The editors of the JME are grateful to its authors, reviewers and readers for their efforts and attention to the important and novel ethical challenges of the COVID-19 pandemic. These efforts meant that the journal published a number of high quality articles analysing these issues and it has shaped subsequent discussions and debate in exactly the way that we strive for. Ultimately, outcomes such as impact, readership and contributing to knowledge are what matters most for a journal, but the imperfect (...) metrics that journal performance is measured against matter too. So, the editors of the JME would also like to thank our authors, reviewers and readers for helping the JME score 5.9 in the most recent Clarivate Impact Factor rating. While that is not the highest IF in bioethics, it is worth mentioning that the highest citing paper from the bioethics journal with the highest IF, would have rated as the seventh most cited paper in the JME during this period. So, this latest rating reveals that the JME has had a very significant impact, readership and contribution to knowledge during the pandemic and we want to thank those who made …. (shrink)

Racism in health and healthcare has long been recognised as a structural issue. While there has been growing research and a number of important initiatives that have come from approaching racism as a structural issue, there is a range of implications that yet have to be explored as they relate to health and healthcare. Conceptualising racism in this way provides a means to consider how it shapes and is shaped by a range of global injustices and serves as a foundation (...) for more egregious harms. It also suggests that if we are to dismantle racism, we need to look both within and beyond the traditional domains of health and healthcare and account for a range of broader forces that sustain and re‐enforce racism. We first discuss the issue of responsibility, drawing on Young's social connection model to argue that we all have a responsibility to take action in addressing structural racism. We will then deal with a question that naturally follows, namely how we discharge our responsibilities, with a focus on the role of disruptive action in challenging power and ignorance in dismantling racism in health and healthcare. (shrink)

Policies promoted and adopted for allocating ventilators during the COVID-19 pandemic have often prioritised healthcare workers or other essential workers. While the need for such policies has so far been largely averted, renewed stress on health systems from continuing surges, as well as the experience of allocating another scarce resource—vaccination—counsel revisiting the justifications for such prioritisation. Prioritising healthcare workers may have intuitive appeal, but the ethical justifications for doing so and the potential harms that could follow require careful analysis. Ethical (...) justifications commonly offered for healthcare worker prioritisation for ventilators rest on two social value criteria: instrumental value, also known as the ‘multiplier effect’, which may preserve the ability of healthcare workers to help others, and reciprocity, which rewards past usefulness or sacrifice. We argue that these justifications are insufficient to over-ride the common moral commitment to value each person’s life equally. Institutional policies prioritising healthcare workers over other patients also violate other ethical norms of the healthcare professions, including the commitment to put patients first. Furthermore, policy decisions to prioritise healthcare workers for ventilators could engender or deepen existing distrust of the clinicians, hospitals and health systems where those policies exist, even if they are never invoked. (shrink)

I argue that Schmidtet al, while correctly diagnosing the serious racial inequity in current ventilator rationing procedures, misidentify a corresponding racial inequity issue in alternative ‘unweighted lottery’ procedures. Unweighted lottery procedures do not ‘compound’ (in the relevant sense) prior structural injustices. However, Schmidtet aldo gesture towards a real problem with unweighted lotteries that previous advocates of lottery-based allocation procedures, myself included, have previously overlooked. On the basis that there are independent reasons to prefer lottery-based allocation of scarce lifesaving healthcare resources, (...) I develop this idea, arguing that unweighted lottery procedures fail to satisfy healthcare providers’ duty to prevent unjust population-level health outcomes, and thus that lotteries weighted in favour of Black individuals (and others who experience serious health injustice) are to be preferred. (shrink)

This article examines some of the ethical challenges of prioritizing intensive care resources during the Covid-19 pandemic by comparing the Italian and United States contexts. After presenting an overview to the clinical, ethical, and public debates in Italy, the article will discuss the development of triage allocation protocols in United States hospitals. Resource allocation criteria underwent increased scrutiny and critique in both countries, which resulted in modified professional and expert guidance regarding healthcare ethics during times of emergency and resource scarcity.

Many countries are looking back at the pandemic and reflecting on what could have been done better. The UK COVID-19 Inquiry rumbles on 1 and other influential groups such as the British Medical Association have already reviewed the British response to the pandemic and made recommendations about what should happen in the future. 2 The UK is not alone in looking for lessons from the pandemic with a view to preparing for the next one. Countries with a very different COVID-19 (...) experience, such as Australia and New Zealand, have also commenced national inquiries with a view to becoming better prepared for the next pandemic. 3 4 While many of the issues revolve around public health and government responses, there are also profound ethical issues that demand reflection on the conceptual resources we use when responding to new ethical challenges. The _Journal of Medical Ethics_... (shrink)

We wholeheartedly agree with Schmidt and colleagues’ efforts to promote equity in intensive care unit triage. We also take issue with their characterisation of the New Jersey allocation framework for ICU beds and ventilators, which is modelled after the multi-principle allocation framework we developed early in the pandemic. They characterise it as a two-criterion allocation framework and claim—without evidence—that it will ‘compound disadvantage for black patients’. However, the NJ triage framework—like the model allocation policy we developed—actually contains four allocation criteria: (...) the two criteria that the authors mentioned and two criteria that they failed to mention which we included to promote equity: giving priority to frontline essential workers and giving priority to younger patients. These omissions are problematic both for reasons of factual accuracy and because the two criteria they failed to acknowledge would likely mitigate rather than exacerbate racial disparities during triage. (shrink)

The fair distribution of health resources is critical to health justice. But distributing healthcare equitably requires careful attention to the existing distribution of other resources, and the economic system which produces these inequalities. Health is strongly determined by socioeconomic factors, such as the effects of racism on the health of communities of colour, as well as the broader market-oriented healthcare and pharmaceutical systems that put the pursuit of profit above the alleviation of suffering. Two papers in this issue confront health (...) injustices at different scales, and make far-reaching recommendations for more just healthcare allocation policies. Orphan drugs are those that pharmaceutical companies are unwilling to develop unless they are offered financial incentives to do so. When a target patient group is very small, or very poor, producing drugs is unprofitable. If patients are to benefit from these drugs in a marketised pharmaceutical regime, governments must step in to provide incentives for research and development. Yet government spending ought to prioritise value for money, and is generally guided by a utilitarian framework. In the case of neglected tropical diseases, there is no moral conflict: large numbers of people would benefit greatly from these treatments. However, there are practical limitations: the governments of affected populations are often unable to fund incentives for research and development, and solidarity from elsewhere is limited.1 2 In the case of rare diseases, Global North governments usually can afford to incentivise the development of treatments to serve their populations, but given the small numbers of beneficiaries, doing so seems a questionable use of resources. Many Global North governments make an exception to the general utilitarian heuristic to accommodate the moral intuition that the claims of a person with a rare …. (shrink)

The widely accepted understanding in contemporary discourse is that race and ethnicity fundamentally arose as social constructs devoid of inherent biological or scientific significance.1 Despite this consensus, discussions abound, including in this journal,2 regarding the extent and manner in which racial and ethnic categorisations should influence the landscape of medical research, practice and policy. In an ideal paradigm, medicine should exude an unwavering commitment to impartiality, extending care and treatment to every individual, unfettered by considerations of their racial or ethnic (...) background—an approach that can be described as ‘colour blind.’ Yet, a cursory examination of medicine’s historical trajectory and the enduring realities of human prejudices unravels a precarious tension. This tension resides at the intersection of two seemingly conflicting imperatives: one, the ethical mandate for medicine to operate as a colour-blind entity, and the other, the ethical duty to candidly acknowledge, confront and rectify the historical and contemporary shortcomings woven into the fabric of our healthcare systems. Navigating this precarious balance demands a nuanced and introspective approach, one that aspires to forge a path towards a more equitable healthcare landscape while remaining steadfastly committed to the principles of honesty, accountability and the pursuit of a just and inclusive future. Scientific journals are confronted with the intricate dilemma of addressing racist scientific records.3 The question at hand pertains to whether content tainted by racism, …. (shrink)

We respond to recent comments on our proposal to improve justice in ventilator triage, in which we used as an example New Jersey’s publicly available and legally binding Directive Number 2020-03. We agree with Bernard Lo and Doug White that equity implications of triage frameworks should be continually reassessed, which is why we offered six concrete options for improvement, and called for monitoring the consequences of adopted triage models. We disagree with their assessment that we mis-characterised their Model Guidance, as (...) included in the NJ Directive, in ways that undermine our conclusions. They suggest we erroneously described their model as a two-criterion allocation framework; that recognising other operant criterion reveals it ‘likely mitigate[s] rather than exacerbate[s] racial disparities during triage’, and allege that concerns about inequitable outcomes are ‘without evidence’. We highlight two major studies robustly demonstrating why concerns about disparate outcomes are justified. We also show that White and Lo seek to retrospectively—and counterfactually—correct the version of the Model Guideline included in the NJ Directive. However, as our facsimile reproductions show, neither the alleged four-criteria form, nor other key changes, such as dropping the Sequential Organ Failure Assessment score, are found in the Directive. These points matter because our conclusions hence stand, because the public version of the Model Guidance had not been updated to reduce the risk of inequitable outcomes until June 2021 and NJ’s Directive still does not reflect these revisions, and, hence, represents a less equitable version, as acknowledged by its authors. We comment on broader policy implications and call for ways of ensuring accurate, transparent and timely updates for users of high-stakes guidelines. (shrink)

The COVID-19 pandemic has forced clinicians, policy-makers and the public to wrestle with stark choices about who should receive potentially life-saving interventions such as ventilators, ICU beds and dialysis machines if demand overwhelms capacity. Many allocation schemes face the question of whether to consider age. We offer two underdiscussed arguments for prioritising younger patients in allocation policies, which are grounded in prudence and fairness rather than purely in maximising benefits: prioritising one’s younger self for lifesaving treatments is prudent from an (...) individual perspective, and prioritising younger patients works to narrow health disparities by giving priority to patients at risk of dying earlier in life, who are more likely to be subject to systemic disadvantage. We then identify some confusions in recent arguments against considering age. (shrink)

While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim to (...) fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters. (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)

COVID-19 presents a variety of ethical challenges in a set of arenas, arenas not always considered in past pandemics. These challenges include issues related to autonomy, distributive ethics, and the establishment of policies of equity and justice. Methods are a literature review based on regular editing of an online textbook during the COVID-19 outbreak and a literature review using key ethical terms. Patients are confronted with new issues related to autonomy. Providers need to expand their concepts of ethical issues to (...) include decisions based on proportionality and public health ethics. The public health sector needs to assess the beneficence of alternative modes of disease control. The research community needs to redefine the concept of informed consent in emergent conditions. All elements of the medical spectrum—physicians, scientists, and the community-at-large including the pharmaceutical industry—need to consider the multifaceted methods for preventing future pandemics. This will require giving particular emphasis to public health funding and ending the documented discrimination that exists in the provision of proven therapies. The developing world is especially at risk for most of the ethical issues, especially those related to equity and justice. The ethical issues associated with the COVID-19 outbreak are not unique but provide a diverse set of issues that apply to patients, providers, social groups, and investigators. The further study of such issues can help with preventing future outbreaks. (shrink)

Socially responsible publishers, such as the BMJ Publishing Group, have demonstrated a commitment to health equity and working towards rectifying the structural racism that exists both in healthcare and in medical publishing.1 The commitment of academic publishers to collecting information relevant to promoting equity and diversity is important and commendable where it leads to that result.2 However, collecting sensitive demographic data is not a morally neutral activity. Rather, it carries with it both known and potential risks. Among these are issues (...) around privacy or data misuse, as well as more basic concerns about how, when or why people should be categorised in certain ways and/or prompted to conceive of themselves or their identities in certain terms.3 If such data are to be collected, therefore, their effectiveness in achieving the stated ends must have a sufficiently compelling evidence base so as to justify the various risks involved. And where possible, these risks must also be identified and minimised. As Varcoe et al 4 argue, > While most leaders and healthcare workers and some patients [in their study] envisioned potential benefits associated with having ethnicity data, these benefits were seen as largely contingent upon action being taken to [actually] ameliorate inequities. Overwhelmingly, however, leaders from ethno-cultural communities and patients of diverse identities anticipated potential harm arising both from having ethnicity data and the process of collection. The analysis illustrates that in today’s sociopolitical context, collecting ethnicity data in clinical contexts may engender considerable harm, particularly for racialized, vulnerable patients. (p1569) Varcoe et al refer to ‘ethnicity’ data, which as they note is an ambiguous concept, potentially encompassing such diverse notions as ancestry, language, religion or culture. It is also a term that is in some contexts—for example, the USA—often used interchangeably with a different, more highly charged term: ‘race’. Data …. (shrink)