Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19.

Importance: Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. Objective: To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. Design, Setting, and Participants: This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Exposures: Race, ethnicity, Social Vulnerability Index. Main Outcomes and Measures: The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Results: Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. Conclusions and Relevance: In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

Ending Restraint of Incarcerated Individuals Giving Birth.

Advocates have long suggested making shackling incarcerated people during childbirth illegal. Yet exceptions would likely still allow prison personnel to implement restraint and leave clinicians no course for freeing a patient. This article argues that clinicians' assessments of laboring individuals' clinical needs must be prioritized, ethically and legally. This article also explains that, without strong policies in place, some clinicians will not feel empowered to demand that a patient be freed during labor. Beyond prohibiting restraint of laboring individuals, health care organizations must support clinicians seeking to execute their ethical duties to care well and justly for patients. Toward this end, this article proposes a model policy.

The Burden of Guardianship: A Matched Cohort Study.

BACKGROUND: In cases where patients are unable to provide informed consent and have no surrogate decisionmaker, a hospital must seek guardian appointment as a legally recognized surrogate decision-maker. OBJECTIVE: The aim of this study was to examine the magnitudes of length of stay (LOS) beyond medical clearance and healthcare costs among patients referred for guardianship. DESIGN, SETTING, PATIENTS: This was a retrospective cohort study of all 61 adult inpatients in a single tertiary care hospital requiring guardianship between October 1, 2014, and September 30, 2015, matched with up to 3 controls from the same discharging services and hospitalized for at least as long as the date of clearance for referred patients. MEASUREMENTS: The following parameters were measured using generalized estimating equations: total LOS, LOS beyond medical clearance (excess LOS), medical complications, and total charges among referred patients, and the LOS and costs were compared with those of matched controls. RESULTS: Mean LOS for patients requiring guardianship was 31 ± 2 days, and the total charges averaged $179,243 ± 22,950. We documented 12 hospital-acquired complications in 10 (16%; 95% confidence interval [CI], 8%-28%) unique patients. Accounting for potential confounders, the process of obtaining guardianship was associated with a 37% longer total LOS (95% CI [12%- 67%]; P = .002), 58% higher excess LOS (95% CI [2%- 145%]; P = .04), and 23% higher total charges (95% CI [4%-46%]; P = .02). CONCLUSIONS: In this single-center cohort study, the guardianship process was associated with prolonged hospital stay and higher total hospital charges even when compared with matched controls. Furthermore, one in six patients suffered from a hospital-associated complication after medical clearance.

Letters, libel, and the law.

Authors of scientific articles and journal editors are subject to antidefamation publication laws. We describe our experience with an accusation of libel. We define libel as it involves the medical literature and explain the ways in which threats of libel influence editorial decisionmaking and lead to negative publication bias by presenting examples drawn from the medical and legal literature.

What is wrong with "ethics for sale"? An analysis of the many issues that complicate the debate about conflicts of interests in bioethics.

This article addresses all of the issues involved in the debate about whether or not bioethicists should be paid by private biomedical companies to perform consultations. These issues include the following: differentiation of this role from bioethicists' other roles, an analysis of to whom bioethicists owe a duty, consideration of what bioethicists are "selling," whether bioethicists should be allowed to get paid, when payment becomes problematic, and whether consulting fee arrangements should be regulated. The author often compares bioethicists' relationship to the companies to bioethicists' other relationships, as well as to professional relationships in other fields, such as law and accounting.