ICU Care in a Pandemic.

This letter to the editor responds to commentaries in the September-October 2021issue of the Hastings Center Report by Douglas B. White and Bernard Lo, by Govind Persad, and by Virginia A. Brown, which were themselves responding, in part, to the article "Life-Years and Rationing in the Covid-19 Pandemic: A Critical Analysis," by MaryKatherine Gaurke, Bernard Prusak, Kyeong Yun Jeong, Emily Scire, and Daniel P. Sulmasy.

Life-Years & Rationing in the Covid-19 Pandemic: A Critical Analysis.

Prominent bioethicists have promoted the preservation of life-years as a rationing strategy in response to the Covid-19 pandemic. Yet the philosophical justification for maximizing life-years is underdeveloped and has a complex history that is not reflected in recent literature. In this article, we offer a critical investigation of the use of life-years, arguing that evidence of public support for the life-years approach is thin and that organ transplantation protocols (heavily cited in pandemic-response protocols) do not provide a precedent for seeking to save the most life-years. We point out that many state emergency-response plans ultimately rejected or severely attenuated the meaning of saving the most life-years, and we argue that philosophical arguments in support of rationing by life-years are remarkably wanting. We conclude by offering a fair alternative that adheres to the standard duties of beneficence, respect for persons, and justice.

Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans.

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

Principled decisions and virtuous care: an ethical assessment of the SIAARTI Guidelines for allocating intensive care resources.

This article sets forth ethical principles for responding to extraordinary circumstances in which the demand for medical care threatens to overwhelm available resources, as in the COVID-19 pandemic. In light of these principles, the author then assesses the ethics of the SIAARTI guidelines for rationing ICU beds and ventilators under such circumstances.

Should Institutions Disclose the Names of Employees with Covid-19?

Prestigious University is a large, private educational institution with a medical school, a university hospital, a law school, and graduate and undergraduate colleges all on a single campus. In the face of the Covid-19 pandemic, students were told during spring break to return to campus only briefly to retrieve their belongings. Classes then went online. On March 23, 2020, the faculty, students, and staff were emailed the following by the university's director of infection control and public health: We have become aware that a Prestigious University staff member has tested positive for the virus that causes Covid-19. The individual, who was last on campus on March 16, is now in isolation at their permanent residence and is doing well clinically. The university has already identified those members of our community who may have been in close contact with this individual, and we are working to notify them. Further, this individual's local health department has a protocol for identifying people who have been in direct contact with anyone testing positive for Covid-19 (such as this Prestigious University staff member) so that they can self-quarantine and watch for COVID-19 symptoms for a period of 14 days from their last contact with the infected individual. A professor in the Philosophy Department has asked the ethicists at the medical school whether such contact tracing suffices. "Don't the members of the community deserve to know who this is? Isn't there a mandate to identify this person in order to maximize public health benefits and slow the spread of this deadly virus?"