ABSTRACT
In the article "Principled Conscientious Provision: Referral Symmetry and Its Implications for Protecting Secular Conscience," Abram L. Brummett, Tanner Hafen, and Mark C. Navin reject what they call the "referral asymmetry" in U.S. conscientious objection law in medicine, which recognizes rights of conscientiously objecting physicians to withhold referrals for medical interventions but does not (yet) recognize rights of physicians to make referrals for medical interventions to which they are morally committed but to which their health care institutions are morally opposed. This commentary concentrates on a second asymmetry, namely, the relationship of a health care provider's referral or nonreferral to the medical standard of care. The commentary argues that this second asymmetry seems to require action more appropriately recognized as civil disobedience than conscientious provision of referral.
Subject(s)
Conscience , Referral and Consultation , Standard of Care , Humans , Standard of Care/ethics , Referral and Consultation/ethics , United States , Physicians/ethicsABSTRACT
Federal and state governments mandate some health care organizations to implement antibiotic stewardship programs (ASPs). Some early adopters developed model ASPs that have helped set industry standards; other benchmarks will likely be forged in subsequent regulation, legislation, and jurisprudence. This article considers how ASP designs can affect professional autonomy, especially of frontline antibiotic stewards who are usually physicians and pharmacists. This article also considers how ASP development and implementation might influence standards of care and malpractice liability.
Subject(s)
Antimicrobial Stewardship , Liability, Legal , Physicians , Professional Autonomy , Humans , Antimicrobial Stewardship/legislation & jurisprudence , Physicians/ethics , Malpractice/legislation & jurisprudence , Anti-Bacterial Agents/therapeutic use , Pharmacists/ethics , Standard of Care/ethicsABSTRACT
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).
Subject(s)
COVID-19/therapy , Critical Care/standards , Health Care Rationing/standards , Practice Guidelines as Topic/standards , Standard of Care/ethics , Triage/standards , COVID-19/virology , Critical Care/ethics , Health Care Rationing/ethics , Humans , SARS-CoV-2/isolation & purification , Triage/ethics , Triage/methodsABSTRACT
During the Covid-19 pandemic, as resources dwindled, clinicians, health care institutions, and policymakers have expressed concern about potential legal liability for following crisis standards of care (CSC) plans. Although there is no robust empirical research to demonstrate that liability protections actually influence physician behavior, we argue that limited liability protections for health care professionals who follow established CSC plans may instead be justified by reliance on the principle of reciprocity. Expecting physicians to do something they know will harm their patients causes moral distress and suffering that may leave lasting scars. Limited liability shields are both appropriate and proportionate to the risk physicians are being asked to take in such circumstances. Under certain narrow circumstances, it remains unclear that the standard of care is sufficiently flexible to protect physicians from liability. Given this uncertainty, the likelihood that physicians would be sued for such an act, and their desire for such immunity, this limited protection is morally legitimate.
Subject(s)
COVID-19/epidemiology , Liability, Legal , Physicians/legislation & jurisprudence , Standard of Care/legislation & jurisprudence , Health Care Rationing/legislation & jurisprudence , Humans , Pandemics , SARS-CoV-2 , Standard of Care/ethicsABSTRACT
In March 2020, the rapid increase in severe COVID-19 cases overwhelmed the healthcare systems in several European countries. The capacities for artificial ventilation in intensive care units were too scarce to care for patients with acute respiratory disorder connected to the disease. Several professional associations published COVID-19 triage recommendations in an extremely short time: in 21 days between March 6 and March 27. In this article, we compare recommendations from five European countries, which combine medical and ethical reflections on this situation in some detail. Our aim is to provide a detailed overview on the ethical elements of the recommendations, the differences between them and their coherence. In more general terms we want to identify shortcomings in regard to a common European response to the current situation.
Subject(s)
COVID-19/therapy , Health Care Rationing , Standard of Care/ethics , Triage/ethics , Age Factors , COVID-19/epidemiology , Europe/epidemiology , Health Personnel/ethics , Health Personnel/psychology , Health Priorities , Hospitalization , Human Rights , Humans , Intensive Care Units/ethics , Practice Guidelines as Topic , SARS-CoV-2/physiology , Treatment Outcome , Ventilators, Mechanical/supply & distribution , Withholding Treatment/ethicsSubject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Standard of Care/standards , Triage/standards , COVID-19 , Coronavirus Infections/prevention & control , Humans , Pandemics/ethics , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , SARS-CoV-2 , Standard of Care/ethics , Triage/ethics , United States/epidemiologyABSTRACT
In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) "Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations," which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both distributive and recognitive justice. The disability rights movement's demand "Nothing about us, without us" requires substantive inclusion of disabled people in decision-making related to their interests, including in crisis planning before, during, and after a pandemic like Covid-19.
Subject(s)
Coronavirus Infections/epidemiology , Disabled Persons , Health Equity/ethics , Pneumonia, Viral/epidemiology , Social Justice/ethics , Standard of Care/ethics , Betacoronavirus , COVID-19 , Communication , Health Equity/legislation & jurisprudence , Humans , Pandemics , SARS-CoV-2 , Social Justice/legislation & jurisprudence , Standard of Care/legislation & jurisprudenceABSTRACT
The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.
Subject(s)
Coronavirus Infections/epidemiology , Health Care Rationing/ethics , Pneumonia, Viral/epidemiology , Standard of Care/ethics , Betacoronavirus , COVID-19 , Health Services Accessibility/ethics , Health Services Accessibility/organization & administration , Healthcare Disparities/ethics , Healthcare Disparities/organization & administration , Humans , Pandemics , Personnel Staffing and Scheduling/ethics , Personnel Staffing and Scheduling/organization & administration , SARS-CoV-2 , Standard of Care/organization & administration , Telemedicine/ethics , Telemedicine/organization & administrationABSTRACT
Background: The COVID-19 pandemic has highlighted health care systems' vulnerabilities. Hospitals face increasing risk of periods of scarcity of life-sustaining resources such as ventilators for mechanical respiratory support, as has been the case in Italy as of March, 2020. The National Academy of Medicine has provided guidance on crisis standards of care, which call for the reallocation of scarce medical resources to those who will benefit most during extreme situations. Given that this will require a departure from the usual fiduciary duty of the bedside clinician, we determined and mapped potential barriers to the implementation of the guidelines from stakeholders using an implementation science framework. Methods: A protocol was created to operationalize national and state guidelines for triaging ventilators during crisis conditions. Focus groups and key informant interviews were conducted from July-September 2018 with clinicians at three acute care hospitals of an urban academic medical center. Respiratory therapists, intensivists, nursing leadership and the palliative care interdisciplinary team participated in focus groups. Key informant interviews were conducted with emergency management, respiratory therapy and emergency medicine. Subjects were presented the protocol and their reflections were elicited using a semi-structured interview guide. Data from transcripts and notes were categorized using a coding strategy based on the Theoretical Domains Framework. Results: Participants anticipated that implementing this protocol would challenge their roles and identities as clinicians including both their fiduciary duty to the patient and their decision-making autonomy. Despite this, many participants acknowledged the need for such a protocol to standardize care and minimize bias as well as to mitigate potential consequences for individual clinicians. Participants identified the question of considering patient quality of life in triage decisions as an important and unresolved ethical issue in disaster triage. Conclusion: Clinicians' discomfort with shifting roles and obligations could pose implementation barriers for crisis standards of care.
Subject(s)
Attitude of Health Personnel , Betacoronavirus , Coronavirus Infections/therapy , Critical Care/standards , Pneumonia, Viral/therapy , Standard of Care , Withholding Treatment/ethics , Academic Medical Centers , COVID-19 , Coronavirus Infections/epidemiology , Critical Care/ethics , Emergency Medicine/standards , Focus Groups , Humans , Interviews as Topic , Pandemics , Pneumonia, Viral/epidemiology , Practice Guidelines as Topic , Quality of Life , Respiration, Artificial/standards , Respiratory Therapy/standards , SARS-CoV-2 , Standard of Care/ethics , Triage/methods , Triage/standardsABSTRACT
Paltering is a form of deception whereby true statements are used to mislead and is widely employed in negotiations, marketing, espionage, and ordinary communications where speakers hold ulterior motives. We argue that paltering is accomplished through strategic violations of communicative norms such as the Gricean cooperative principles of relevance, quantity, quality and manner. We further argue that, just as genuine paltering deceives by deliberately violating communicative norms, inadvertent violations of these norms may be just as misleading. In this work, we demonstrated that educational information presented prominently on the American Diabetes Association website violated the Gricean communicative principles and disrupted readers' performance on a test of diabetes knowledge. To establish the effects of these communicative violations, we revised the ADA's information to preserve the original content while better adhering to pragmatic principles. When these ADA explanations were judiciously revised to minimize pragmatic violations, they were transformed from misleading to educational.
Subject(s)
Communication , Health Knowledge, Attitudes, Practice , Marketing/ethics , Standard of Care/ethics , Diabetes Mellitus/epidemiology , HumansABSTRACT
The Director-General of the WHO has suggested that China's approach to the COVID-19 crisis could be the standard of care for global epidemics. However, as remarkable as the Chinese strategy might be, it cannot be replicated in other countries and certainly not in Europe. In Europe, there is a distribution of power between the European Union and its member states. In contrast, China's political power is concentrated in the central government. This enables it to take immediate measures that affect the entire country, such as massive quarantines or closing borders. Moreover, the Chinese legal framework includes restrictions on privacy and other human rights that are unknown in Europe. In addition, China has the technological power to easily impose such restrictions. In most European countries, that would be science fiction. These conditions have enabled China to combat epidemics like no other country can. However, the WHO might have been overoptimistic. The Chinese standard of care for treating COVID-19 also raises problematic issues for human rights, and the real consequences of these actions remain to be seen.
Subject(s)
Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Standard of Care/ethics , Standard of Care/standards , Betacoronavirus , COVID-19 , China/epidemiology , Europe/epidemiology , Human Rights/ethics , Human Rights/standards , Humans , Pandemics , Privacy , SARS-CoV-2ABSTRACT
During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift-to some degree-from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by "crisis standards of care," but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities.
Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Pneumonia, Viral/epidemiology , Standard of Care/ethics , Triage/ethics , COVID-19 , Coronavirus Infections/prevention & control , Humans , Pandemics/ethics , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , SARS-CoV-2 , United States/epidemiologyABSTRACT
The aim of this systematic review was to locate and analyze United States state crisis standards of care (CSC) documents to determine their prevalence and quality. Following PRISMA guidelines, Google search for "allocation of scarce resources" and "crisis standards of care (CSC)" for each state. We analyzed the plans based on the 2009 Institute of Medicine (IOM) report, which provided guidance for establishing CSC for use in disaster situations, as well as the 2014 CHEST consensus statement's 11 core topic areas. The search yielded 42 state documents, and we excluded 11 that were not CSC plans. Of the 31 included plans, 13 plans were written for an "all hazards" approach, while 18 were pandemic influenza specific. Eighteen had strong ethical grounding. Twenty-one plans had integrated and ongoing community and provider engagement, education, and communication. Twenty-two had assurances regarding legal authority and environment. Sixteen plans had clear indicators, triggers, and lines of responsibility. Finally, 28 had evidence-based clinical processes and operations. Five plans contained all 5 IOM elements: Arizona, Colorado, Minnesota, Nevada, and Vermont. Colorado and Minnesota have all hazards documents and processes for both adult and pediatric populations and could be considered exemplars for other states.
Subject(s)
Pandemics/prevention & control , Resource Allocation/methods , State Government , Disaster Planning/methods , Humans , Resource Allocation/supply & distribution , Resource Allocation/trends , Standard of Care/ethics , Standard of Care/standards , United StatesABSTRACT
The standard of the patient's best interests is the main bioethical standard used in the decision-making process that involves incompetent patients (i.e. neonatology, pediatric patients and incompetent adults). This standard has been widely criticized as being self-destructive, individualistic, vague, unknown, dangerous and open to abuse. With the purpose of defending it, several reforms of this standard have been proposed, especially in the pediatric field. We propose a redefinition of the standard based on two concepts: 1) medical futility as a negative criterion, and 2) the principle of proportionality as a positive criterion. Our work includes a new relationship between concepts in classical moral theology (i.e. ordinary / extraordinary; proportionate / disproportionate) applied to the bioethics of life-sustaining treatments for incompetent patients.
Subject(s)
Standard of Care/ethics , Humans , Medical Futility , Patient AdvocacyABSTRACT
The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.
Subject(s)
Coronavirus Infections/epidemiology , Health Care Rationing/ethics , Jews/psychology , Judaism/psychology , Pneumonia, Viral/epidemiology , Triage/ethics , Betacoronavirus , COVID-19 , Clinical Protocols/standards , Humans , Morals , Pandemics , SARS-CoV-2 , Standard of Care/ethics , Ventilators, Mechanical/supply & distributionABSTRACT
The opening quote by Alexandra Adams, the first deaf-blind medical student in the United Kingdom, is a response to naysayers on her decision to join medicine. The cover page of this issue of IJME also highlights the underrepresented in medicine: portraying a healthcare professional with an acquired visual impairment who works with full professional rigour and dedication.
Subject(s)
Disabled Persons , Standard of Care , Students, Medical , Students, Nursing/psychology , Female , Humans , Morals , Standard of Care/ethics , United KingdomABSTRACT
BACKGROUND: Nursing care is rapidly evolving due to the advanced technological and medical development, and also due to an increased focus on standardization and the logic of production, permeating today's hospital cultures. Nursing is rooted in a holistic approach with an ethical obligation to maintain and respect the individual's dignity and integrity. However, working within time limits and heavy workload leads to burnout and ethical insensitivity among nurses, and may challenge nurses' options to act on the basis of ethical and moral grounds in the individual care situation. AIM: The aim of this study is to describe and discuss ethical dilemmas described and experienced by nurses in clinical practice today. METHOD: The study was performed as a literature review following the matrix method allowing to synthesize literature across methodological approaches. A literature search was performed, including relevant studies published between 2011 and 2016. A total of 15 articles were included and analyzed focusing on their description of ethical dilemmas. ETHICAL CONSIDERATION: We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources. RESULTS: The analysis revealed three themes, relating to important aspects of nursing practice, such as the nurse-patient relationship, organizational structures, and collaboration with colleagues. The findings are summarized in the following three themes: (1) balancing harm and care, (2) work overload affecting quality, and (3) navigating in disagreement. Ethically difficult situations are evident across settings and in very diverse environments from neonatal care to caring for the older people. Organizational structures and being caught in-between professional values, standardization, and busyness was evident, revealing the complexity of nursing practice and the diversity of ethical dilemmas, concerns, and distress experienced by clinical nurses. CONCLUSION: Nursing practice is challenged by organizational structures and the development of the health care system, inhibiting nurses' professional decision-making and forcing them to compromise basic nursing values.