A proposal for formal fairness requirements in triage emergency departments: publicity, accessibility, relevance, standardisability and accountability.

This paper puts forward a wish list of requirements for formal fairness in the specific context of triage in emergency departments (EDs) and maps the empirical and conceptual research questions that need to be addressed in this context in the near future. The pandemic has brought to the fore the necessity for public debate about how to allocate resources fairly in a situation of great shortage. However, issues of fairness arise also outside of pandemics: decisions about how to allocate resources are structurally unavoidable in healthcare systems, as value judgements underlie every allocative decision, although they are not always easily identifiable. In this paper, we set out to bridge this gap in the context of EDs. In the first part, we propose five formal requirements specifically applied for ED triage to be considered fair and legitimate: publicity, accessibility, relevance, standardisability and accountability. In the second part of the paper, we map the conceptual and empirical ethics questions that will need to be investigated to assess whether healthcare systems guarantee a formally just ED triage. In conclusion, we argue that there is a vast research landscape in need of an in-depth conceptual and empirical investigation in the context of ED triage in ordinary times. Addressing both types of questions in this context is vital for promoting a fair and legitimate ED triage and for fostering reflection on formal fairness allocative issues beyond triage.

Attitudes, intentions and procreative responsibility in current and future assisted reproduction.

Procreative obligations are often discussed by evaluating only the consequences of reproductive actions or omissions; less attention is paid to the moral role of intentions and attitudes. In this paper, I assess whether intentions and attitudes can contribute to defining our moral obligations with regard to assisted reproductive technologies already available, such as preimplantation genetic diagnosis (PGD), and those that may be available in future, such as reproductive genome editing and ectogenesis, in a way compatible with person-affecting constraints. I propose the parent-child relationship argument, which is based on the moral distinction between creating and parenting a child. Hence, I first argue that intentions and attitudes can play a role in defining our moral obligations in reproductive decisions involving PGD. Second, I maintain that if we accept this and recognize reproductive genome editing and ectogenesis as person-affecting procedures, we should be committed to arguing that prospective parents may have moral reasons to prefer reproduction via such techniques than via sexual intercourse. In both cases, I observe an extension of our procreative responsibility beyond what is proposed by the consequentialist person-affecting morality.

Affecting future individuals: Why and when germline genome editing entails a greater moral obligation towards progeny.

Assisted reproductive technologies have greatly increased our control over reproductive choices, leading some bioethicists to argue that we face unprecedented moral obligations towards progeny. Several models attempting to balance the principle of procreative autonomy with these obligations have been proposed. The least demanding is the minimal threshold model (MTM), according to which every reproductive choice is permissible, except creating children whose lives will not be worth living. Hence, as long as the future child is likely to have a life worth living, prospective parents may be allowed to use preimplantation genetic diagnosis (PGD) to select embryos with genetic diseases or disabilities. Assuming a consequentialist person-affecting view of morality, this paper investigates whether the MTM is an appropriate tool to guide procreative decisions given the continuous development of reproductive genetic technologies. In particular, I consider germline genome editing (GGE) and I argue that its application in human reproduction, unlike PGD, should be conceived as person-affecting towards future progeny. I claim that even if we assume the plausibility of the MTM within PGD, we are committed to accepting that a greater moral obligation towards progeny should guide procreative decisions if GGE were available. In this case, the MTM should no longer be considered an appropriate instrument to guide procreative choices. Finally, I investigate when we face this greater moral obligation, concluding that it applies only when prospective parents have already engaged in the in vitro fertilization process.

Below-ground biomass of plants, with a key contribution of buried shoots, increases foredune resistance to wave swash.

BACKGROUND AND AIMS: Sand dunes reduce the impact of storms on shorelines and human infrastructure. The ability of these ecosystems to provide sustained coastal protection under persistent wave attack depends on their resistance to erosion. Although flume experiments show that roots of perennial plants contribute to foredune stabilization, the role of other plant organs, and of annual species, remains poorly studied. Furthermore, it remains unknown if restored foredunes provide the same level of erosion resistance as natural foredunes. We investigated the capacity of three widespread pioneer foredune species (the perennial Ammophila arenaria and the annuals Cakile maritima and Salsola kali) to resist dune erosion, and compared the erosion resistance of Ammophila at natural and restored sites. METHODS: Cores collected in the field were tested in a flume that simulated a wave swash. A multi-model inference approach was used to disentangle the contributions of different below-ground compartments (i.e. roots, rhizomes, buried shoots) to erosion resistance. KEY RESULTS: All three species reduced erosion, with Ammophila having the strongest effect (36 % erosion reduction versus unvegetated cores). Total below-ground biomass (roots, rhizomes and shoots), rather than any single compartment, most parsimoniously explained erosion resistance. Further analysis revealed that buried shoots had the clearest individual contribution. Despite similar levels of total below-ground biomass, coarser sediment reduced erosion resistance of Ammophila cores from the restored site relative to the natural site. CONCLUSIONS: The total below-ground biomass of both annual and perennial plants, including roots, rhizomes and buried shoots, reduced dune erosion under a swash regime. Notably, we show that (1) annual pioneer species offer erosion protection, (2) buried shoots are an important plant component in driving sediment stabilization, and (3) management must consider both biological (plants and their traits) and physical (grain size) factors when integrating dunes into schemes for coastal protection.

The First- and Second-Order Ethical Reasons Approach: The Case of Human Challenge Trials.

At the height of the Covid pandemic, there was much discussion in the literature about using human challenge trials (HCTs) to expedite the development of effective Covid-19 vaccines. Historically, reluctance to fully accept HCTs has largely been due to potential conflicts with the principle of nonmaleficence in bioethics. Only a few commentators have explored this topic in depth. In this paper, we claim that to address ethical concerns regarding HCTs, two types of ethical reasons should be identified and investigated: first-order reasons that can be given to claim that a practice in itself is in direct conflict with the principles of bioethics; and second-order reasons that take into consideration how a practice is carried out and its consequences. We argue that understanding these ethical reasons is crucial for guiding the implementation of HCTs. We investigate a first-order reason against HCTs when the practice is in conflict with the principle of nonmaleficence, and when it is not. Following this argument and assuming there is no first-order reason based on nonmaleficence that hinders using HCTs, we argue there may be second-order reasons to guide implementation of this practice, such as difficulty in obtaining informed consent; protection of the weaker party; and trust in the scientific enterprise.

Clinical decision-making process and distributive justice: The mediating role of economic analysis. Empirical evidence from Italy.

BACKGROUND: The COVID-19 pandemic has not only tested the resilience of public health systems but also underscored the criticality of allocative choices on health resources. These choices, however, are not confined to health emergencies but are integral to public health decisions, which inherently grapple with limited resources. In this context, physicians play a pivotal role as the architects of clinical actions in various scenarios. Therefore, doctors are called upon to make their decisions by considering not only the criteria of clinical appropriateness but also the ethical aspects linked, in particular, to the principle of justice. Indeed, the assessment of the effectiveness of a treatment for a particular patient must be balanced against criteria of equity and justice for the whole. To be fully applied, the principle of justice presupposes the use of economic evaluation techniques designed to drive the organisation decisions by effectiveness and efficiency. METHODS: The present paper aims to empirically analyse whether and to what extent economic evaluation is known and used by doctors in healthcare decision-making and, therefore, what the most widespread approaches are used in such processes. In particular, this paper intends to present the results of an empirical study on a sample of doctors registered with the Order of Physicians in Lombardy (Italy), one of the areas most affected by the COVID-19 pandemic. RESULTS: The research reveals a particular awareness of the criticality of allocation issues accompanied by a lack of knowledge of the economic evaluation techniques or, more broadly, by an almost total disuse of financial criteria. The main reasons are doctors' need for more knowledge of these tools and insufficient availability of economic information at the country system level. CONCLUSION: In the conclusion, we propose some suggestions to facilitate the transition to more current decision-making models consistent with the characteristics of more advanced national healthcare contexts.

Top ten priorities for global saltmarsh restoration, conservation and ecosystem service research.

Coastal saltmarshes provide globally important ecosystem services including 'blue carbon' sequestration, flood protection, pollutant remediation, habitat provision and cultural value. Large portions of marshes have been lost or fragmented as a result of land reclamation, embankment construction, and pollution. Sea level rise threatens marsh survival by blocking landward migration where coastlines have been developed. Research-informed saltmarsh conservation and restoration efforts are helping to prevent further loss, yet significant knowledge gaps remain. Using a mixed methods approach, this paper identifies ten research priorities through an online questionnaire and a residential workshop attended by an international, multi-disciplinary network of 35 saltmarsh experts spanning natural, physical and social sciences across research, policy, and practitioner sectors. Priorities have been grouped under four thematic areas of research: Saltmarsh Area Extent, Change and Restoration Potential (including past, present, global variation), Spatio-social contexts of Ecosystem Service delivery (e.g. influences of environmental context, climate change, and stakeholder groups on service provisioning), Patterns and Processes in saltmarsh functioning (global drivers of saltmarsh ecosystem structure/function) and Management and Policy Needs (how management varies contextually; challenges/opportunities for management). Although not intended to be exhaustive, the challenges, opportunities, and strategies for addressing each research priority examined here, providing a blueprint of the work that needs to be done to protect saltmarshes for future generations.

Wrack enhancement of post-hurricane vegetation and geomorphological recovery in a coastal dune.

Coastal ecosystems such as sand dunes, mangrove forests, and salt marshes provide natural storm protection for vulnerable shorelines. At the same time, storms erode and redistribute biological materials among coastal systems via wrack. Yet how such cross-ecosystem subsidies affect post-storm recovery is not well understood. Here, we report an experimental investigation into the effect of storm wrack on eco-geomorphological recovery of a coastal embryo dune in north-eastern Florida, USA, following hurricane Irma. We contrasted replicated 100-m2 wrack-removal and unmanipulated (control) plots, measuring vegetation and geomorphological responses over 21 months. Relative to controls, grass cover was reduced 4-fold where diverse storm wrack, including seagrass rhizomes, seaweed, and wood, was removed. Wrack removal was also associated with a reduction in mean elevation, which persisted until the end of the experiment when removal plots had a 14% lower mean elevation than control plots. These results suggest that subsides of wrack re-distributed from other ecosystem types (e.g. seagrasses, macroalgae, uplands): i) enhances the growth of certain dune-building grasses; and ii) boosts the geomorphological recovery of coastal dunes. Our study also indicates that the practice of post-storm beach cleaning to remove wrack-a practice widespread outside of protected areas-may undermine the resilience of coastal dunes and their services.

Virus contamination and infectivity in beach environment: Focus on sand and stranded material.

To assess the exposure of beachgoers to viruses, a study on seawater, sand, and beach-stranded material was carried out, searching for human viruses, fecal indicator organisms, and total fungi. Moreover, for the first time, the genome persistence and infectivity of two model viruses was studied in laboratory-spiked sand and seawater samples during a one-week experiment. Viral genome was detected in 13.6 % of the environmental samples, but it was not infectious (Human Adenovirus - HAdV, and enterovirus). Norovirus and SARS-CoV-2 were not detected. The most contaminated samples were from sand and close to riverine discharges. In lab-scale experiments, the infectivity of HAdV5 decreased by ~1.5-Log10 in a week, the one of Human Coronavirus-229E disappeared in <3 h in sand. The genome of both viruses persisted throughout the experiment. Our results confirm viral contamination of the beach and suggest HAdV as an index pathogen for beach monitoring and quantitative risk assessment.

Impact of storms and proximity to entry points on marine litter and wrack accumulation along Mediterranean beaches: Management implications.

Beach litter can affect public health and economic activities worldwide forcing local authorities to expensive beach cleaning. Understanding the key mechanisms affecting the accumulation of this waste on beaches, such as sea state and proximity to entry points, is critical to plan effective management strategies. In this one-year study, we estimated the impact of storm events and waterways runoff on litter abundance and local economy using as a model a managed, peri-urban beach facing a north-western sector of the Mediterranean Sea. We also investigated the relationship between litter composition/density and beach proximity to major/closest harbors/rivers at regional scale by combining our data with those on litter density available in literature. Autumn/winter storms caused larger litter depositions than spring/summer ones in the peri-urban beach. No preferential accumulation occurred near to waterway mouths. Litter mainly consisted of plastic, and its composition in terms of micro-categories varied over seasons. In total, 367,070 items were deposited along 4.7 km of beach over one year, and the cost for the removal of this waste amounted to approximately 27,600 euros per km/year. At regional scale, beach litter density was positively correlated to the proximity of major harbors while its composition was related to the proximity to both major harbors and rivers. Results indicate that autumn/winter storms are important drivers of marine litter deposition. They also suggest that beaches in front of the convergence zone of littoral currents and close to major harbors can be particularly subjected to this kind of pollutant. To increase their effectiveness, litter mitigation/cleaning activities should be planned based on predictions of major storm events and performed at spatial scales encompassing at least coastal regional sectors.

Substrate Type Influences the Structure of Epiphyte Communities and the Growth of Posidonia oceanica Seedlings.

Epiphytes colonizing adult seagrasses highly contribute to seagrass ecosystem functioning and plant growth. Yet, little information exists on epiphytic communities developing on seagrass seedlings. Moreover, for some species our knowledge about seedling performance is limited to early establishment phases, and the role of substrate type in affecting their growth is still unclear. These are considerable knowledge gaps, as seedlings play an important role in meadow expansion and recovery from disturbance. In this study, seedlings of Posidonia oceanica, a keystone species of the Mediterranean, were grown in a shallow (1.5 m deep) coastal area along the Tuscany coast (Italy). After five years of growth (July 2009), seedlings were collected and, through multivariate analysis, we examined whether the epiphytic communities of leaves (both internal and external side) and rhizomes, as well as the growth characteristics differed between rock and sand substrate. The epiphytic communities of seedlings largely reflected those found on adult shoots. Epiphyte cover was similar between the two leaf sides, and it was higher on seedlings grown on rock than on sand, with encrusting algae dominating the community. No differences in epiphyte cover and community structure on rhizomes were found between substrates. Seedling growth characteristics did not differ between substrates, apart from the number of standing leaves being higher on rock than on sand. No correlation was found among epiphyte communities and seedling growth variables (i.e., leaf area, maximum leaf length, number of leaves, total number of leaves produced, rhizome length, total biomass, and root to shoot biomass ratio). Results indicate that epiphytes successfully colonize P. oceanica seedlings, and the surrounding micro-environment (i.e., substrate type) can influence the leaf epiphytic community. This study provides new valuable insights on the biological interactions occurring in seagrass ecosystems and highlights the need for better understanding the effects of seedling epiphytes and substrate on the formation of new meadows.

Plastics and sedimentation foster the spread of a non-native macroalga in seagrass meadows.

Plastics are found in marine environments worldwide, and their effects on macrophytes (seagrasses and macroalgae) colonizing sandy bottoms are still poorly known. Seagrass meadows are valuable but declining ecosystems due to local and global-change related stressors, including sediment disturbance and introduced macroalgae. Understanding whether plastics pose a further threat to seagrasses is critically important. In two simultaneous additive experiments performed in an aquaculture tank, we examined the individual and combined effects of macroplastics (non-biodegradable high-density polyethylene and biodegradable starch-based) and sedimentation (no and repeated sedimentation) on the performance (in terms of biomass and architectural variables) of a native Mediterranean seagrass (Cymodocea nodosa) and an introduced macroalga (Caulerpa cylindracea), and on the intensity of their interactions. Macroplastics were still present in sediments after 18 months. Cymodocea nodosa produced a greater biomass and longer horizontal rhizome internodes forming clones with more spaced shoots probably to escape from plastics. Plastics prevented C. nodosa to react to sedimentation by increasing vertical rhizome growth. Under C. cylindracea invasion, C. nodosa allocated more biomass to roots, particularly to fine roots. In the presence of C. nodosa, C. cylindracea performance was reduced. High-density polyethylene (HDPE) plastic and sedimentation shifted species interactions from competitive to neutral. These results suggest that both HDPE and biodegradable starch-based macroplastics, if deposited on marine bottoms, could make seagrasses vulnerable to sedimentation and reduce plant cover within meadows. HDPE plastic and sedimentation could contribute to the decline of seagrass habitats by facilitating the spread of non-native macroalgae within meadows. Overall, the study highlights the urgent need to implement more effective post-marketing management actions to prevent a further entering of plastics in natural environments in the future, as well as to establish to conservation measures specifically tailored to protect seagrass habitats from plastic pollution.

Transepithelial transport of P-glycoprotein substrate by the Malpighian tubules of the desert locust.

Extrusion of xenobiotics is essential for allowing animals to remove toxic substances present in their diet or generated as a biproduct of their metabolism. By transporting a wide range of potentially noxious substrates, active transporters of the ABC transporter family play an important role in xenobiotic extrusion. One such class of transporters are the multidrug resistance P-glycoprotein transporters. Here, we investigated P-glycoprotein transport in the Malpighian tubules of the desert locust (Schistocerca gregaria), a species whose diet includes plants that contain toxic secondary metabolites. To this end, we studied transporter physiology using a modified Ramsay assay in which ex vivo Malpighian tubules are incubated in different solutions containing the P-glycoprotein substrate dye rhodamine B in combination with different concentrations of the P-glycoprotein inhibitor verapamil. To determine the quantity of the P-glycoprotein substrate extruded we developed a simple and cheap method as an alternative to liquid chromatography-mass spectrometry, radiolabelled alkaloids or confocal microscopy. Our evidence shows that: (i) the Malpighian tubules contain a P-glycoprotein; (ii) tubule surface area is positively correlated with the tubule fluid secretion rate; and (iii) as the fluid secretion rate increases so too does the net extrusion of rhodamine B. We were able to quantify precisely the relationships between the fluid secretion, surface area, and net extrusion. We interpret these results in the context of the life history and foraging ecology of desert locusts. We argue that P-glycoproteins contribute to the removal of xenobiotic substances from the haemolymph, thereby enabling gregarious desert locusts to maintain toxicity through the ingestion of toxic plants without suffering the deleterious effects themselves.