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.

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.

Criteria for allocation of life-saving resources during the SARS-COV-2 pandemic: ethical implications and aspects of legal liability.

The issue of political, institutional and professional liability in the context of the SARS-COV-2 pandemic is currently widely debated and involves several levels of investigation. One crucial aspect relates to the allocation of life-saving resources in situations where there is an imbalance between need and availability and the associated questions of ethical and legal liability. This work looks at the implications of the criteria applied to rationing under extraordinary conditions and the issue of their legitimacy. Considering the European scenario, we describe the approach taken by Italy in proposing criteria for pandemic triage of intensive treatment and highlight certain problems and critical issues. We emphasise that the decision, based on a comparative assessment, to deny treatment to a patient in critical condition, compromising that patient's right to care, exceeds the scope of decision-making autonomy of the professional concerned and requires a theoretical and procedural definition shared at multiple levels of society.

Allocation of scarce resources in Africa during COVID-19: Utility and justice for the bottom of the pyramid?

The COVID-19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub-Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high-income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID-19 pandemic in low-income countries suffering from chronic shortages in health care resources, and chronic high morbidity and mortality from non-COVID-19 causes. A parallel is drawn between the distribution of severity of COVID-19 disease and the classic "Fortune at the bottom of the pyramid" model that is relevant in SSA. Focusing allocation of resources during COVID-19 on the 'thick' part of the pyramid in Low-to-Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post-COVID-19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID-19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non-pandemic times.

A moment for reflection. Ethical aspects in the pandemic SARS-CoV-2/COVID-19 in our clinical practice. / Un momento para la reflexión. Aspectos éticos en la pandemia SARS-CoV-2/COVID-19 en nuestra práctica clínica.

The entire world has suffered the devastating action of the SARS-CoV-2/COVID-19 pandemic. This is the ideal moment to stop and ask ourselves what happened and how we acted; to reflect on what we have learned not only for similar situations but for all of our clinical practice. This work is an ethical reflection via the clinical experience of professionals dedicated to the care of critical patients in one of the countries most affected by the SARS-CoV-2/COVID-19 pandemic in the world. Some of the moral values and categories involved in decision-making in situations of limited resources are analysed, and the need for bioethics to be a part of daily practice is proposed, along with some strategies for doing so, thus facilitating decision-making by the health professional and fair and appropriate care for the patient in situations of particular vulnerability such as those experienced in this health and social crisis.

Contractualist age rationing under outbreak circumstances.

Age rationing is a central issue in the health care priority-setting literature, but it has become ever more salient in the light of the Covid-19 outbreak, where health authorities in several countries have given higher priority to younger over older patients. But how is age rationing different under outbreak circumstances than under normal circumstances, and what does this difference imply for ethical theories? This is the topic of this paper. The paper argues that outbreaks such as that of Covid-19 involve special circumstances that change how age should influence our prioritization decisions, and that while this shift in circumstances poses a problem for consequentialist views such as utilitarianism and age-weighted consequentialism, contractualism is better equipped to cope with it. The paper then offers a contractualist prudential account of age rationing under outbreak circumstances.

Healthcare in Extreme and Austere Environments: Responding to the Ethical Challenges.

Clinicians may increasingly find themselves practicing, by choice or necessity, in resource-poor or extreme environments. This often requires altering typical patterns of practice with a different set of medical and ethical considerations than are usually faced by clinicians practicing in hospitals in the United States and Europe. Practitioners may be required to alter their usual scope of practice or their standard ways of medically treating patients. Limited resources will also often place clinicians in the position of having to make decisions about fairly allocating healthcare, which will alter the physician-patient relationship. This does not absolve physicians and other healthcare practitioners of providing the best quality of care that can be given under the circumstances. In addition, the lack of a well-developed healthcare infrastructure and limited resources will require working with established providers to determine the needs of the community, and what types of healthcare are feasible given these limitations. The essays in this issue of HEC Forum encourage readers to reflect on the unique ethical challenges faced in the extreme or austere environment.

[Bioethics, Human Rights and COVID-19]. / Bioética, Derechos Humanos y COVID-19.

In this paper present, from a bioethical perspective, a reflection on how to reconcile efforts to combat the COVID-19 pandemic with the safeguard of human rights. To do this, I develop three points. First, the regulatory framework that justifies the restriction or suspension of rights in the face of serious threats to public health. Second, the declarations of the international bioethics committees on the way in which human rights should be protected during public health crisis. And third, a review of the main rights threatened both by the public health crisis and by the means adopted to combat it. Before going into each of these points, I offer a preliminary note to clarify certain legal concepts and underline the need to overcome disjunctive approaches in considering human rights.

[Vulnerability and Health Care. Law and Medical Protocols]. / Vulnerabilidad y Atención Sanitaria: Derecho y Protocolos Médicos.

The article deals with the analysis of the criteria for the allocation of scarce health resources during the pandemic produced by the COVID 19 virus in Spain. It critically analyses the absence of a legal-constitutional perspective in the elaboration of such criteria and suggests the incorporation of the criterion of equity as a guarantee of the effective exercise of the constitutional right to health protection by vulnerable persons.

[Ethical reflections on the Measures Taken in Nursing Homes During Pandemic]. / Reflexiones éticas en torno a las Medidas tomadas en las Residencias durante la Pandemia.

The crisis in the health system caused by COVID-19 has left some important humanitarian deficits on how to care for the sick in their last days of life. The humanization of the dying process has been affected in three fundamental aspects, each of which constitutes a medical and ethical duty necessary. In this study, I analyze why dying accompanied, with the possibility of saying goodbye and receiving spiritual assistance, constitutes a specific triad of care and natural obligations that should not be overlooked - even in times of health crisis - if we do not want to see human dignity violated and violated some fundamental rights derived from it.

El médico frente a la COVID-19: lecciones de una pandemia / The doctor and COVID-19: lessons from a pandemic

Aparte de su enorme impacto sanitario y económico, la pandemia de COVID-19 ha modificado la forma de practicar la medicina y la educación médica. Es probable que dicho efecto acelere la transformación que están experimentando ambas actividades. El presente trabajo, escrito en el momento más álgido de la crisis, plantea algunas reflexiones sobre cuatro temas: 1) la publicación de noticias falsas y sensacionalistas; 2) los riesgos de la toma de decisiones médicas no basadas en evidencias; 3) las implicaciones bioéticas cuando no hay suficientes recursos para todos, y 4) los posibles efectos de la crisis en la enseñanza de la medicina. Esta crisis debería servir a médicos, docentes y estudiantes de medicina para extraer conclusiones y estar mejor preparados para el futuro. En primer lugar, es esencial mantener un pensamiento crítico que proteja contra la «infodemia». Además, no deberían rebajarse, sino mantener íntegros, los estándares científicos y éticos aprendidos en la facultad. Por último, debe recordarse que, en una pandemia tan devastadora como la actual, aparte de la medicina científica, la que se practica con el cerebro, debe ejercerse también esa otra medicina que se practica con el corazón

Apart from its enormous health and economic impact, the COVID-19 pandemic has changed the way of practicing medicine and medical education. It is likely that this effect may accelerate the transformation that both activities are experiencing. The present article, written at the peak of the crisis, sets out some thoughts on four topics: 1) the publication of false and sensationalist news; 2) the risks of taking medical decisions not based on the evidence; 3) the bioethical implications when there are sufficient resources available for everybody and; 4) the possible effects of the crisis on the teaching of medicine. This crisis should enable doctors, teachers and, students of medicine to draw conclusions and be better prepared for the future. Firstly, it is essential to maintain critical thinking that may protect against the ‘infodemic’. Furthermore, the scientific and ethical standards learned in the faculty, should not be forgotten. Lastly, it should be remembered that, in a devastating pandemic like the current one, apart from scientific medicine, which is practised with the brain, the other medicine that is practiced with the heart must also be practiced

[Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances.] / Raccomandazioni di etica clinica per l'ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili.

On February 21st, 2020 the first case of severe acute respiratory syndrome due to the coronavirus 2 (SARS-CoV-2) causing the CoViD-19 disease, was identified in Italy. In the following days, despite the restrictive public health measures aimed to avoid the infection's spread, the number of cases increased. As of March 8th, 2020, Italy is the 2nd most affected country in the world. As of March 6th, 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published operational recommendations and ethical considerations to support the clinicians involved in the care of critically-ill CoViD-19 patients, in regard a probable scenario where an imbalance between supply and demand of ICU beds, is put in place by a steadily rising number of these patients.

Ebola vaccine? Family first! Evidence from using a brief measure on Ebola vaccine demand in a national household survey during the outbreak in Sierra Leone.

BACKGROUND: Vaccination against Ebolavirus is an emerging public health tool during Ebola Virus Disease outbreaks. We examined demand issues related to deployment of Ebolavirus vaccine during the 2014-2015 outbreak in Sierra Leone. METHODS: A cluster survey was administered to a population-based sample in December 2014 (N = 3540), before any Ebola vaccine was available to the general public in Sierra Leone. Ebola vaccine demand was captured in this survey by three Likert-scale items that were used to develop a composite score and dichotomized into a binary outcome to define high demand. A multilevel logistic regression model was fitted to assess the associations between perceptions of who should be first to receive an Ebola vaccine and the expression of high demand for an Ebola vaccine. RESULTS: The largest proportion of respondents reported that health workers (35.1%) or their own families (29.5%) should receive the vaccine first if it became available, rather than politicians (13.8%), vaccination teams (9.8%), or people in high risk areas (8.2%). High demand for an Ebola vaccine was expressed by 74.2% of respondents nationally. The odds of expressing high demand were 13 times greater among those who said they or their families should be the first to take the vaccine compared to those who said politicians should be the first recipients (adjusted odds ratio [aOR] 13.0 [95% confidence interval [CI] 7.8-21.6]). The ultra-brief measure of the Ebola vaccine demand demonstrated acceptable scale reliability (Cronbach's α = 0.79) and construct validity (single-factor loadings > 0.50). CONCLUSION: Perceptions of who should be the first to get the vaccine was associated with high demand for Ebola vaccine around the peak of the outbreak in Sierra Leone. Using an ultra-brief measure of Ebola vaccine demand is a feasible solution in outbreak settings and can help inform development of future rapid assessment tools.