Ethical and social reflections on the proposed European Health Data Space

The COVID-19 pandemic demonstrated the benefits of international data sharing. Data sharing enabled the health care policy makers to make decisions based on real-time data, it enabled the tracking of the virus, and importantly it enabled the development of vaccines that were crucial to mitigating the impact of the virus. This data sharing is not the norm as data sharing needs to navigate complex ethical and legal rules, and in particular, the fragmented application of the General Data Protection Regulation (GDPR). The introduction of the draft regulation for a European Health Data Space (EHDS) in May 2022 seeks to address some of these legal issues. If passed, it will create an obligation to share electronic health data for certain secondary purposes. While there is a clear need to address the legal complexities involved with data sharing, it is critical that any proposed reforms are in line with ethical principles and the expectations of the data subjects. In this paper we offer a critique of the EHDS and offer some recommendations for this evolving regulatory space.

Ethics and Health Security in the Australian COVID-19 Context: A Critical Interpretive Literature Review

Background The concept of "health security" is often used to motivate public health responses, yet the ethical values that underpin this concept remain largely unexamined. The recent Australian responses to COVID-19 serve as an important case study by which we can analyse the pre-existing literature to see what ethical values shaped, and continue to shape, Australia's response. Methods We conducted a critical interpretive literature review of academic and grey literatures within key databases, resulting in 2,220 sources. After screening for duplicates and relevance, we analysed ninety-six sources. Results First, risk and uncertainty are a leading focus, with a heavy concentration on risks to life and health. Second, free movement, safety, and security were recurringly emphasized, albeit narrowly focused upon the safety of the population. Third, legitimacy was a recurring theme, and it is here that discussions of "health security" figured highly. Conclusion Discussions of harm from government and associated official bodies fail to adequately distinguish between various senses of harm. Moreover, while the literature often discusses the balancing of rights, the steps involved in the weighing of these rights is rarely adequately explained and defended. We suggest that decision-makers should endeavour to clearly identify and defend the values undergirding their decisions in the public sphere.

Herd Immunity: History, Concepts, and Ethical Rationale

Public health emergencies are fraught by epistemic uncertainty, which raises policy issues of how to handle that uncertainty and devise sustainable public health responses. Among such responses, a herd immunity policy might be an option. Particularly before the development of vaccines, the current COVID-19 pandemic has highlighted the polarized nature of the political debate concerning the ethical feasibility of herd immunity strategies. This article provides a conceptual framework tailored to uncover the ethical rationale behind such strategies. Clarity on this issue is important in order to facilitate the terms of the political debate when tackling future health emergencies.

Exploring the Ethics of a Nurses' Strike During a Pandemic

ABSTRACT

It's usually considered a violation of professional ethics for health care workers, including nurses, to refuse to work during mass medical emergencies, especially if their refusal is over concerns like compensation. Strikes and other forms of work stoppage may result in harm to patients and, therefore, violate professional obligations of beneficence. However, in rare circumstances a health care worker's choice to remain on the job despite risk or potential harm to themselves or even their family may be considered beyond their professional obligation. During a pandemic such as COVID-19, the ethical calculus (that is, finding the right balance between beneficence and harm before deciding on a course of action) must take account of a confluence of factors, including the risks to present patients, future patients, and health care workers; the severity and duration of the risks; and the availability of ameliorative or protective steps that reduce risk and harm. The principle of beneficence to both future patients and health care workers may be thwarted if the risk analysis is confined only to short-term concerns (that is, to concerns occurring within a narrow temporal window). If a significantly elevated risk has been demonstrated to affect nurses and other health care workers of color disproportionately, racial justice must also be considered. The purpose of this article is to assess the moral framework of a work stoppage by nurses during a pandemic.

Ethical issues and public communication in the development of cell-based treatments for COVID-19: Lessons from the pandemic

The significant morbidity and mortality of coronavirus disease 19 (COVID-19) prompted a global race to develop new therapies. These include interventions using cell- or cell-derived products, several of which are being tested in well-designed, properly controlled clinical trials. Yet, the search for cell-based COVID-19 treatments has also been fraught with hyperbolic claims; flouting of crucial regulatory, scientific, and ethical norms; and distorted communication of research findings. In this paper, we critically examine ethical issues and public communication challenges related to the development of cell-based therapeutics for COVID-19. Drawing on the lessons learned from this ongoing process, we argue against the rushed development of cell-based interventions. We conclude by outlining ways to improve the ethical conduct of cell-based clinical investigations and public communication of therapeutic claims.

Public health ethics and the COVID-19 pandemic

Health is a human right anchored in values as a basic necessity of life. It promotes the well-being of persons, communities, economic prosperity, and national development. The coronavirus disease-2019 (COVID-19) pandemic caught the world unaware and unprepared. It presented a huge challenge to the health and economic systems of every country. Across the spectrum of human endeavor and liberty, several ethical questions have been raised with regard to its management, particularly the public health control measures. Decisions for pandemic control measures are made under difficult circumstances driven by urgency and panic, with uncertainties and complexities for public goods over individual rights. Global solidarity in controlling the pandemic is being tested. National governments have the responsibility to protect public health on the grounds of common good. Political considerations should not be the basis for decision-making against the best available epidemiological data from pandemic disease dynamics. Hence, the need to adhere to the values of honesty, trust, human dignity, solidarity, reciprocity, accountability, transparency, and justice are major considerations. A literature search was conducted for the publications from academic databases and websites of health-relevant organizations. I discuss the ethical questions and challenges of the COVID-19 pandemic in the context of public health control measures using the standard ethical principles of respect for autonomy, beneficence, nonmaleficence, and social (distributive) justice. It is observed that, at the country level, the World Health Organization (WHO) guidelines are used to control the pandemic. As WHO through the COVAX strategy distributes the vaccines to less developed countries, a lot still needs to be done to address the complex bottlenecks of allocation and distribution. There is a need to ensure acceptable and transparent system that promotes cooperation, equitable access, and fair distribution of vaccines on a global scale.

Impact of donors' financial fairness perception on donation intention in nonprofit organizations after COVID-19 outbreak

Based on the investigation of financial fairness perception and donation intention of individual donors in non-profit organizations (NPOs), this paper uses structural equation model to analyze the impact of individual donors' financial fairness perception on donation intention. The results show that individual donors' perceptions on financial result fairness, financial procedure fairness and financial information fairness all have positive impact on donation intention; among which the perception on financial result fairness only has direct impact on individual donation intention, while the perceptions on financial procedure fairness and financial information fairness have direct and indirect impact on individual donation intention.

Fundamental privacy rights in a pandemic state

Faced with the emergence of the Covid-19 pandemic, and to better understand and contain the disease's spread, health organisations increased the collaboration with other organisations sharing health data with data scientists and researchers. Data analysis assists such organisations in providing information that could help in decision-making processes. For this purpose, both national and regional health authorities provided health data for further processing and analysis. Shared data must comply with existing data protection and privacy regulations. Therefore, a robust de-identification procedure must be used, and a re-identification risk analysis should also be performed. De-identified data embodies state-of-the-art approaches in Data Protection by Design and Default because it requires the protection of direct and indirect identifiers (not just direct). This article highlights the importance of assessing re-identification risk before data disclosure by analysing a data set of individuals infected by Covid-19 that was made available for research purposes. We stress that it is highly important to make this data available for research purposes and that this process should be based on the state of the art methods in Data Protection by Design and by Default. Our main goal is to consider different re-identification risk analysis scenarios since the information on the intruder side is unknown. Our conclusions show that there is a risk of identity disclosure for all of the studied scenarios. For one, in particular, we proceed to an example of a re-identification attack. The outcome of such an attack reveals that it is possible to identify individuals with no much effort.

If fetuses are persons, abortion is a public health crisis

Pro-life advocates commonly argue that fetuses have the moral status of persons, and an accompanying right to life, a view most pro-choice advocates deny. A difficulty for this pro-life position has been Judith Jarvis Thomson's violinist analogy, in which she argues that even if the fetus is a person, abortion is often permissible because a pregnant woman is not obliged to continue to offer her body as life support. Here, we outline the moral theories underlying public health ethics, and examine the COVID-19 pandemic as an example of public health considerations overriding individual rights. We argue that if fetuses are regarded as persons, then abortion is of such prevalence in society that it also constitutes a significant public health crisis. We show that on public health considerations, we are justified in overriding individual rights to bodily autonomy by prohibiting abortion. We conclude that in a society that values public health, abortion can only be tolerated if fetuses are not regarded as persons.

Pandemic ICU triage challenge and medical ethics

The COVID-19 pandemic has made unprecedented global demands on healthcare in general and especially the intensive care unit (ICU). the virus is spreading out of control. To this day, there is no clear, published directive for doctors regarding the allocation of ICU beds in times of scarcity. This means that many doctors do not feel supported by their government and are afraid of the medicolegal consequences of the choices they have to make. Consequently, there has been no transparent discussion among professionals and the public. The thought of being at the mercy of absolute arbitrariness leads to fear among the population, especially the vulnerable groups.

Covid-19 in Historical Context: Creating a Practical Past

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" (Rosenberg 1989, pp. 2, 9). 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: (1) pandemics and disease crises in the past, along with public health responses to them, have had implications for civil liberties and government authority; (2) disease crises have acted as a sort of stress test on society, revealing, amplifying or widening existing social fissures and health disparities; (3) 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.

Utilitarian Principlism as a Framework for Crisis Healthcare Ethics

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.

Integrity during pandemic times: The case for flexible adamancy

The Covid-19 pandemic has dominated people's lives since late 2019, for more than nine months now. Healthcare resources and medicine have been completely consumed by the Covid 19 illness globally. This is a particularly difficult time for health systems because of the onerous responsibility to care for large numbers of sick people, protecting populations from contracting the infection by effective quarantine, isolation, and containment measures. In addition to this burden of work, healthcare providers are also overcome by fear of contracting the infection and transmitting it to their loved ones. It is during such difficult times that the integrity of healthcare providers is challenged. In this paper I will describe some challenges that a healthcare provider in a typical low resource setting faces during this pandemic time, and will propose the idea of "flexible adamancy" to address these challenges to the health system's integrity.

Commentary on "Pandemics and Beyond: Considerations When Personal Risk and Professional Obligations Converge"

The excellent article by Daniel J. Benedetti, Mithya Lewis-Newby, Joan S. Roberts, and Douglas S. Diekema draws strength by dealing both with micro ethical (personal) and macro ethical (institutional policies and structures) considerations. One should further note that often, the macro factors are even stronger than the article implies, although individuals can affect the macro context. A particularly important macro factor for all matters concerning healthcare, indeed all human services, is the tension between the profit motive and ethical decisions.

Dignity, Autonomy, and Allocation of Scarce Medical Resources During COVID-19

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.

Not all Bad: Sparks of Hope in a Global Disaster

The focus of discussion about the ethical issues associated with the COVID-19 pandemic has been on the great suffering to which it has given rise. However, there may be some unexpected positive outcomes that also emerge from the global disaster. The rupturing of entrenched systems and processes, the challenging of certainties that seemed beyond question, and the disruption of the assumed consensus of modernity may contribute to a rediscovery of the challenges that compose an ethical life. Elements of such a process are evident in the surge of community support and mutual caring, of spontaneous acts of joyous solidarity, of suspension of past conflicts, and exploration of new forms of reconciliation. The experiences are tentative and the outcomes uncertain, but at least for a moment the hope of a new way forward has been raised.

Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of "Duty" for Health Practitioners

From the ethics perspective, "duty of care" is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the "duty of care" from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of "duty" in their response to COVID-19.

Rethinking the Central Role of Equity in the Global Governance of Pandemic Response

Our initial response to COVID-19 has been plagued by a series of failures-many of which have extended inequity within and across populations, especially in low- and middle-income countries. The global health governance of pandemic preparedness and response needs to move further away from the advocacy of a one-size-fits-all approach that tends to prioritize the interests of high-income countries towards a context-sensitive approach that gives equity a central role in guiding our pandemic preparedness and response strategies.

COVID-19 Ethics-Looking Down the Muzzle

Public health and pandemic ethics frequently concern themselves with organizing principles, utility, and public policy. But the effects of pandemics, and the impact of measures to control them, are experienced by individuals and families. This is particularly true for those who are most vulnerable to COVID-19-the elderly and "infirm." So while ethics must assist in articulating the policies that will determine the allocation of resources during this and future pandemics, it must, at the same time, be alert to the intimate narratives of the infection. This is an account from someone looking down the muzzle of COVID-19.

Antibodies as Currency: COVID-19's Golden Passport

Due to COVID-19, the fragile economy, travel restrictions, and generalized anxieties, the concept of antibodies as a "declaration of immunity" or "passport" is sweeping the world. Numerous scientific and ethical issues confound the concept of an antibody passport; nonetheless, antibodies can be seen as a potential currency to allow movement of people and resuscitation of global economics. Just as financial currency can be forged, so too is the potential for fraudulent antibody passports. This paper explores matters of science, ethics, and identity theft, as well as the problems of bias and discrimination that could promulgate a world of pandemic "golden passports."

The Left Reflects on the Global Pandemic and Speaks to Transform!

The structure of this intervention is deliberately schizo-analytic: "and then-," and "then-." They are preparatory notes for a webinar by Transform! Europe on the COVID, arranged before the global explosion of Black Lives Matter. I question the top-down philanthropy of the bourgeois Left. I take the Rohingyas as bottom-line victims. I speak from two hometowns-Calcutta and New York. I ask the bourgeois Euro-U.S. Left not to monolithize the Global South. Many examples of how "India" is constructed are given. From New York, the United States is declared a failed state. Trump's delinquencies are mentioned. It is argued that the only remedy at present is human behaviour and the typical U.S. character is not ready to practice this. This empirical fact shows the failure of the Kantian Sublime and reminds us that Kant thinks that the human moral will comes in to protect us from a hugely frightening natural phenomenon only by "subreption," the same impulse that says that following steps provided by institutional religion will absolve us. Class and caste are taken into consideration throughout. I mention that as a coronavirus convalescent, I am donating plasma regularly.

The Rejuvenation of the Withering Nation State and Bio-power: The New Dynamics of Human Interaction

The outbreak of COVID-19 comes at the time when a shrinking public sector healthcare is an acknowledged fact in post-colonial societies. The policies adopted by the apparatus of most nation states for the past thirty years or more reveal that providing healthcare to all sections of societies is not a priority. The gradual process of economic liberalization has established "market" as the only legitimate mechanism of the distribution of goods/services as per the efficiency principle. The financial markets are globalized in such a manner that nation states are constantly losing their capacity to perform redistributive functions. State withdrawal from the provision of welfare rights is undermining its moral authority to impose any normative imperative to the people who are being left alone at the mercy of market forces. But the spread of COVID-19 on a global scale has provided an opportunity to the nation state. With the help of healthcare systems, the State has reasserted itself as the ultimate archangel to define human beings and their respective status in the newly emerging nomenclature of the public sphere. In this paper, the rejuvenation of the nation state with respect to bio-power will be discussed in the postcolonial context.

The Appointment in Samarra: A New Use for Some Old Jokes

The coronavirus epidemic is not just a biological phenomenon which affects humans: it is also a moment of a profound global and ecological crisis that includes many human and nonhuman actors. To confront the crisis, a radical philosophical change is needed, which penetrates to natural, economic, and cultural processes. The amassing of dictatorial powers of state apparatuses evoked by the pandemic highlights their basic impotence and the fact that the system as we know it cannot continue in its existing liberal-permissive form. While the final outcome is uncertain what is most probable is that a new barbarian capitalism will prevail: many old and weak will be sacrificed and let to die, workers will have to accept much lower standards of living, digital control of our lives will remain a permanent feature, and class distinctions will become much more than now a matter of life and death.

Synergistic Disparities and Public Health Mitigation of COVID-19 in the Rural United States

Public health emergencies expose social injustice and health disparities, resulting in calls to address their structural causes once the acute crisis has passed. The COVID-19 pandemic is highlighting and exacerbating global, national, and regional disparities in relation to the benefits and burdens of undertaking critical basic public health mitigation measures such as physical distancing. In the United States, attempts to address the COVID-19 pandemic are complicated by striking racial, economic, and geographic inequities. These synergistic inequities exist in both urban and rural areas but take on a particular character and impact in areas of rural poverty. Rural areas face a diverse set of structural challenges, including inadequate public health, clinical, and other infrastructure and economic precarity, hampering the ability of communities and individuals to implement mitigation measures. Public health ethics demands that personnel address both the tactical, real-time adjustment of typical mitigation tools to improve their effectiveness among the rural poor as well as the strategic, longer-term structural causes of health and social injustice that continue to disadvantage this population.

It Didn't Have to be This Way: Reflections on the Ethical Justification of the Running Ban in Northern Italy in Response to the 2020 COVID-19 Outbreak

In this paper I discuss the ethical justifiability of the limitation of freedom of movement, in particular of the ban on running outdoors, enforced in Italy as a response to the COVID-19 outbreak in the spring of 2020. I argue that through the lens of public health ethics literature, the ban on running falls short of the criterion of proportionality that public health ethics scholars and international guidelines for the ethical management of infectious disease outbreak recommend for any measure that restricts essential individual freedoms, such as the freedom of movement. The public health ethics framework, however, falls short of explaining the widespread public support that the running ban has had in Italy. I discuss possible factors which could explain the public support for the ban in Italy. Finally, I raise the question of what societal implications the abandonment of the public health ethics framework based on proportionality might have. I conclude that if it is the case, as the history of pandemics teaches us, we will experience further waves of COVID-19 outbreaks, it becomes very important to raise these questions now, with an eye towards informing public health policies for the management of future COVID-19 outbreaks. This discussion should not become politicized along the lines of liberal pro-lockdown/conservative anti-lockdown. Instead, we should reflect on the trade-offs of lockdown policies according to a pluralist framework, in which COVID-19 related deaths are not the only possible value to pursue.

What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France

In today's pandemic, many countries have experienced shortages of medical resources and many healthcare providers have often been faced with dramatic decisions about how to allocate beds, intensive care, or ventilators. Despite recognizing the need for triage, responses are not the same everywhere, and opinions and practices differ around what guidelines should be used, how they should be implemented, and who should ultimately decide. To some extent, triage issues reflect community values, revealing a given society's moral standards and ideals. Our goal is to study two countries which share many common features-Italy and France-as they deal with the pandemic, revealing the moral organization of medicine and healthcare, the power structures, and the nature of the disruptions in each context.

[Ethical considerations during health crisis: about SARS-CoV-2 coronavirus pandemic.]

In 2009, the H1N1 pandemic raised a series of ethical considerations that influenced the approach to the crisis. In the framework of the SARS-CoV-2 coronavirus pandemic, these issues have been repeated, and the analysis of what happened in 2009 can be seen as a warning. The principles of justice, solidarity, equity, transparency and reciprocity should be included in future pandemic response plans, including lessons learned.

Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?

A recent update to the Geneva Declaration's 'Physician Pledge' involves the ethical requirement of physicians to share medical knowledge for the benefit of patients and healthcare. With the spread of COVID-19, pockets exist in every country with different viral expressions. In the Chareidi ('ultra-orthodox') religious community, for example, rates of COVID-19 transmission and dissemination are above average compared with other communities within the same countries. While viral spread in densely populated communities is common during pandemics, several reasons have been suggested to explain the blatant flouting of public health regulations. It is easy to fault the Chareidi population for their proliferation of COVID-19, partly due to their avoidance of social media and internet aversion. However, the question remains: who is to blame for their community crisis? The ethical argument suggests that from a public health perspective, the physician needs to reach out and share medical knowledge with the community. The public's best interests are critical in a pandemic and should supersede any considerations of cultural differences. By all indications, therefore, the physician has an ethical obligation to promote population healthcare and share medical knowledge based on ethical concepts of beneficence, non-maleficence, utilitarian ethics as well as social, procedural and distributive justice. This includes the ethical duty to reduce health disparities and convey the message that individual responsibility for health has repercussions within the context of broader social accountability. Creative channels are clearly demanded for this ethical challenge, including measured medical paternalism with appropriate cultural sensitivity in physician community outreach.

Why lockdown of the elderly is not ageist and why levelling down equality is wrong

In order to prevent the rapid spread of COVID-19, governments have placed significant restrictions on liberty, including preventing all non-essential travel. These restrictions were justified on the basis the health system may be overwhelmed by COVID-19 cases and in order to prevent deaths. Governments are now considering how they may de-escalate these restrictions. This article argues that an appropriate approach may be to lift the general lockdown but implement selective isolation of the elderly. While this discriminates against the elderly, there is a morally relevant difference-the elderly are far more likely to require hospitalisation and die than the rest of the population. If the aim is to ensure the health system is not overwhelmed and to reduce the death rate, preventing the elderly from contracting the virus may be an effective means of achieving this. The alternative is to continue to keep everyone in lockdown. It is argued that this is levelling down equality and is unethical. It suggests that in order for the elderly to avoid contracting the virus, the whole population should have their liberty deprived, even though the same result could be achieved by only restricting the liberty of the elderly. Similar arguments may also be applied to all groups at increased risk of COVID-19, such as men and those with comorbidities, the obese and people from ethnic minorities or socially deprived groups. This utilitarian concern must be balanced against other considerations, such as equality and justice, and the benefits gained from discriminating in these ways must be proportionately greater than the negative consequences of doing so. Such selective discrimination will be most justified when the liberty restriction to a group promotes the well-being of that group (apart from its wider social benefits).

Maternal request caesareans and COVID-19: the virus does not diminish the importance of choice in childbirth

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections (MRCS) as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people's health and autonomy in childbirth and argue that this remains crucial during the current emergency. We consider some potential arguments-based on pregnant people's health and resource allocation-that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital's ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances.

Recommendations on COVID-19 triage: international comparison and ethical analysis

On March 11, 2020 the World Health Organization classified COVID-19, caused by Sars-CoV-2, as a pandemic. Although not much was known about the new virus, the first outbreaks in China and Italy showed that potentially a large number of people worldwide could fall critically ill in a short period of time. A shortage of ventilators and intensive care resources was expected in many countries, leading to concerns about restrictions of medical care and preventable deaths. In order to be prepared for this challenging situation, national triage guidance has been developed or adapted from former influenza pandemic guidelines in an increasing number of countries over the past few months. In this article, we provide a comparative analysis of triage recommendations from selected national and international professional societies, including Australia/New Zealand, Belgium, Canada, Germany, Great Britain, Italy, Pakistan, South Africa, Switzerland, the United States, and the International Society of Critical Care Medicine. We describe areas of consensus, including the importance of prognosis, patient will, transparency of the decision-making process, and psychosocial support for staff, as well as the role of justice and benefit maximization as core principles. We then probe areas of disagreement, such as the role of survival versus outcome, long-term versus short-term prognosis, the use of age and comorbidities as triage criteria, priority groups and potential tiebreakers such as 'lottery' or 'first come, first served'. Having explored a number of tensions in current guidance, we conclude with a suggestion for framework conditions that are clear, consistent and implementable. This analysis is intended to advance the ongoing debate regarding the fair allocation of limited resources and may be relevant for future policy-making.

Deaths in people from Black, Asian and minority ethnic communities from both COVID-19 and non-COVID causes in the first weeks of the pandemic in London: a hospital case note review

OBJECTIVE

To undertake a case review of deaths in a 6-week period during the COVID-19 pandemic commencing with the first death in the hospital from COVID-19 on 12th of March 2020 and contrast this with the same period in 2019.

SETTING

A large London teaching hospital.

PARTICIPANTS

Three groups were compared: group 1-COVID-19-associated deaths in the 6-week period (n=243), group 2-non-COVID deaths in the same period (n=136) and group 3-all deaths in a comparison period of the same 6 weeks in 2019 (n=194).

PRIMARY AND SECONDARY OUTCOME MEASURES

This was a descriptive analysis of death case series review and as such no primary or secondary outcomes were pre-stipulated.

RESULTS

Deaths in patients from the Black, Asian and minority ethnic (BAME) communities in the pandemic period significantly increased both in the COVID-19 group (OR=2.43, 95% CI=1.60-3.68, p<0.001) and the non-COVID group (OR=1.76, 95% CI=1.09-2.83, p=0.02) during this time period and the increase was independent of differences in comorbidities, sex, age or deprivation. While the absolute number of deaths increased in 2020 compared with 2019, across all three groups the distribution of deaths by age was very similar. Our analyses confirm major risk factors for COVID-19 mortality including male sex, diabetes, having multiple comorbidities and background from the BAME communities.

CONCLUSIONS

There was no evidence of COVID-19 deaths occurring disproportionately in the elderly compared with non-COVID deaths in this period in 2020 and 2019. Deaths in the BAME communities were over-represented in both COVID-19 and non-COVID groups, highlighting the need for detailed research in order to fully understand the influence of ethnicity on susceptibility to illness, mortality and health-seeking behaviour during the pandemic.

Lifted Up from Lockdown

The pandemic has impacted every scientist differently. Many negative impacts are frequently discussed. Here we highlight unexpected positives that we have found and hope will persist: improved access to experts; deeper and broader human engagement among colleagues, collaborators, and competitors; and significant democratization of research.

Teaching Professional Formation in Response to the COVID-19 Pandemic

In response to the COVID-19 pandemic, the Association of American Medical Colleges has called for a temporary suspension of clinical teaching activities for medical students. Planning for the continued involvement of learners in patient care during this pandemic should include teaching learners professional formation. The authors provide an ethical framework to guide such teaching, based on the ethical principle of beneficence and the professional virtues of courage and self-sacrifice from professional ethics in medicine. The authors show that these concepts support the conclusion that learners are ethically obligated to accept reasonable, but not unreasonable, risk. Based on this ethical framework, the authors provide an account of the process of teaching professional formation that medical educators and academic leaders should implement. Medical educators and academic leaders should embrace the opportunity that the COVID-19 pandemic presents for teaching professional formation. Learners should acquire the conceptual vocabulary of professional formation. Learners should recognize that risk of infection from patients is unavoidable. Learners should become aware of established ethical standards for professional responsibility during epidemics from the history of medicine. Learners should master understandable fear. Medical educators and academic leaders should ensure that didactic teaching of professional formation continues when it becomes justified to end learners' participation in the processes of patient care; topics should include the professionally responsible management of scarce medical resources. The COVID-19 pandemic will not be the last major infectious disease that puts learners at risk. Professional ethics in medicine provides powerful conceptual tools that can be used as an ethical framework to guide medical educators to teach learners, who will bear leadership responsibilities in responses to future pandemics, professional formation.

An international multicenter study of protocols for liver transplantation during a pandemic: A case for quadripartite equipoise

BACKGROUND & AIMS

The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources.

METHODS

We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources.

RESULTS

Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic.

CONCLUSIONS

This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems.

LAY SUMMARY

There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.

[Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic : Clinical and ethical recommendations of DIVI, DGINA, DGAI, DGIIN, DGNI, DGP, DGP and AEM. German version]

In view of the globally evolving Coronavirus Disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary authors group with support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethico-legal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supra-individual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. Assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient's general health status prior to the current illness.

COVID-19 Interconnectedness: Health Inequity, the Climate Crisis, and Collective Trauma

The COVID-19 pandemic brings to the forefront the complex interconnected dilemmas of globalization, health equity, economic security, environmental justice, and collective trauma, severely impacting the marginalized and people of color in the United States. This lack of access to and the quality of healthcare, affordable housing, and lack of financial resources also continue to have a more significant impact on documented and undocumented immigrants. This paper aims at examining these critical issues and developing a framework for family therapists to address these challenges by focusing on four interrelated dimensions: cultural values, social determinants of health, collective trauma, and the ethical and moral responsibility of family therapists. Given the fact that family therapists may unwittingly function as the best ally of an economic and political system that perpetuates institutionalized racism and class discrimination, we need to utilize a set of principles, values, and practices that are not just palliative or after the fact but bring forth into the psychotherapeutic and policy work a politics of care. Therefore, a strong call to promote and advocate for the broader continuum of health and critical thinking preparing professionals to meet the challenges of health equity, as well as economic and environmental justice, is needed. The issues discussed in this paper are specific to the United States despite their relevance to family therapy as a field. We are mindful not to generalize the United States' reality to the rest of the world, recognizing that issues discussed in this paper could potentially contribute to international discourse.