Why should HCWs receive priority access to vaccines in a pandemic?

BACKGROUND: Viral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers (HCWs) should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines. MAIN TEXT: In this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation. CONCLUSIONS: We argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs.

Use of guidelines when planning home care of a girl with severe congenital myopathy.

We use issues that arose in the management of a 4-year old girl with a congenital myopathy to consider the tension between respecting the choices and decisions of the child's parents and applying clinical practice guidelines that emphasise minimising risk to the child. This case raises the issue of when it is reasonable to override parents' choice of management options.

Spinal muscular atrophy type I: do the benefits of ventilation compensate for its burdens?

We report the progress of an 8-year-old child with spinal muscular atrophy (SMA) type 1. The parents elected in infancy that the child should be on long-term ventilation, but all attempts to establish this care at home have failed, so the child remains ventilated in the hospital. The leader of the long-term ventilation team reports on the child's progress and describes a week in the child's life. Two paediatricians argue that the benefits of long-term ventilation have not and do not compensate the child for the burdens imposed on her by this treatment and explain why they would not support the withdrawal of long-term ventilation now. They argue that long-term ventilation might have been avoided by applying to a court of law when the child was an infant. An ethicist discusses ethical aspects of decision-making in SMA type 1.

Religious perspectives on umbilical cord blood banking.

Umbilical cord blood is a valuable source of haematopoietic stem cells. There is little information about whether religious affiliations have any bearing on attitudes to and decisions about its collection, donation and storage. The authors provided information about umbilical cord blood banking to expert commentators from six major world religions (Catholicism, Anglicanism, Islam, Judaism, Hinduism and Buddhism) and asked them to address a specific set of questions in a commentary. The commentaries suggest there is considerable support for umbilical cord blood banking in these religions. Four commentaries provide moral grounds for favouring public donation over private storage. None attach any particular religious significance to the umbilical cord or to the blood within it, nor place restrictions on the ethnicity or religion of donors and recipients. Views on ownership of umbilical cord blood vary. The authors offer a series of general points for those who seek a better understanding of religious perspectives on umbilical cord blood banking.

Palivizumab: a debate about funding.

A clinician and the chair of the hospital drug committee debate the merits of the use of palivizumab as prophylaxis against respiratory syncytial virus infection for a preterm baby with oxygen-dependent, chronic lung disease and discuss the issue of public funding of palivizumab. An ethicist comments on ethical aspects of the debate about cost-effectiveness.

Managing ethically questionable parental requests: growth suppression and manipulation of puberty.

Doctors sometimes struggle with ethically challenging requests for treatment from children's parents. For instance, we have recently had two requests by parents of children, a girl and a boy, each with a severe developmental disability, for hormonal therapy to suppress growth and puberty: the girl's parents requested, in addition, hysterectomy and mastectomy. We propose a reliable approach to assessing the ethical and legal aspects of these and other requests for 'non-therapeutic' treatment of a minor who lacks the capacity to give informed consent. We argue that a doctor should first assess whether the request is one that he or she can, in conscience, accede to, and then, if it is, seek the authorisation of a court. We outline considerations relevant to the doctor's assessment of both the ethical issues and to the need for court authorisation.

How certain are you, doctor?

OBJECTIVE: To argue that pediatric intensive care physicians have difficulties in responding to parental questions about prognostic certainty, and that this constitutes a failure in their professional responsibility to parents. CONCLUSIONS: These difficulties arise from three sources: 1) the structure and organization of contemporary intensive care, 2) the neglect of prognostication, and 3) the failure to distinguish scientific certainty from practical certainty. It is proposed that an understanding of these issues will enable physicians to respond to the parental question "How certain are you, doctor?" with more authenticity and sincerity.

When does severe childhood obesity become a child protection issue?

Severe childhood obesity and its associated comorbidities are increasing in prevalence. Extreme childhood obesity may be viewed as a mirror image of severe non-organic failure to thrive. Parental neglect may be a causative factor in both circumstances. When suspicion of parental neglect arises, health care professionals may have both an ethical obligation and a statutory duty to notify child protection services. Guidelines on the point at which medical practitioners should seek state assistance in cases of severe childhood obesity would be helpful, not only for medical practitioners, but also for child protection services.

Ethical issues in immunisation.

Discussions about current and future immunisation programmes raise novel questions about familiar ethical issues. Two sets of ethical issues dominate these discussions. The first is the issue of compulsory immunisation: what should be done about parents who fail to immunise their children? The second is: given competing demands on health care budgets, how should principles of justice in access and distribution inform vaccination programmes? This paper considers these two issues in the light of traditional ethical principles. With respect to the first, we argue that compulsion is justified only in cases in which we know with practical certainty that parental failure to immunise puts their own child or other children at high risk of severe illness. We also argue that the state should compensate those who suffer vaccine-related injury. With respect to the second, we claim that allocating resources according to health care need requires establishing priorities between public health programmes such as immunisation and other treatment programmes.

Spinal muscular atrophy type 1: is long-term mechanical ventilation ethical?

We present a baby with spinal muscular atrophy type 1, an inherited disorder causing progressive weakness, leading to complete paralysis of respiratory, facial and limb muscles. Without intervention, death occurs in infancy due to respiratory failure. Mechanical ventilatory support can prolong life, but the child's quality of life is highly debatable. We discuss the appropriateness of initiating and continuing intensive care for this child and others in a similar position.