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1.
Indian J Med Ethics ; V(2): 168-169, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32393441

RESUMO

Early last month, the Italian Society of Anaesthesia was forced to publish the above guideline (1) for the country's hospitals. Besides the rising cases of infection, the doctors realised that patients required up to 15-20 days of intensive care as the disease progressed (2). In the face of medical resource scarcities, the guideline established that everyone could not be saved from the coronavirus. And a massive death toll ensued.


Assuntos
Infecções por Coronavirus , Serviços Médicos de Emergência , Alocação de Recursos para a Atenção à Saúde , Pandemias , Pneumonia Viral , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Tomada de Decisões , Serviços Médicos de Emergência/ética , Alocação de Recursos para a Atenção à Saúde/ética , Humanos , Índia/epidemiologia , Itália/epidemiologia , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto
5.
BMC Med Ethics ; 20(1): 97, 2019 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-31856803

RESUMO

BACKGROUND: Rationing and allocation decisions at the clinical level - bedside rationing - entail complex dilemmas that clinicians and managers often find difficult to handle. There is a lack of mechanisms and aids for promoting fair decisions, especially in hard cases. Reports indicate that clinical ethics committees (CECs) sometimes handle cases that involve bedside rationing dilemmas. Can CECs have a legitimate role to play in bedside rationing? MAIN TEXT: Aided by two frameworks for legitimate priority setting, we discuss how CECs can contribute to enhanced epistemic, procedural and political legitimacy in bedside rationing decisions. Drawing on previous work we present brief case vignettes and outline several potential roles that CECs may play, and then discuss whether these might contribute to rationing decisions becoming legitimate. In the process, key prerequisites for such legitimacy are identified. Legitimacy places demands on aspects such as the CEC's deliberation process, the involvement of stakeholders, transparency of process, the opportunity to appeal decisions, and the competence of CEC members. On these conditions, CECs can help strengthen the legitimacy of some of the rationing decisions clinicians and managers have to make. CONCLUSIONS: On specified conditions, CECs can have a well-justified advisory role to play in order to enhance the legitimacy of bedside rationing decisions.


Assuntos
Comitês de Ética Clínica , Alocação de Recursos para a Atenção à Saúde/ética , Tomada de Decisões , Prioridades em Saúde , Administração dos Cuidados ao Paciente
6.
Am J Bioeth ; 19(11): 13-24, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31647757

RESUMO

Transplantation programs commonly rely on clinicians' judgments about patients' social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients' personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation.


Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Equidade em Saúde , Transplante de Órgãos/ética , Seleção de Pacientes/ética , Apoio Social , Adulto , Viés , Tomada de Decisão Clínica/ética , Tomada de Decisão Clínica/métodos , Alocação de Recursos para a Atenção à Saúde/métodos , Política de Saúde , Humanos
7.
Inquiry ; 56: 46958019856975, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31189387

RESUMO

The objective of this study was to investigate and describe how the use of the term "elderly" contributes to bias and problems within the medical system. A systematic review of the relevant literature and history was conducted. The term "elderly" does not define age accurately and carries bias and prejudice that lead to harm through discriminatory practices, institutional prejudices, and "ageist" policies in society and medicine. Doctors and healthcare providers seldom intentionally try to harm any patient, but might do so through unconscious anti-elderly bias. Studies indicate that medical students already demonstrate anti-elderly bias; researchers may lump patients aged 65 and over together, confounding specific information needed for individualized treatments; and out of unwarranted concern, medical and surgical treatments may be denied, despite minimal increased risk of mortality. When the cost of healthcare rises, it is the elderly against whom rationing is suggested. The term "elderly" has no place in medicine. Anti-elderly health care rationing is as unethical as rationing targeted against any group. It is reverse paternalism to make rules that limit others' medical care, happiness, and life span without their consent. Medicine is the science and art of individual communication, evaluation and treatment. Once we deny care to any one group, we open the door to denial to others.


Assuntos
Envelhecimento/ética , Medicina , Preconceito , Discriminação Social/ética , Idoso , Comunicação , Assistência à Saúde , Alocação de Recursos para a Atenção à Saúde/ética , Humanos , Medicina/organização & administração
8.
Kennedy Inst Ethics J ; 29(1): 1-31, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31080175

RESUMO

Physicians' advocacy obligations are best understood as going beyond advocacy on behalf of individual patients, which I call the "individualistic view," to include advocacy for intelligent research-based allocation schemes that promote good outcomes and cost-effective care for all patients, which I call the "systemic view." This systemic view includes moving beyond self-interest to promote less-wasteful and more cost-conscious allocation decisions and the setting of priorities at all levels to expand health care access. It includes physician involvement in discussions with patients in the context of clinical care, involvement in the formulation and administration of benefit structures and other allocation policies, and, finally, involvement in promoting public dialogue about health care priorities. This involvement is based on a concept of a deliberative process that can result in "just enough" decisions within systems for the preservation and promotion of health care and other societal goods.


Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Acesso aos Serviços de Saúde/ética , Defesa do Paciente/ética , Papel do Médico , Alocação de Recursos/ética , Justiça Social/ética , Alocação de Custos/ética , Tomada de Decisões , Custos de Cuidados de Saúde/ética , Alocação de Recursos para a Atenção à Saúde/economia , Prioridades em Saúde/economia , Prioridades em Saúde/ética , Promoção da Saúde/economia , Promoção da Saúde/ética , Acesso aos Serviços de Saúde/economia , Humanos , Consentimento Livre e Esclarecido/ética , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Reembolso de Seguro de Saúde/ética , Defesa do Paciente/economia , Alocação de Recursos/economia
9.
Narrat Inq Bioeth ; 9(1): 77-82, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31031293

RESUMO

An 18-year-old male who had been diagnosed at age 7 with a rare, progressive liver disease was referred to the transplant center and received a transplant, even though he did not meet the center's criteria for a patient with hepatopulmonary syndrome (HPS). Complications required relisting the patient urgently, but he eventually fully recovered; total hospital charges for his treatment exceeded $5 million. Reflection upon the case resulted in analysis of two ethical questions: primarily, clinician obligation to balance the provision of actuarially fair health care to society against the healing of a single patient; secondarily, the effects of malleable transplant criteria on trust in the patient selection process. We affirmed that physicians should not be principally responsible for justifying financial investment to society or for upholding beneficence beyond the individual physician and patient relationship in order to contain costs. We concluded, however, that such instances, when combined with manipulation of transplant center criteria, pose a potential threat to public trust. We therefore suggested that transplant centers maintain independent ethics committees to review such cases.


Assuntos
Hepatopatias/cirurgia , Transplante de Fígado/ética , Adolescente , Beneficência , Ética Médica , Custos de Cuidados de Saúde/ética , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/ética , Síndrome Hepatopulmonar/economia , Síndrome Hepatopulmonar/cirurgia , Custos Hospitalares/ética , Humanos , Transplante de Fígado/economia , Masculino , Princípios Morais , Doenças Raras
10.
Int J Technol Assess Health Care ; 35(1): 5-9, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30744713

RESUMO

OBJECTIVES: The way choice is presented has an impact on decision-making. This is the case also in the context of neonatal intensive care units (NICUs), particularly in the challenging cases that concern the limit of viability. The objective of this article is to examine the role of nudging in the shared decision-making in neonatology and elaborate on the respective moral challenges. RESULTS: Nudging is not morally neutral. There are two key sources of ethical issues at the heart of nudging. The first one concerns the lack of transparency, while the second concerns the background value judgments that are imminent whenever nudging is used for achieving a particular end. To solve the underlying conflict, a virtue ethics approach combined with the accountability for reasonableness framework is suggested to guide the use of the tool of nudging. CONCLUSIONS: NICU professionals ought to use the tool of nudging transparently in line with their act of profession and their practically wise judgment.


Assuntos
Tomada de Decisões/ética , Alocação de Recursos para a Atenção à Saúde/ética , Unidades de Terapia Intensiva Neonatal/ética , Neonatologia/ética , Áustria , Cognição , Humanos , Julgamento , Princípios Morais
11.
Pediatrics ; 143(Suppl 1): S14-S21, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30600266

RESUMO

NICUs are a priority implementation area for genomic medicine. Rapid genomic testing in the NICU is expected to be genomic medicine's "critical application," providing such clear benefits that it drives the adoption of genomics more broadly. Studies from multiple centers worldwide have now demonstrated the clinical utility and cost-effectiveness of rapid genomic sequencing in this setting, paving the way for widespread implementation. However, the introduction of this potentially powerful tool for predicting future impairment in the NICU also raises profound ethical challenges. Developing models of good practice that incorporate the identification, exploration, and analysis of ethical issues will be critical for successful implementation. In this article, we analyze 3 such issues: (1) the value and meaning of gaining consent to a complex test in a stressful, emotionally charged environment; (2) the effect of rapid diagnosis on parent-child bonding and its implications for medical and family decisions, particularly in relation to treatment limitation; and (3) distributive justice (ie, whether the substantial cost and diversion of resources to deliver rapid genomic testing in the NICU can be justified).


Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Terapia Intensiva Neonatal/ética , Apego ao Objeto , Consentimento dos Pais/ética , Sequenciamento Completo do Genoma/ética , Temas Bioéticos , Tomada de Decisão Clínica/ética , Genômica/ética , Alocação de Recursos para a Atenção à Saúde/economia , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal/economia , Relações Pais-Filho , Pais , Alocação de Recursos/economia , Alocação de Recursos/ética , Sequenciamento Completo do Genoma/economia , Sequenciamento Completo do Genoma/métodos
12.
Bioethics ; 33(2): 261-266, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30480809

RESUMO

There is a growing body of literature which suggests that decisions about healthcare priority setting should take into account the extent to which patients are worse off. However, such decisions are often based on how badly off patients are with respect to the condition targeted by the treatment whose priority is under consideration (condition-specific severity). In this paper I argue that giving priority to the worse off in terms of condition-specific severity does not reflect the morally relevant sense of being worse off. I conclude that an account of giving priority to the worse off relevant for healthcare priority setting should take into account how badly off patients are when all of their conditions are considered (holistic severity).


Assuntos
Comorbidade , Tomada de Decisões/ética , Alocação de Recursos para a Atenção à Saúde/ética , Prioridades em Saúde/ética , Acesso aos Serviços de Saúde/ética , Nível de Saúde , Disparidades em Assistência à Saúde/ética , Temas Bioéticos , Humanos , Índice de Gravidade de Doença
13.
Health Care Anal ; 27(2): 77-92, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28866792

RESUMO

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications.


Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Prioridades em Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Determinação de Necessidades de Cuidados de Saúde
14.
Nurs Ethics ; 26(5): 1528-1539, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29607703

RESUMO

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.


Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Cuidados de Enfermagem/normas , Alocação de Recursos/ética , Alocação de Recursos para a Atenção à Saúde/métodos , Humanos , Irlanda , Cuidados de Enfermagem/métodos , Alocação de Recursos/métodos , Inquéritos e Questionários
16.
J Med Philos ; 43(6): 724-745, 2018 Nov 17.
Artigo em Inglês | MEDLINE | ID: mdl-30452677

RESUMO

This article argues that values that apply to health care allocation entail the possibility of "spectrum arguments," and that it is plausible that they often fail to determine a best alternative. In order to deal with this problem, a two-step process is suggested. First, we should identify the Strongly Uncovered Set that excludes all alternatives that are worse than some alternatives and not better in any relevant dimension from the set of eligible alternatives. Because the remaining set of alternatives often contain more than one element, we need some complementary method of selecting a unique alternative. In order to address this issue, I suggest that we must invoke caps on the values that are used to evaluate alternatives, and that these caps must be grounded in collective commitments.


Assuntos
Teoria Ética , Alocação de Recursos para a Atenção à Saúde/ética , Prioridades em Saúde/ética , Princípios Morais , Bioética , Análise Custo-Benefício , Humanos , Filosofia , Anos de Vida Ajustados por Qualidade de Vida
17.
Otol Neurotol ; 39(8): e651-e653, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30001278

RESUMO

INTRODUCTION: Cochlear reimplantation procedures account for approximately 5% of all implant cases and may be caused by internal device failure, skin flap complications, or an unexpected decline in auditory performance. This issue, in concert with changing demographics, expanded audiometric candidacy criteria, adult bilateral implantation, and implantation for unilateral hearing loss, all place escalating pressure on device availability and resource allocation in a publically funded health care system. OBJECTIVE: The predictable and problematic access to a scare medical resource requires rigor in establishing program priority and formal policy. We present a single cochlear implant center's working reflections and an attempt at a principled approach to rationing health care decisions. METHODS: Different approaches to health care rationing are examined and discussed. We describe a method of allocation that is currently employed by a large Canadian quaternary care center and ground this method in important principles of distributive justice as they apply to health care systems. RESULTS: We elect to recognize device failure as analogous to sudden sensorineural hearing loss, with the associated need to expedite reimplantation. We consider this an ethical approach grounded in the egalitarian principle of equality of opportunity within cohorts of patients. CONCLUSION: Porting the practice from sudden sensorineural hearing loss, the time-sensitive need for hearing restoration, and maximized communication outcomes, dictates prioritization for this patient population. The predicted evolution of health systems globally and the shape of future medical practice will be heavily influenced by both the macro and micro level resource-dependent decisions implant centers currently face.


Assuntos
Implante Coclear , Falha de Equipamento , Alocação de Recursos para a Atenção à Saúde/ética , Seleção de Pacientes/ética , Reoperação/ética , Adulto , Canadá , Implante Coclear/métodos , Implantes Cocleares , Feminino , Alocação de Recursos para a Atenção à Saúde/métodos , Perda Auditiva Neurossensorial/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade
18.
Indian J Med Ethics ; 3(4): 324-326, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29981232

RESUMO

Ineffective diabetes management results in suboptimal glycaemic control and adverse health outcomes. In resource-poor settings, a combination of high burden of medication nonadherence in patients and therapeutic inertia amongst clinicians is largely attributed to the failure to achieve glycaemic targets in diabetic populations. The potential health risks from intensification of medical therapy for aggressive lowering of glucose levels in Type 2 diabetes patients represents an ethical dilemma between averting risk from overtreatment and preventing future harm from raised blood glucose levels. However, the ethical dilemmas experienced by clinicians in most of the developing world when contemplating prescription of additional oral hypoglycaemic agents or initiating insulin have received little attention from the medical community. Such ethical dilemmas unique to resource-poor settings often emerge from poor availability of drugs, diagnostics and physician consultation time for diabetic patients. Furthermore, existing evidence-based guidelines for diabetes management assume a standard of care which is lacking in such settings. This often compels the developing world clinicians when confronted with such diabetes-related ethical dilemmas to rely solely on their clinical judgement which could be ethically unjust and medically prone to error. Newer research needs to generate evidence to develop best practice guidelines for optimal therapeutic outcomes, while acknowledging the reality of limited healthcare services available in resource-poor settings.


Assuntos
Tomada de Decisões/ética , Países em Desenvolvimento , Diabetes Mellitus Tipo 2/tratamento farmacológico , Ética Médica , Alocação de Recursos para a Atenção à Saúde/ética , Recursos em Saúde , Acesso aos Serviços de Saúde , Temas Bioéticos , Glicemia/metabolismo , Assistência à Saúde/ética , Gerenciamento Clínico , Humanos , Hipoglicemiantes/provisão & distribução , Hipoglicemiantes/uso terapêutico , Insulina/provisão & distribução , Insulina/uso terapêutico , Justiça Social
20.
Int J Health Policy Manag ; 7(6): 532-541, 2018 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-29935130

RESUMO

BACKGROUND: Priority setting in publicly financed healthcare systems should be guided by ethical norms and other considerations viewed as socially valuable, and we find several different approaches for how such norms and considerations guide priorities in healthcare decision-making. Common to many of these approaches is that interventions are ranked in relation to each other, following the application of these norms and considerations, and that this ranking list is then translated into a coverage scheme. In the literature we find at least two different views on how a ranking list should be translated into coverage schemes: (1) rationing from the bottom where everything below a certain ranking order is rationed; or (2) a relative degree of coverage, where higher ranked interventions are given a relatively larger share of resources than lower ranked interventions according to some "curve of coverage." METHODS: The aim of this article is to provide a normative analysis of how the background set of ethical norms and other considerations support these two views. RESULTS: The result of the analysis shows that rationing from the bottom generally gets stronger support if taking background ethical norms seriously, and with regard to the extent the ranking succeeds in realising these norms. However, in non-ideal rankings and to handle variations at individual patient level, there is support for relative coverage at the borderline of what could be covered. A more general relative coverage curve could also be supported if there is a need to generate resources for the healthcare system, by getting patients back into production and getting acceptance for priority setting decisions. CONCLUSION: Hence, different types of reasons support different deviations from rationing from the bottom. And it should be noted that the two latter reasons will imply a cost in terms of not living up to the background set of ethical norms.


Assuntos
Assistência à Saúde/organização & administração , Alocação de Recursos para a Atenção à Saúde/ética , Prioridades em Saúde/ética , Normas Sociais , Humanos
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