Developing a Triage Protocol for the COVID-19 Pandemic: Allocating Scarce Medical Resources in a Public Health Emergency.

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the triage protocol, summarize the protocol itself, and discuss the major ethical challenges encountered, along with our answers to these challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments. We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges that they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the COVID-19 pandemic and similar public health emergencies.

Avoiding Ineffective End-of-Life Care: A Lesson from Triage?

Ethicists and physicians all over the world have been working on triage protocols to plan for the possibility that the Covid-19 pandemic will result in shortages of intensive care unit beds, ventilators, blood products, or medications. In reflecting on those protocols, many health care workers have noticed that, outside the pandemic shortage situation, we routinely supply patients in the ICU with invasive and painful care that will not help the patients survive even their hospitalization. This is the kind of pointless care that even the most basic protocol would triage against. Perhaps this widespread reflection on triage standards will draw our attention to our ongoing custom of supplying burdensome and inefficacious care to those near the end of life-care that most health care providers would not want for themselves. This essay argues that reflecting on triage could help us improve end-of-life care.

Addressing Ethical Challenges in US-Based HIV Phylogenetic Research.

In recent years, phylogenetic analysis of HIV sequence data has been used in research studies to investigate transmission patterns between individuals and groups, including analysis of data from HIV prevention clinical trials, in molecular epidemiology, and in public health surveillance programs. Phylogenetic analysis can provide valuable information to inform HIV prevention efforts, but it also has risks, including stigma and marginalization of groups, or potential identification of HIV transmission between individuals. In response to these concerns, an interdisciplinary working group was assembled to address ethical challenges in US-based HIV phylogenetic research. The working group developed recommendations regarding (1) study design; (2) data security, access, and sharing; (3) legal issues; (4) community engagement; and (5) communication and dissemination. The working group also identified areas for future research and scholarship to promote ethical conduct of HIV phylogenetic research.

Work Requirements That Don't Work.

Early in 2018, the Trump administration's Centers for Medicare and Medicaid Services issued a guidance letter outlining a new and controversial kind of Medicaid waiver proposal. The administration invited states to propose waivers that would impose work (or other "community engagement") requirements as a condition of eligibility for Medicaid. The Trump administration and state proponents of work requirements want to force able-bodied Medicaid beneficiaries into the workplace. Critics allege that this is because they mistakenly believe that low-income individuals are not working because they're lazy or because aid programs provide them with a disincentive to work. Proponents respond that the requirements can lower the public programs' costs while helping its recipients. Medicaid data seems to show that the work-requirement proposals are a solution in search of a real-life problem.

On Essentiality and the World Health Organization's Model List of Essential Medicines.

BACKGROUND: In 1977 the World Health Organization created its first Model List of Essential Medicines-a list designed to aid countries in determining which medicines to prioritize on their National Essential Medicines Lists. In classifying drugs as "essential," the World Health Organization has historically stressed drugs' ability to meet priority health needs of populations and cost. OBJECTIVES: In this paper we trace the fluctuations in the application of cost and priority status of disease as criteria for essential medicines throughout the reports published by the WHO Expert Committee on Selection and Use of Essential Medicines since 1977. METHODS: We analyzed essential medicines lists published on the World Health Organization website since 1977 for trends in criteria concerning cost and priority status of disease. Where, available, analyzed the World Health Organization Expert Committee analysis rationalizing why certain medicines were or were not added and were or were not removed. RESULTS: The application of the criteria of cost and priority status of essential medicines has fluctuated dramatically over the years. CONCLUSIONS: The definition of essential medicines has shifted and now necessitates a new consensus on normative definitions and criteria. A more standardized and transparent set of procedures for choosing essential medicines is required.

Trump's Abortion-Promoting Aid Policy.

On the fourth day of his presidency, Donald Trump reinstated and greatly expanded the "Mexico City policy," which imposes antiabortion restrictions on U.S. foreign health aid. In general, the policy has prohibited U.S. funding of any family-planning groups that use even non-U.S. funds to perform abortions; prohibited aid recipients from lobbying (again, even with non-U.S. money) for liberalization of abortion laws; prohibited nongovernment organizations from creating educational materials on abortion as a family-planning method; and prohibited health workers from referring patients for legal abortions in any cases other than rape, incest, or to save the life of the mother. The policy's prohibition on giving aid to any organization that performs abortions is aimed at limiting alleged indirect funding of abortions. The argument is that if U.S. money is used to fund nonabortion programs of an abortion-providing NGO, then the NGO can simply shift the money thus saved into its abortion budget. Outside the context of abortion, we do not reason this way. And the policy's remaining three prohibitions are deeply troubling.

Between public opinion and public policy: human embryonic stem-cell research and path-dependency.

In bioethics as in other areas of health policy, historical institutional factors can shape policy independently of interests or public opinion. This article finds policy divergence among countries with similar national moral views of stem cell research, and explains that divergence as the product of path-dependency.

Ethics in the marketing of medical services.

This paper deals with the ethics of marketing medical services by physicians, medical groups, hospitals and other mainstream medical caregivers in the United States. It does not deal with pharmaceutical marketing, since that raises a number of special issues, some of them legal and some having to do with the unique culture of pharmaceutical marketing, which really ought to be dealt with separately. Nor does it touch on the little-explored field of marketing alternative and complementary medicine. It begins with a general description of what is included in "the marketing process." It then briefly tours some of the difficulties faced by those who would market medical services ethically, and ends with some comments on the relevance of professionalism to ethical marketing.

Medical professionalism: a Parsonian view.

This paper argues for a normative conception of medical professionalism based on the work of sociologist Talcott Parsons. Such a conception grounds medical professionalism on the expert authority of the physician; the concept of authority is therefore discussed at length. Parsons view also lays much stress on the fact that the proper exercise of medical authority nearly always involves aligning the interests of individual patients with those of society at large. Parsonian professionalism looks to professional institutions such as medical schools, societies and journals to secure the competence and ethical behavior of professionals, and to help ensure that professionals exercise of authority is never biased by private financial interests or by public political power. Professional institutions should encourage professionals to develop a set of preferences and desires (e.g., for respect of their peers, and not for power or financial gain) that will tend to make them trustworthy authorities.