When Equality Is Not Equity: The Ethics of Access to Trauma Care: A Surgical Perspective.

OBJECTIVE: The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program. BACKGROUND: Traumatic injury is a leading cause of death and disability in the United States. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city, leading to a fallacy of distributive justice. METHODS: A descriptive analysis of community partners, trauma program leadership, trauma surgeons, and the violence intervention program director was performed. RESULTS: The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country, with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes ( P <0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018, developing both community-based and medical-legal partnerships. CONCLUSIONS: The persistent efforts of the community and key stakeholders led to a system change that improved trauma care for the South Side of Chicago.

Respect for bioethical principles and human rights in prisons: a systematic review on the state of the art.

BACKGROUND: Respect for human rights and bioethical principles in prisons is a crucial aspect of society and is proportional to the well-being of the general population. To date, these ethical principles have been lacking in prisons and prisoners are victims of abuse with strong repercussions on their physical and mental health. METHODS: A systematic review was performed, through a MESH of the following words (bioethics) AND (prison), (ethics) AND (prison), (bioethics) AND (jail), (ethics) AND (jail), (bioethics) AND (penitentiary), (ethics) AND (penitentiary), (prison) AND (human rights). Inclusion and exclusion criteria were defined and after PRISMA, 17 articles were included in the systematic review. RESULTS: Of the 17 articles, most were prevalence studies (n.5) or surveys (n.4), followed by cross-sectional studies (n.3), qualitative studies (n.1), retrospective (n.1) and an explanatory sequential mixed-methods study design (n.1). In most cases, the studies associated bioethics with prisoners' access to treatment for various pathologies such as vaccinations, tuberculosis, hepatitis, HIV, it was also found that bioethics in prisons was related to the mental health of prisoners, disability, ageing, the condition of women, the risk of suicide or with the request for end-of-life by prisoners. The results showed shortcomings in the system of maintaining bioethical principles and respect for human rights. CONCLUSIONS: Prisoners, in fact, find it difficult to access care, and have an increased risk of suicide and disability. Furthermore, they are often used as improper organ donors and have constrained autonomy that also compromises their willingness to have end-of-life treatments. In conclusion, prison staff (doctors, nurses, warders, managers) must undergo continuous refresher courses to ensure compliance with ethical principles and human rights in prisons.

Emergency Physicians' Ethical Issues with Hospital Business Models.

BACKGROUND: The changing hospital business model has raised ethical issues for emergency physicians (EPs) in a healthcare system that often prioritizes profits over patient welfare. For-profit hospitals, driven by profit motives, may prioritize treating patients with lucrative insurance plans and those who can afford expensive treatments. Private equity investors, who now own many for-profit hospitals, focus on short-term financial gains, leading to cost-cutting measures and pressure on EPs to prioritize financial goals over patient welfare. Nonprofit hospitals, mandated to provide charity care to the underserved, may fail to meet their community service obligations, resulting in disparities in healthcare access. OBJECTIVE: This review examines the ethical challenges faced by emergency physicians (EPs) in response to the evolving hospital business model, which increasingly prioritizes profits over patient welfare. DISCUSSION: Emergency physicians face ethical dilemmas in this changing environment, including conflicts between patient care and financial interests. Upholding professional ethics and the principle of beneficence is essential. Another challenge is equitable access to healthcare, with some nonprofit hospitals reducing charity care, thus exacerbating disparities. EPs must uphold the ethical principle of justice, ensuring quality care for all patients, regardless of financial means. Conflicts of interest may arise when EPs work in hospitals owned by private equity firms or with affiliations with pharmaceutical companies or medical device manufacturers, potentially compromising patient care. CONCLUSION: Emergency physicians must navigate these ethical issues while upholding professional ethics and advocating for patients' best interests. Collaboration with hospital administrators, policymakers, and stakeholders is vital to address these concerns and prioritize patient welfare in healthcare delivery.

No (true) right to die: barriers in access to physician-assisted death in case of psychiatric disease, advanced dementia or multiple geriatric syndromes in the Netherlands.

Even in the Netherlands, where the practice of physician-assisted death (PAD) has been legalized for over 20 years, there is no such thing as a 'right to die'. Especially patients with extraordinary requests, such as a wish for PAD based on psychiatric suffering, advanced dementia, or (a limited number of) multiple geriatric syndromes, encounter barriers in access to PAD. In this paper, we discuss whether these barriers can be justified in the context of the Dutch situation where PAD is legally permitted for those who suffer unbearably and hopelessly as a result of medical conditions. Furthermore, we explore whether there are options to address some of the barriers or their consequences, both within the Dutch legal framework or by adjusting the legal framework, and whether these options are feasible. We conclude that although there are insufficient arguments to overrule the doctor's freedom of conscience in the Netherlands, there are ways to address some of the barriers, mainly by offering support to doctors that would be willing to support a request. Moreover, we believe it is morally required to reduce or mitigate where possible the negative consequences of the barriers for patients, such as the long waiting time for those who suffer from psychiatric disorders, because it is unlikely the adjustments suggested to the system will ensure reasonable access for these patient groups.

Collateral damage: Impact of SARS-CoV-2 pandemic in people living with HIV.

People living with HIV (PLWH) may be at higher risk for adverse outcomes indirectly associated with the severe acute respiratory syndrome coronavirus (SARS-CoV-2). When comparing responses to questionnaires administered when social distancing and quarantine guidelines were first implemented, we found that PLWH were more likely to have restricted access to medical care, increased financial stress, increased symptoms of anxiety and depression, and increased substance use compared to demographically-similar people without HIV.

Restricted access to assisted reproductive technology and fertility preservation: legal and ethical issues.

Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.

Use of Telemedicine and Smart Technology in Obstetrics: Barriers and Privacy Issues.

While telemedicine had been utilized in varying ways over the last several years, it has dramatically accelerated in the era of the COVID-19 pandemic. In this article we describe the privacy issues, in relation to the barriers to care for health care providers and barriers to the obstetric patient, licensing and payments for telehealth services, technological issues and language barriers. While there may be barriers to the use of telehealth services this type of care is feasible and the barriers are surmountable.

Withdrawal of intensive care during times of severe scarcity: Triage during a pandemic only upon arrival or with the inclusion of patients who are already under treatment?

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID-19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time-limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care.

Solidarity in the Time of COVID-19?

This article critically examines how solidarity has been enacted in the first 2 months of the COVID-19 pandemic, mainly, but not exclusively, from a United Kingdom perspective.1 Solidaristic strategies are framed in two ways: aspirations to overcome COVID-19 (utopian anthropocentric solidarity); and those that are illusory, incompatible, contradictory, and disrupting of solidaristic ideals (heterotopian solidarity). Solidarity can also be understood more widely from a biocentric perspective (solidarity with all life). In the context of COVID-19 a lack of biocentric solidarity points to a probable cause of the pandemic; where COVID-19, harmless in bats, jumped species as a consequence of closer contact with humans. Solidarity, therefore, is not only expressed in a fight against a viral "enemy" but is also a reminder of human activity that has upset balances within ecosystems.

Oral Health Matters: The Ethics of Providing Oral Health During COVID-19.

Oral health is a critical part of overall health. The current COVID-19 pandemic has highlighted the importance of oral health. In this article, we describe how dental practice has been impacted by COVID-19, identify the public health response to COVID-19, and explain the gradual resumption of dental care after the initial disruption due to the pandemic. Finally, we discuss how long-standing health disparities in oral health have been exacerbated by the current pandemic.

Moral Distress in Nephrology: Perceived Barriers to Ethical Clinical Care.

Moral distress occurs when individuals are unable to act in accordance with what they believe to be ethically correct or just. It results from a discrepancy between a clinician's perception of "the right thing to do" and what is actually happening and is perpetuated by perceived constraints that limit the individual from speaking up or enacting change. Moral distress is reported by many clinicians in caring for patients with serious illness, including chronic kidney disease and kidney failure. If left unidentified, unexpressed, or unaddressed, moral distress may cause burnout, exhaustion, detachment, and ineffectiveness. At an extreme, moral distress may lead to a desire to abandon the speciality entirely. This article offers an international perspective on moral distress in nephrology in diverse contexts and health care systems. We examine and discuss the sociocultural factors that contribute to moral distress in nephrology and offer suggestions for interventions from individual provider, facility, and health care systems perspectives to reduce the impact of moral distress on nephrology providers.

Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa.

Strategies for HIV prevention among infants, children, and adolescents have evolved significantly over the past 20 years. These include the global scale-up of simplified multidrug HIV regimens for pregnant women, leading to impressive reductions in new child HIV infections. However, significant gaps remain, especially in high HIV-burden sub-Saharan African countries. For example, many pregnant women living with HIV (WLHIV) are unable to access and sustain HIV testing and treatment partly due to low agency and harmful gender norms. Among pregnant WLHIV, adolescent girls face an additional layer of societal and health-system barriers in accessing care for themselves and their exposed infants. Legal and structural barriers limit access to HIV prevention-related sexual and reproductive health services among high-risk adolescents, including girls and young men who have sex with men. Key ethical issues underlying HIV prevention gaps for infants, children, and adolescents prevail. This narrative review explores these issues and highlights counter-measures for programming and policy, including gender empowerment, improving access to and appropriateness of critical health services, rights-based policy and legislation, closing research gaps, and considering the values and preferences of young people for HIV prevention and treatment services.

Regulatory oversight of cell therapy in China: Government's efforts in patient access and therapeutic innovation.

In recent years, remarkable progress has been made in the fundamental research and on clinical development of cell therapy. Although China has launched a series of regulations to establish a proper regulatory framework that facilitates the development of cell therapy products, the regulatory framework has not been able to meet the country's regulatory requirements. This article introduced the development of regulation and current regulatory pathways for cell therapy in China and identified the main challenges in clinical studies. China has recently tightened its policy on cell therapy clinical studies after medical chaos occurred in the area of cell therapy over the past few years. Currently the regulatory jurisdiction between NMPA and NHC are not very clear, especially for clinical somatic cell research, further efforts are necessary to establish a legislative system with a clear and functional regulatory framework for cell therapy.

Global Surgery Pro-Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

Global surgery, especially academic global surgery, is of tremendous interest to many surgeons. Classically, it entails personnel from high-income countries going to low- and middle-income countries and engaging in educational activities as well as procedures. Academic medical personnel have included students, residents, and attendings. The pervasive notion is that this is a win-win situation for the volunteers and the hosts, that is, a pathway to bilateral academic success. However, a critical examination demonstrates that it can easily become the bold new face of colonialism of a low- and middle-income country by a high-income country.

Economic arguments in migrant health policymaking: proposing a research agenda.

Welfare states around the world restrict access to public healthcare for some migrant groups. Formal restrictions on migrants' healthcare access are often justified with economic arguments; for example, as a means to prevent excess costs and safeguard scarce resources. However, existing studies on the economics of migrant health policies suggest that restrictive policies increase rather than decrease costs. This evidence has largely been ignored in migration debates. Amplifying the relationship between welfare state transformations and the production of inequalities, the Covid-19 pandemic may fuel exclusionary rhetoric and politics; or it may serve as an impetus to reconsider the costs that one group's exclusion from health can entail for all members of society.The public health community has a responsibility to promote evidence-informed health policies that are ethically and economically sound, and to counter anti-migrant and racial discrimination (whether overt or masked with economic reasoning). Toward this end, we propose a research agenda which includes 1) the generation of a comprehensive body of evidence on economic aspects of migrant health policies, 2) the clarification of the role of economic arguments in migration debates, 3) (self-)critical reflection on the ethics and politics of the production of economic evidence, 4) the introduction of evidence into migrant health policymaking processes, and 5) the endorsement of inter- and transdisciplinary approaches. With the Covid-19 pandemic and surrounding events rendering the suggested research agenda more topical than ever, we invite individuals and groups to join forces toward a (self-)critical examination of economic arguments in migration and health, and in public health generally.

Integrating philosophy, policy and practice to create a just and fair health service.

To practise 'fairly and justly' a clinician must balance the needs of both the many and the few: the individual patient in front of them, and the many unseen patients in the waiting room, and in the county. They must consider the immediate clinical needs of those in the present, and how their actions will impact on future patients. The good medical practice guidance 'Make the care of your patient your first concern' provides no guidance on how doctors should act when they care for multiple patients with conflicting needs. Moreover, conflicting needs extend far past simply those between different patients. At an organisational level, financial obligations must be balanced with clinical ones; the system must support those who work within it in a variety of roles; and, finally, in order for a healthcare service to be sustainable, the demands of current and future generations must be balanced.The central problem, we propose, is that there is no shared philosophical framework on which the provision of care or the development of health policy is based, nor is there a practical, fair and transparent process to ensure that the service is equipped to deal justly with new challenges as they emerge. Many philosophers have grappled with constructing a set of principles which would lead to a 'good' society which is just to different users; prominent among them is Rawls.Four important principles can be derived using a Rawlsian approach: equity of access, distributive justice, sustainability and openness. However, Rawls' approach is sometimes considered too abstract to be applied readily to policymaking; it does not provide clear guidance for how individuals working within existing institutions can enact the principles of justice. We therefore combine the principles derived from Rawls with Scanlonian contractualism: by demanding that decisions are made in a way which cannot be 'reasonably rejected' by different stakeholders (including 'trustees' for those who cannot represent themselves), we ensure that conflicting needs are considered robustly.We demonstrate how embedding this framework would ensure just policies and fair practice. We illustrate this by using examples of how it would help prevent injustice among different socioeconomic groups, prevent intergenerational injustice and prevent injustice in a crisis, for example, as we respond to new challenges such as COVID-19.Attempts to help individual doctors practise fairly and justly throughout their professional lives are best focused at an institutional or systemic level. We propose a practical framework: combining Scanlonian contractualism with a Rawlsian approach. Adopting this framework would equip the workforce and population to contribute to fair policymaking, and would ultimately result in a healthcare system whose practice and policies-at their core-were just.

Patient and Family Descriptions of Ethical Concerns.

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants (N = 196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.

Equitable access to ectogenesis for sexual and gender minorities.

As the technology for ectogenesis continues to advance, the ethical implications of such developments should be thoroughly and proactively explored. The possibility of full ectogenesis remains hypothetical at present, and myriad concerns regarding the safety and efficacy of the technology must be evaluated and addressed, while pressing moral considerations should be fully deliberated. However, it is conceivable that the technology may become sufficiently well established in the future and that eventually full ectogenesis might be deemed ethically acceptable as a reproductive alternative to gestation within a human womb under certain circumstances. If the safety and efficacy of full ectogenesis are established, if ethical dilemmas are sufficiently well addressed, and if the technology is offered as a reproductive option to cisgender heterosexual individuals or couples desiring to become parents, there is a moral obligation grounded in social justice to ensure that full ectogenesis be made available to individuals or couples identifying as members of sexual- or gender-minority groups who likewise seek to pursue parenthood. We examine the history of access to current family-building options, including assisted reproductive technology, surrogacy and adoption, for these populations and conclude that in the absence of robust empirical evidence suggesting an increased risk of harm to children of individuals and couples who identify as members of sexual- or gender-minority groups, equitable access to ectogenesis as a pathway to parenthood for sexual and gender minorities must be assured as a matter of reproductive justice.