What should be the guidelines for fair allocation of scarce Intensive Care Units in the Covid-19 pandemic? In this paper we present a proposal that adopts the directive of the highest probability of patient recovery. Some institutional preconditions are supported. First, that the competent authorities establish the protocol and declare the period of calamity during which the protocol is to be observed. Second, that medical triage teams, separate from the intensive care teams, be established in each institution with ICUs for the admission of critically ill patients. The guidelines would then be as follows: the triage team, consisting of specialized and experienced professionals, would classify patients into three priority groups, according to the degree of greatest chance of recovery, as measured by the SOFA (Sequential Organ Failure Assessment) score, except for two situations, [a] front-line health professionals, in high priority, and [b] patients whose condition did not recommend intensive care at all, in low priority. With the SOFA total scores, a classification of patients in order of priority care would be obtained, from the lowest score to the highest. To break ties, within the priority groups, it is proposed to adopt, first, the use of the life-cycle, and, if the tie persists, a draw. We present the main ethical reason for the proposal, to save the greatest number of people. Then, we discuss some opposing reasons, compare the proposal with four others released in Brazil in 2020, and criticize the use of performance status present in one of them.
The health emergency provoked by Coronavirus spreading, the high and exponentially growing number of people affected, the impact on people's lives and health care systems all over the world, the lack of personal protective equipment, ICU beds, medical staff, artificial respirators, etc. determined a scenario where social emergency led to an impact on the economy, fundamental rights, etc. There are some bioethical considerations in order to recommend decision-making on patient access to special care units in pandemic situations.
Bioethics and Law Observatory of U. Barcelona proposes some recommendations based on international human rights y bioethical principles such as respect, equity, transparency. Recommendations were done following a critical literature review of reports of different scientific organizations such as the Spanish Minister of Health, Hastings Center, Nuffield Council of Bioethics, NEJM, OMS, among others.
Two sets of recommendations: one regarding issues to consider beforehand (such as assessment of available resources, of the expected benefit for the individual patients, of clinical course, of the will of the patients and their families); and guidelines for action (among others: early and proactive assessment, comorbidity of patients, prioritisation of access to and use of these resources, the conformation of Hospital Triage Commitees, adequacy of end-of-life care and emotional support measures for professionals) should be done.
The context of triage determine some obligations: to organise contingency plans for health emergencies, equity measures for public health, caring for the privacy and confidentiality of patients, health providers, etc.; collegiate decision-making, assessing the ethical dilemmas of pandemics.
Given the health emergency conditions, this proposal is intended to guide the actions of professionals and facilitate homogeneous decision-making in the field of critical patient care.
The IHRs are the primary international legal instruments that guide international and states action against a public health emergency. They are envisaged and guided, primarily, by human rights and scientific principles and considers common issues such as the role of consent and confidentiality.
Unfortunately, these regulations do not function properly and create a collective international response against the Covid-19 pandemic. This paper, by revisiting the IHRs, argues that this failure is because these regulations lack a soul and a heart that are the core values underpinning these regulations and/or their understanding. The Covid-19 pandemic shows a rude fact that although human rights and scientific principles are fundamental and universal, without such a soul and a heart, they are easy to be neutralized, inaction, and of little value to guild a collective response.
Then, this paper, by taking an approach from the values and virtues perspective, offers a critical account of their current form and function and insights as to how they can be or remain fit-for-purpose in bioethical terms into the future. This paper suggests that an installation, reinstatement, or at least reiteration of core values and virtues such as benevolence, righteousness, and fiduciary as foundations underpinning these regulations, their understanding, and the deep analysis and interpretation about and based on such can help inform and improve the operation of the IHRs and responses against emergencies over time.
Logic would dictate that any State response to the Covid-19 pandemic should be guided by public health principles and core values. However, this has not been the experience in many countries where fragmented and often conflicting government actions and policies have resulted in not only escalating the pandemic in many instances; but more significantly, resulted in a greater loss of trust in public health responses, the scientific endeavour and the role of the State. This paper argues that there is a need for an integrated approach based on the principles of coherence, integration and trustworthiness.
The twin aims of public health are to promote overall population health and reduce health inequities. It is often not possible to promote these aims simultaneously, which leads to trade-offs. These trade-offs are salient in the distribution of COVID-19 vaccines. For example, many have been willing to eschew concerns of inequity and unfairness when confronted with pressures to get “vaccines in arms” as quickly as possible. Even with stated commitments to equity, fairness, and allocating vaccines on the basis of risk, many have proposed allocation schemes that, for example, proceed strictly on the basis of age despite sometimes similar or greater risks experienced among younger populations who are clinically extremely vulnerable, disadvantaged populations living in congregate living settings, and Black, Indigenous, and other racialized populations who have tended to experience a disproportionately greater burden of COVID-19. Others have argued that prioritization itself is antithetical to rapid administration of vaccines, and so should be abandoned altogether.
This paper examines whether and when it is ethically tolerable to compromise equity and fairness when commitments to these values increase logistical complexity, sow confusion among the public about vaccine rollout, and slow vaccine rollout. Given that the competing aims of speed and equity represent well-trodden debates concerning utilitarianism and fairness, this paper will also use COVID-19 vaccine distribution as a case example to examine whether decision-making in the context of public health emergencies ought to be more utilitarian by prioritizing its aim of reducing overall population-level morbidity and mortality.