Ethical prioritization of critical care resources during COVID-19: perspectives from Italy and the United States.

This article examines some of the ethical challenges of prioritizing intensive care resources during the Covid-19 pandemic by comparing the Italian and United States contexts. After presenting an overview to the clinical, ethical, and public debates in Italy, the article will discuss the development of triage allocation protocols in United States hospitals. Resource allocation criteria underwent increased scrutiny and critique in both countries, which resulted in modified professional and expert guidance regarding healthcare ethics during times of emergency and resource scarcity.

Protocol to assess performance of crisis standards of care guidelines for clinical triage.

During the COVID-19 pandemic, US states developed Crisis Standards of Care (CSC) algorithms to triage allocation of scarce resources to maximize population-wide benefit. While CSC algorithms were developed by ethical debate, this protocol guides their quantitative assessment. For CSC algorithms, this protocol addresses (1) adapting algorithms for empirical study, (2) quantifying predictive accuracy, and (3) simulating clinical decision-making. This protocol provides a framework for healthcare systems and governments to test the performance of CSC algorithms to ensure they meet their stated ethical goals. For complete details on the use and execution of this protocol, please refer to Jezmir et al. (2021).

Public Preferences for Allocation Principles for Scarce Medical Resources in the COVID-19 Pandemic in Korea: Comparisons With Ethicists' Recommendations.

OBJECTIVES: The purpose of this study was to investigate public preferences regarding allocation principles for scarce medical resources in the coronavirus disease 2019 (COVID-19) pandemic, particularly in comparison with the recommendations of ethicists. METHODS: An online survey was conducted with a nationally representative sample of 1509 adults residing in Korea, from November 2 to 5, 2020. The degree of agreement with resource allocation principles in the context of the medical resource constraints precipitated by the COVID-19 pandemic was examined. The results were then compared with ethicists' recommendations. We also examined whether the perceived severity of COVID-19 explained differences in individual preferences, and by doing so, whether perceived severity helps explain discrepancies between public preferences and ethicists' recommendations. RESULTS: Overall, the public of Korea agreed strongly with the principles of "save the most lives," "Koreans first," and "sickest first," but less with "random selection," in contrast to the recommendations of ethicists. "Save the most lives" was given the highest priority by both the public and ethicists. Higher perceived severity of the pandemic was associated with a greater likelihood of agreeing with allocation principles based on utilitarianism, as well as those promoting and rewarding social usefulness, in line with the opinions of expert ethicists. CONCLUSIONS: The general public of Korea preferred rationing scarce medical resources in the COVID-19 pandemic predominantly based on utilitarianism, identity and prioritarianism, rather than egalitarianism. Further research is needed to explore the reasons for discrepancies between public preferences and ethicists' recommendations.

Medical Ethics, Moral Courage, and the Embrace of Fallibility.

Experts have an obligation to make difficult decisions rather than offloading these decisions onto others who may be less well equipped to make them. This commentary considers this obligation through the lens of drafting critical care rationing protocols to address COVID-19-induced scarcity. The author recalls her own experience as a member of multiple groups charged with the generation of protocols for how hospitals and states should ration critical care resources like ventilators and intensive care unit beds, in the event that there would not be enough to go around as the COVID-19 pandemic intensified. She identifies several obvious lessons learned through this process, including the need to combat the pervasive effects of racism, ableism, and other forms of discrimination; to enhance the diversity, equity, and inclusion built into the process of drafting rationing protocols; and to embrace transparency, including acknowledging failings and fallibility. She also comes to a more complicated conclusion: Individuals in a position of authority, such as medical ethicists, have a moral obligation to embrace assertion, even when such assertions may well turn out to be wrong. She notes that when the decision-making process is grounded in legitimacy, medical ethics must have the moral courage to embrace fallibility.

Time for the ethical management of COVID-19 vaccines.

The ethical distribution of life-saving medical and public health interventions to vulnerable groups has often been overlooked. Valuation of life linked to an individual's country of origin, the pharmaceutical industry's prioritisation of profit, the exploitation of vulnerable groups in clinical trials, and the resulting hesitancy towards drugs and vaccines have, among other factors, made the human right to health unattainable for many people. The COVID-19 pandemic presents itself as an opportunity to reverse this long-standing trajectory of unethical practices in global health. By ensuring the ethical inclusion of vulnerable groups in the vaccine development process and making a safe, effective vaccine accessible to all, pharmaceutical companies, governments, and international organisations can usher in a new era of global health that relies solely on ethical decision making.

Justice through a Wide-Angle Lens.

In the lead article of the May-June 2021 issue of the Hastings Center Report, Nancy Jecker and Caesar Atuire argue that the Covid-19 crisis is best understood as a syndemic, "a convergence of biosocial forces that interact with one another to produce and exacerbate clinical disease and prognosis." A syndemic framework, the authors advise, will enable bioethicists to recognize the ethical principles that should guide efforts to reduce the unequal effects that Covid-19 has on populations. Drawing on sub-Saharan African conceptions of solidarity, the authors lay out an approach to global vaccine distribution that prioritizes low- and middle-income countries. Like Jecker and Atuire's article, an essay by philosopher Keisha Ray pushes bioethicists to recognize broader justice-oriented responsibilities with the aid of a wide-angle lens. Ray's essay focuses on contemporary examples of environmental injustices that sicken, disable, or kill Black people.

What Has Covid-19 Exposed in Bioethics? Four Myths.

The Covid-19 pandemic has exposed four myths in bioethics. First, the flood of bioethics publications on how to allocate scarce resources in crisis conditions has assumed authorities would declare the onset of crisis standards of care, yet few have done so. This leaves guidelines in limbo and patients unprotected. Second, the pandemic's realities have exploded traditional boundaries between clinical, research, and public health ethics, requiring bioethics to face the interdigitation of learning, doing, and allocating. Third, without empirical research, the success or failure of ethics guidelines remains unknown, demonstrating that crafting ethics guidance is only the start. And fourth, the pandemic's glaring health inequities require new commitment to learn from communities facing extraordinary challenges. Without that new learning, bioethics methods cannot succeed. The pandemic is a wake-up call, and bioethics must rise to the challenge.

COVID-19 Pandemic Healthcare Resource Allocation, Age and Frailty.

The current coronavirus pandemic presents the greatest healthcare crisis in living memory. Hospitals across the world have faced unprecedented pressure. In the face of this tidal wave of demand for limited healthcare resources, how are clinicians to identify patients most likely to benefit? Should age or frailty be discriminators? This paper seeks to analyse the current evidence-base, seeking a nuanced approach to pandemic decision-making, such as admission to critical care.

Medical Triage During the COVID-19 Pandemic: A Medical and Ethical Burden.

During the COVID-19 pandemic, the number of patients who require intensive care treatment may outnumber the number of intensive care beds, even in industrialized nations. Consequently, triage may become necessary. In Italy, France, and Spain, age has been used as a leading parameter to decide who is admitted to the intensive care unit, and who receives palliative care. Although age is an objective and easy-to-use parameter, it is ethically not ideal to withdraw ventilator therapy from elderly people who suffer from COVID-19. We have developed a simple and easy-to-use scoring system to allow for triage that is based upon scientific outcome data and, at the same time, fulfills ethical standards.

Prioritising 'already-scarce' intensive care unit resources in the midst of COVID-19: a call for regional triage committees in South Africa.

BACKGROUND: The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. DISCUSSION: Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. CONCLUSION: We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.

Incorporating Stakeholder Perspectives on Scarce Resource Allocation: Lessons Learned from Policymaking in a Time of Crisis.

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work.

[Vaccine against covid-19: an open question.] / Vaccino contro la covid-19: una questione aperta.

For covid-19, a disease that has proved fatal in many cases, a specific therapy has not yet been found, but the vaccine. This has triggered a further series of issues. Who to vaccinate first, how to achieve the so-called "herd immunity", especially if it is right, as it is being done, start with the medical staff and immediately after safeguard the elderly which also involve the problem of a clear explanation and acceptance, through informed consent, which it can be particularly difficult to illustrate.

A consequentialist argument for considering age in triage decisions during the coronavirus pandemic.

Most ethics guidelines for distributing scarce medical resources during the coronavirus pandemic seek to save the most lives and the most life-years. A patient's prognosis is determined using a SOFA or MSOFA score to measure likelihood of survival to discharge, as well as a consideration of relevant comorbidities and their effects on likelihood of survival up to one or five years. Although some guidelines use age as a tiebreaker when two patients' prognoses are identical, others refuse to consider age for fear of discriminating against the elderly. In this paper, I argue that age is directly relevant for maximizing health benefits, so current ethics guidelines are wrongly excluding or deemphasizing life-stage in their triage algorithms. Research on COVID-19 has shown that age is a risk factor in adverse outcomes, independent of comorbidities. And limiting a consideration of life-years to only one or five years past discharge does not maximize health benefits. Therefore, based on their own stated values, triage algorithms for coronavirus patients ought to include life-stage as a primary consideration, along with the SOFA score and comorbidities, rather than excluding it or using it merely as a tiebreaker. This is not discriminatory because patients ought to have equal opportunity to experience life-stages. The equitable enforcement of that right justifies unequal treatment based on age in cases when there is a scarcity of life-saving resources. A consideration of life-stage would thus allow healthcare workers to responsibly steward public resources in order to maximize lives and life-years saved.