Allocating Ventilators During the COVID-19 Pandemic and Conscientious Objection

Social Support: From Exclusion Criteria to Medical Service

One of the criteria used by many transplant centers in assessing psychosocial eligibility for solid organ transplantation is social support. Yet, social support is a highly controversial requirement that has generated ongoing debate between ethicists and clinicians who favor its consideration (i.e., utility maximizers) and those who object to its use on equity grounds (i.e., equity maximizers). The assumption underlying both of these approaches is that social support is not a commodity that can be purchased in the marketplace. This essay argues for the reconceptualization of social support as a product that can-and should-be purchased for transplant candidates to render them eligible for transplant.

Participatory Approach to Develop Evidence-Based Clinical Ethics Guidelines for the Care of COVID-19 Patients: A Mixed Method Study From Nepal

During health emergencies such as the COVID-19 pandemic, healthcare workers face numerous ethical challenges while catering to the needs of patients in healthcare settings. Although the data recapitulating high-income countries ethics frameworks are available, the challenges faced by clinicians in resource-limited settings of low- and middle-income countries are not discussed widely due to a lack of baseline data or evidence. The Nepali healthcare system, which is chronically understaffed and underequipped, was severely affected by the COVID-19 pandemic in its capacity to manage health services and resources for needy patients, leading to ethical dilemmas and challenges during clinical practice. This study aimed to develop a standard guideline that would address syndemic ethical dilemmas during clinical care of COVID-19 patients who are unable to afford standard-of-care. A mixed method study was conducted between February and June of 2021 in 12 government designated COVID-19 treatment hospitals in central Nepal. The draft guideline was discussed among the key stakeholders in the pandemic response in Nepal. The major ethical dilemmas confronted by the study participants (50 healthcare professionals providing patient care at COVID-19 treatment hospitals) could be grouped into five major pillars of ethical clinical practice: rational allocation of medical resources, updated treatment protocols that guide clinical decisions, standard-of-care regardless of patient's economic status, effective communication among stakeholders for prompt patient care, and external factors such as political and bureaucratic interference affecting ethical practice. This living clinical ethics guideline, which has been developed based on the local evidence and case stories of frontline responders, is expected to inform the policymakers as well as the decision-makers positioned at the concerned government units. These ethics guidelines could be endorsed with revisions by the concerned regulatory authorities for the use during consequent waves of COVID-19 and other epidemics that may occur in the future. Other countries affected by the pandemic could conduct similar studies to explore ethical practices in the local clinical and public health context.

Priorities Towards Fair Allocation of Ventilators During COVID-19 Pandemic: A Delphi Study

Background

COVID-19 pandemic has resulted in severe shortage in vital resources, including invasive mechanical ventilators. The current imbalance between demand and supply of mechanical ventilators has called for investigations on the fair allocation of mechanical ventilators.

Objective

To determine the priorities of the medical experts towards the fair allocation of ventilators during the COVID-19 pandemic.

Methods

This study was conducted from May 28 to Aug 20, 2020. The questionnaire was sent to 50 medical specialists as the Delphi panel. Participants were asked to rate each prioritising factor: “−1” for low priority, “+1” for high priority, and “Zero” for equal priority.

Results

Among 38 experts who responded to the email, the responses of 35 were analysed. 31 (88.6%) participants recommended that pregnant women be considered high priority in allocating ventilators, 27 (77.1%) mothers of children <5 years, 26 (74.3%) patients under 80-years, and 23 (65.7%) front-line-healthcare-workers. In contrast, 28 (80.0) participants recommended that patients who are terminally ill should be considered as a low priority, 27 (77.1%) patients with active-malignancy, 25 (71.4%) neurodegenerative diseases, and 16 (45.7%) patients aged >80. The panel did not reach a consensus regarding the role of patients' laboratory profiles, underlying diseases, or drug abuse in the prioritisation of ventilators.

Conclusions

The panel considered pregnant mothers, mothers of children under 5 years, age groups younger than 80, and front-line healthcare workers to have high priority in allocating mechanical ventilators.

Ethics of ICU triage during COVID-19

INTRODUCTION

The coronavirus disease 2019 pandemic has placed intensive care units (ICU) triage at the center of bioethical discussions. National and international triage guidelines emerged from professional and governmental bodies and have led to controversial discussions about which criteria-e.g. medical prognosis, age, life-expectancy or quality of life-are ethically acceptable. The paper presents the main points of agreement and disagreement in triage protocols and reviews the ethical debate surrounding them.

SOURCES OF DATA

Published articles, news articles, book chapters, ICU triage guidelines set out by professional societies and health authorities.

AREAS OF AGREEMENT

Points of agreement in the guidelines that are widely supported by ethical arguments are (i) to avoid using a first come, first served policy or quality-adjusted life-years and (ii) to rely on medical prognosis, maximizing lives saved, justice as fairness and non-discrimination.

AREAS OF CONTROVERSY

Points of disagreement in existing guidelines and the ethics literature more broadly regard the use of exclusion criteria, the role of life expectancy, the prioritization of healthcare workers and the reassessment of triage decisions.

GROWING POINTS

Improve outcome predictions, possibly aided by Artificial intelligence (AI); develop participatory approaches to drafting, assessing and revising triaging protocols; learn from experiences with implementation of guidelines with a view to continuously improve decision-making.

AREAS TIMELY FOR DEVELOPING RESEARCH

Examine the universality vs. context-dependence of triaging principles and criteria; empirically test the appropriateness of triaging guidelines, including impact on vulnerable groups and risk of discrimination; study the potential and challenges of AI for outcome and preference prediction and decision-support.