we respect autonomy and for why it can be legitimate to override autonomy in (...) times of critical care resource shortages. Dignity affirms the worth of the human individual as a meaning-making embodied subject, who is always in relationship to others, the world, time, and transcendence, and who realizes their dignity through their moral behaviour. Such an understanding means people should be helped to make morally right decisions about their own treatment, which may include forgoing potentially beneficial treatment for the good of others. Respect for dignity does not require fulfilling the morally wrong choices of one who insists on treatment at the expense of others. Dignity also protects the discretion of clinicians to make decisions appropriate to their competence by prohibiting the application of broad-based criteria such as age. (shrink)

During the coronavirus pandemic, communities have faced shortages of important healthcare resources such as COVID-19 vaccines, medical staff, ICU beds and ventilators. Public health officials in the U.S. have had to make decisions about two major issues: which infected patients should be treated first, and which people who are at risk of infection should be inoculated first. Following Beauchamp and Childress’s principlism, adopted guidelines have tended to value both whole lives and life-years. This process of collective moral reasoning has revealed (...) our common commitment to both Kantian and utilitarian principles. For Kant, respecting people’s rights entails that we ought to value whole lives equally. Therefore we ought to allocate resources so as to maximise the number of patients who survive to discharge. By contrast, the principle of utility has us maximise life-years so that people can satisfy more of their considered preferences. Although people are treated impartially in the utilitarian calculus, it does not recognise their equal worth. Subjecting Kantian ethics and utilitarianism to the process of reflective equilibrium lends support to the idea that we need a pluralistic approach that would accommodate our moral intuitions regarding both the equal value of whole lives and the additive value of life-years. (shrink)

In response to the COVID‐19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an important (...) higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre‐existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID‐19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives. (shrink)

Volume 20, Issue 7, July 2020, Page 106-109.

The aim of this article is to study the relationship between Epicureanism and pandemic priority-setting and to explore whether Epicurus's philosophy is compliant with the later developed utilitarianism. We find this aim interesting because Epicurus had a different way of valuing death than our modern society does: Epicureanism holds that death—understood as the incident of death—cannot be bad (or good) for those who die (self-regarding effects). However, this account is still consistent with the view that a particular death can be (...) bad for everyone else but those who die, such as family, friends, and society (other-regarding effects). During the pandemic, the focus has been on the number of deaths more than on the suffering and reduced well-being of those infected and the rest of society. However, since the pandemic requires prioritization, it is, on a utilitarian account, important to consider priorities that do the most good overall. In this article, we approach the harm of death from an Epicurean point of view, seeking to flesh out potential implications for pandemic priority-setting, and healthcare in general, using a case study of COVID-19 priority-setting. We also explore whether this would conflict with utilitarianism. We conclude that an Epicurean pandemic priority-setting approach would be different but, surprisingly, not radically different from many of the actual priority-setting decisions we saw under the COVID-19 pandemic. (shrink)

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the most common ethical (...) arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs. (shrink)

As Alfandre and colleagues describe in “Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures”, efforts to maintain standards of care durin...

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 pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, (...) and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety‐net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community‐based care, and fully staff hospitals and clinics on nights and weekends. (shrink)

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each (...) guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources. (shrink)

Volume 20, Issue 7, July 2020, Page 103-106.

In response to the Covid‐19 pandemic, health care systems worldwide canceled or delayed elective surgeries, outpatient procedures, and clinic appointments. Although such measures may have been necessary to preserve medical resources and to prevent potential exposures early in the pandemic, moving forward, the indirect effects of such an extensive medical shutdown must not outweigh the direct harms of Covid‐19. In this essay, we argue for the reopening of evidence‐based health care with assurance provided to patients about the safety and necessity (...) of high‐value vaccinations, screenings, therapeutics, and procedures. To ensure that virtually all non‐Covid‐related services do not come to a halt again, health care systems and physician practices must preemptively increase their capacity, secure adequate personal protective equipment to safeguard health care personnel, and develop a measured approach to reclosing such routine health care, should it become necessary in the future. (shrink)

La pandemia de la COVID-19 ha levantado sospechas de edadismo y gerontofobia en diversas prácticas de racionamiento sanitario. La edad es un criterio de triaje controvertido. En este artículo se esclarece la relevancia ética de la edad dentro de los sistemas de triaje, analizando particularmente su rol dentro de los principios de equidad y de eficiencia. La equidad requiere dar más oportunidades a aquellos que han cumplido menos ciclos vitales. La eficiencia tiene en cuenta la edad de manera subrepticia al (...) tratar de maximizar los beneficios a corto plazo (salvar vidas) y a largo plazo (salvar años de vida). Finalmente, la edad no debe ser la última ratio de las decisiones de triaje, aunque es una variable a tener en cuenta debido a su presencia implícita en principios fundamentales de priorización. The COVID-19 pandemic has raised suspicions of ageism and gerontophobia in various health rationing practices. Age is a controversial triage criterion. This article clarifies the ethical relevance of age within triage systems, particularly its role within the principles of fairness and efficiency. Fairness requires giving more opportunities to those who have completed fewer life cycles. Efficiency takes age into account surreptitiously when trying to maximize short-term (saving lives) and long-term (saving years of life) benefits. Finally, age should not be the final rationale in triage decisions, although it is a variable to be taken into account because of its implicit presence in fundamental principles of prioritization. (shrink)

Robert Veatch’s The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, (...) and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch’s book, but a commonality is the question of who should get what limited resources when needs and urgency vary. (shrink)

This article approaches the ethical dilemma of healthcare allocation and rationing from the perspective of pragmatist ethics, mainly following John Dewey’s ethics. The moral dilemma of healthcare allocation arises whenever we allocate limited resources, and rationing is a necessary option for distributing available resources. In a broader sense, the moral problems of healthcare allocation also encompass the issue of access to primary healthcare, especially for low-income sections of communities. In this sense, allocation always entails rationing – denying service to someone (...) for the benefit of others. Such aspects of allocation and rationing and the relational aspect of disease and health make the problem morally controversial, which makes it difficult to agree on a principle or principles of allocation and rationing applicable across different contexts. Hence, this paper argues that moral challenges of healthcare rationing ought not to be addressed through the appeal to principles, but rather through deliberation that embraces a more pragmatic and democratic approach to negotiating health resource allocation and rationing. However, this does not mean that moral principles and values are insignificant in healthcare allocation. (shrink)

BackgroundThe expectation of pandemic-induced severe resource shortages has prompted authorities to draft and update frameworks to guide clinical decision-making and patient triage. While these documents differ in scope, they share a utilitarian focus on the maximization of benefit. This utilitarian view necessarily marginalizes certain groups, in particular individuals with increased medical needs.Main bodyHere, we posit that engagement with the disability critique demands that we broaden our understandings of justice and fairness in clinical decision-making and patient triage. We propose the capabilities (...) theory, which recognizes that justice requires a range of positive capabilities/freedoms conducive to the achievement of meaningful life goals, as a means to do so. Informed by a disability rights critique of the clinical response to the pandemic, we offer direction for the construction of future clinical triage protocols which will avoid ableist biases by incorporating a broader apprehension of what it means to be human.ConclusionThe clinical pandemic response, codified across triage protocols, should embrace a form of justice which incorporates a vision of pluralistic human capabilities and a valuing of positive freedoms. (shrink)

BackgroundWhen rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of (...) relative scarcity.MethodsFourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used.ResultsParticipants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers.ConclusionsWe conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level. (shrink)

The reality of resource limitation during the Coronavirus Disease 2019 pandemic has deeply challenged established approaches to healthcare system emergency response. Early preparation du...

Diagnostic testing can be used for many purposes, including testing to facilitate the clinical care of individual patients, testing as an inclusion criterion for clinical trial participation, and both passive and active surveillance testing of the general population in order to facilitate public health outcomes, such as the containment or mitigation of an infectious disease. As such, diagnostic testing presents us with ethical questions that are, in part, already addressed in the literature on clinical care as well as clinical research (...) (such as the rights of patients to refuse testing or treatment in the clinical setting or the rights of participants in randomized controlled trials to withdraw from the trial at any time). However, diagnostic testing, for the purpose of disease surveillance also raises ethical issues that we do not encounter in these settings, and thus have not been much discussed. In this paper we will be concerned with the similarities and differences between the ethical considerations in these three domains: clinical care, clinical research, and public health, as they relate to diagnostic testing specifically. Via an examination of the COVID-19 case we will show how an appeal to the concept of diagnostic justice helps us to make sense of the (at times competing) ethical considerations in these three domains. (shrink)

In “Racism and Bioethics: the myth of color blindness” Braddock convincingly argues that a “color blind” approach to triage and resource allocation in the setting of the COVID-19 pandemic pe...

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving (...) the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work. (shrink)

Decades ago, in his foundational essay on the early days of the AIDS crisis, medical historian Charles Rosenberg wrote, “epidemics start at a moment in time, proceed on a stage limited in space and duration, following a plot line of increasing revelatory tension, move to a crisis of individual and collective character, then drift toward closure.” In the course of epidemics, societies grappled with sudden and unexpected mortality and also returned to fundamental questions about core social values. “Epidemics,” Rosenberg wrote, (...) “have always provided occasion for retrospective moral judgment”. Following Rosenberg’s observations, this essay places COVID-19 in the context of epidemic history to examine common issues faced during health crises—moral, political, social, and individual. Each disease crisis unfolds in its own time and place. Yet, despite specific contexts, we can see patterns and recurring concerns in the history of pandemics: pandemics and disease crises in the past, along with public health responses to them, have had implications for civil liberties and government authority; disease crises have acted as a sort of stress test on society, revealing, amplifying or widening existing social fissures and health disparities; pandemics have forced people to cope with uncertain knowledge about the origin and nature of disease, the best sources of therapies, and what the future will hold after the crisis. While historians are not prognosticators, understanding past experience offers new perspectives for the present. The essay concludes by identifying aspects of history relevant to the road ahead. (shrink)

In principle, all patients deserve to receive optimal medical treatment equally. However, in situations in which there is scarcity of time or resources, medical treatment must be prioritized based on a triage. The conventional guidelines of medical triage mandate that treatment should be provided based solely on medical necessity regardless of any non-medical value-oriented considerations (“worst-first”). This study empirically examined the influence of value-oriented considerations on medical triage decision–making. Participants were asked to prioritize medical treatment relating to four case scenarios (...) of an emergency situation resulting from a car collision. The cases differ by situational characteristics pertaining to the at-fault driver, which were related to culpability attribution. In three case scenarios most participants gave priority to the most severely injured individual, unless the less severely injured individual was their brother. Nevertheless, in the aftermath of a vehicle-ramming terror attack most participants prioritized the less severely injured individual (“victim-first”). Our findings indicate that when caregivers are presented with concrete highly conflictual triage situations their choices may be based on value-oriented considerations related to contextual characteristics of the emergency situation. Philosophical and practical ramifications of our findings are discussed. (shrink)

BackgroundThe worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide (...) clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context.DiscussionBeyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation.ConclusionWe propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa. (shrink)

The advent of COVID-19 has been the occasion for a renewed interest in the principles governing triage when the number of critically ill patients exceeds the healthcare infrastructure’s capacity in a given location. Some scholars advocate that it would be morally acceptable in a crisis to withdraw resources like life support and ICU beds from one patient in favor of another, if, in the judgment of medical personnel, the other patient has a significantly better prognosis. The paper examines the arguments (...) for and against this approach from the point of view of natural law theory, especially using the principle of double effect. We conclude that it is inadmissible to withdraw life-saving medical interventions from patients who are still benefiting from them, on the sole grounds that other patients might benefit more. Those who are currently using such technology should only interrupt their treatment if, in the judgment of medical personnel and, if possible, taking into account the wishes and needs of the patient and his family, the treatment is deemed futile, burdensome, or disproportionate. (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)

How should we think of the preferences of citizens? Whereas self-optimal policy is relatively straightforward to produce, socially optimal policy often requires a more detailed examination. In this paper, we identify an issue that has received far too little attention in welfarist modelling of public policy, which we name the "hidden assumptions" problem. Hidden assumptions can be deceptive because they are not expressed explicitly and the social planner (e.g. a policy maker, a regulator, a legislator) may not give them the (...) critical attention they need. We argue that ethical expertise has a direct role to play in public discourse because it is hard to adopt a position on major issues like public health policy or healthcare prioritisation without making contentious assumptions about population ethics. We then postulate that ethicists are best situated to critically evaluate these hidden assumptions, and can therefore play a vital role in public policy debates. (shrink)

Volume 20, Issue 7, July 2020, Page 199-201.

When the Covid‐19 pandemic reached the United States in spring 2020, many states and hospitals announced crisis standards of care plans that used age as a categorical exclusion criterion. Such age choosing was quickly flagged as discriminatory, and so some states and hospitals shifted to embedding age as a tiebreaker deeper in their plans. Different rationales were given for using age as a tiebreaker: that younger patients were more likely to survive than older patients, that saving younger patients would save (...) more life years, and that younger patients deserved a chance to live through life's stages. We provide a critical analysis of these three rationales, noting the differences between them, and then questioning the ethical and legal justifications for such age choosing. (shrink)

When confronted by the novel ethical challenges posed by a pandemic, it is helpful to turn to history for guidance and direction. In this essay, the author revisits Thucydides's description of the Plague of Athens from The Peloponnesian War as he considers the New York State Task Force on Life and the Law's 2015 guidelines on ventilator allocation. Confronted by the exigencies of the Covid‐19 surge that struck New York, he questions the task force's decision not to give any degree (...) of preference to health care workers who might become ill. He posits that they are due a compensatory ethic and some deference given the risks they have assumed, often with inadequate protective gear. Reflecting on his ambivalence, he asks if his change of heart reflects the impact of experiential learning or the erosion of nomos—or governing norms—described by Thucydides when the plague struck Athens. (shrink)

Saving as many lives as possible while ensuring equity for vulnerable groups through access to triage resources has been the dominant position since the onset of the COVID-19 pandemic in 2020. However, the exact relationship between the principles of social justice and efficiency remains a controversial and unresolved issue. In this paper, we aim to systematically distinguish between different models of this relationship and show that conceptualizing social justice as a ‘moral side-constraint’ or adopting a ‘balancing approach’ that attempt to (...) reconcile social justice with efficiency inevitably lead to significant moral costs that require further justification. Based on this discussion, we propose a novel “threshold model” for trading-off moral costs. According to this model, the structural impact of triage must be considered in order to determine whether one opts for triage with the primary aim of efficiency or social justice. This contextualization further explains why, in some societies and circumstances, social justice can rightly be seen as the primary concern, while in other societies and circumstances, efficiency can be defended as the primary concern. (shrink)