Investigating ethical tradeoffs in crisis standards of care through simulation of ventilator allocation protocols.

INTRODUCTION: Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. METHODS: A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. RESULTS: The simulation demonstrated stronger performance for age-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 29 lives and 3400 life-years per thousand patients. Proposed protocols from New York and Maryland which allocated without considering age saved the fewest lives (~13.2 and 8.5 lives) and life-years (~416 and 420 years). Unlike other protocols, the New York and Maryland algorithms did not generate significant disparities in lives saved and life-years saved between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. For all protocols, we observed a positive correlation between lives saved and life-years saved, but also between lives saved overall and inequality in the number of lives saved in different race and ethnicity sub-populations. CONCLUSION: While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols.

Introduction: Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. Methods: A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. Results: The simulation demonstrated stronger performance for age- and comorbidity-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 28.7 lives and 3408 life-years per thousand patients, while ranking by Sequential Organ Failure Assessment (SOFA) bands saved the fewest lives (13.2) and life-years (416). For all protocols, we observed a positive correlation between lives saved and life-years saved. For all protocols except lottery and the banded SOFA, significant disparities in lives saved and life-years saved were noted between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. Conclusion: While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

The Ethics of Implementing Emergency Resource Allocation Protocols.

AbstractWe explore the various ethical challenges that arise during the practical implementation of an emergency resource allocation protocol. We argue that to implement an allocation plan in a crisis, a hospital system must complete five tasks: (1) formulate a set of general principles for allocation, (2) apply those principles to the disease at hand to create a concrete protocol, (3) collect the data required to apply the protocol, (4) construct a system to implement triage decisions with those data, and (5) create a system for managing the consequences of implementing the protocol, including the effects on those who must carry out the plan, the medical staff, and the general public. Here we illustrate the complexities of each task and provide tentative solutions, by describing the experiences of the Coronavirus Ethics Response Group, an interdisciplinary team formed to address the ethical issues in pandemic resource planning at the University of Rochester Medical Center. While the plan was never put into operation, the process of preparing for emergency implementation exposed ethical issues that require attention.

Open Reduction Internal fixation of Incarcerated Greater Tuberosity Avulsion Fracture: A Case Report.

Introduction: Proximal humerus fractures are common injuries of the upper extremity. These fractures are frequent in the elderly population due to low-energy trauma and in the younger patient secondary to high-energy trauma that is associated with shoulder dislocations. Proximal humerus fractures are frequently classified according to the Neer classification which is defined by the number of segments and the amount displacement required to define the fracture as displaced. Segments include the greater tuberosity (GT), the lesser tuberosity, the humeral head, and the humeral shaft. Fractures are considered displaced if there is at least 45° of angulation or 1 cm of displacement. Case Report: We present a case of a 42-year-old Caucasian patient with a displaced and incarcerated GT avulsion fracture following a motorcycle accident. In this report, we describe the patient positioning, technique using open reduction internal fixation utilizing multiple anchors and suture to treat this injury and the successful outcome of our patient 1 year from the injury. Conclusion: While standard open reduction internal fixation techniques using plates and screws are appropriate for treating these injuries, we chose to pursue a method that involved only bio-absorbable suture anchors. Using these anchors, we were able to achieve an anatomic reduction of the GT fragment that ultimately went on to achieve full healing.

A Technique for Anterior Cruciate Ligament Reconstruction in the Setting of Unicompartmental Knee Arthroplasty.

Unicompartmental knee arthroplasty (UKA) is becoming a more prevalent treatment for medial-compartment arthritis. Traditionally, a competent anterior cruciate ligament (ACL) is required to achieve satisfactory results. This leads to the question of treatment for medial-compartment arthritis in the setting of an incompetent ACL. A treatment option for this subset of patients is concurrent UKA and ACL reconstruction; however, this technique addresses the cohort of patients with a previously stable UKA who sustain an injury to the ACL, leading to symptomatic instability. The purpose of this article is to detail a technique for ACL reconstruction in the setting of a previous UKA.

The role of the dorsal dentate gyrus in object and object-context recognition.

The aim of this study was to determine the role of the dorsal dentate gyrus (dDG) in object recognition memory using a black box and object-context recognition memory using a clear box with available cues that define a spatial context. Based on a 10 min retention interval between the study phase and the test phase, the results indicated that dDG lesioned rats are impaired when compared to controls in the object-context recognition test in the clear box. However, there were no reliable differences between the dDG lesioned rats and the control group for the object recognition test in the black box. Even though the dDG lesioned rats were more active in object exploration, the habituation gradients did not differ. These results suggest that the dentate gyrus lesioned rats are clearly impaired when there is an important contribution of context. Furthermore, based on a 24 h retention interval in the black box the dDG lesioned rats were impaired compared to controls.

Transparent vessels?: What organ donors should be allowed to know about their recipients.

A live organ donor needs to be informed carefully about the risks and benefits of her donation for both herself and her recipient, but a key ethical question is how much the donor is allowed to know about the recipient. To decide this question, we must first decide whether, out of respect for autonomy, the donor should decide how much she wants to know, or whether the transplant team, as the professionals, should decide what information is relevant to the donor's decision. I argue that the transplant team should control the process. While the donor has the right to know enough about her recipient to assess the risk to herself and the prospects for a successful donation, she is not entitled to any further information, no matter how much she wants it. In particular, I argue that donors are not entitled to information that has not been shown to affect outcomes, but that they should be told if a recipient is HIV or that he has rejected a previous organ due to non-compliance. Donors have a right to make decisions with all the information they need, but recipients need not make their lives completely transparent.

Better brains, better selves? The ethics of neuroenhancements.

The idea of enhancing our mental functions through medical means makes many people uncomfortable. People have a vague feeling that altering our brains tinkers with the core of our personalities and the core of ourselves. It changes who we are, and doing so seems wrong, even if the exact reasons for the unease are difficult to define. Many of the standard arguments against neuroenhancements--that they are unsafe, that they violate the distinction between therapy and enhancements, that they undermine equality, and that they will be used coercively--fail to show why the use of any such technologies is wrong in principle. Two other objections--the arguments that such changes undermine our integrity and that they prevent us from living authentic lives--will condemn only a few of the uses that are proposed. The result is that very few uses of these drugs are morally suspect and that most uses are morally permissible.