CZECH EXPERT STATEMENTS ON PATIENT PRIORITISATION IN THE COVID-19 PANDEMIC IN INTERNATIONAL COMPARISON

In November 2020, facing the increasing second wave of the pandemic, several professional societies of the Czech Medical Association of J. E. Purkyně issued a statement on the allocation of scarce health resources. The Statement has since been criticised at times as too legalistic and vague. However, the positive Czech law is rather strict in determining what criteria can be used for patient prioritisation and fails to foresee possible nationwide crises when the standard rules might be difficult to comply with. Another expert document on patient prioritisation was issued by a team from the Academy of Sciences of the Czech Republic. The two documents are very different in their approach: while the former aims at providing legal certainty, the latter predominantly uses ethical arguments. The paper analyses both statements and provides a comparison with selected guidelines from other countries as well as international law requirements. © 2021, Czech Society of International Law. All rights reserved.

How patient age affects triage in the Covid-19 pandemic

The Author draws upon a set of guidelines issued by the Italian Society of Anaesthesia, Analgesia, Reanimation and Intensive Care (ISAARIC) and discusses the role played by patient age, at the triage stage, as the Covid-19 pandemic relentlessly unfolds. The limiting standard for admitting patients to intensive care units that best serves in terms of transparency and equality is the "first come, first served" approach;yet, in times of pandemic, patient age carries substantial weight in that selection process. In order to avoid wasting available resources and to treat as many patients as possible, therapies are discontinued for patients who do not seem to positively respond to them (as it frequently happens with elderly patients) and given to those with better chances of survival. Age is even more relevant in relation to the prognosis-based standard. Preexisting conditions, commonly associated with old age, could preclude access to intensive care. In order to avoid age-based discrimination, a) age should constitute but one standard through which the patient's chances of survival are determined;b) residual life expectancy should be disregarded;c) patients should never be cut off from receiving intensive care based on their age alone. Considering the primacy of the right to life over any other, it could be deemed ethically admissible to exclude patients, from receiving intensive care, only after the government institutions have taken any possible organizational measure, aimed at broadening health care access, while avoiding wasteful spending in the public provision of services. © 2021, William S. Hein & Co., Inc.. All rights reserved.

The Crisis in Standards of Care.

Since the start of the Covid-19 pandemic, debates have waged about "crisis standards of care" ("CSC")-the guidelines for the allocation of resources if those resources are too scarce to meet the needs of all patients. The Hastings Center Report's September-October 2021 issue features a collection of pieces on this debate. In the lead article, MaryKatherine Gaurke and colleagues object to the idea that the allocation of scarce resources should aim to save the most "life-years," arguing instead that the objective should be to save the most lives. Gaurke et al. assert that it is only theorists who have favored the life-years strategy; the public has not-or at least, there is no good evidence that the public has. This claim is elaborated in the article by Alex Rajczi and colleagues, who argue that identifying and applying the public's will-a process they call "political reasoning"-is the core work in developing CSC. Five commentaries-two coauthored, by Douglas B. White and Bernardo Lo and by Anuj B. Mehta and Matthew K. Wynia, and three solo authored, by Govind Persad, Virginia A. Brown, and Robert D. Truog-offer further arguments about and insights into CSC.

Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources.

The September-October 2021 issue of the Hastings Center Report highlights the important topic of allocating scarce critical care resources during the Covid-19 pandemic. The article by Alex Rajczi and colleagues urges that policy-makers use public reasoning, not private reasoning, when developing triage policies. We completely agree. We show how the allocation framework we developed as private scholars, the "Pittsburgh framework," has been supported by public reasoning. The article by MaryKatherine Gaurke and colleagues criticizes rationing based on maximizing life-years saved and mistakenly claims that our framework recommended this approach. We explain that our framework never contained such a criterion but instead included a more limited consideration of near-term prognosis. In December 2020, in response to emerging data and important criticisms, we modified our framework to further strengthen equity. We are committed to improving allocation guidelines during crisis standards of care through reflective discussions and debates.

Ventilator Allocation Protocols: Sophisticated Bioethics for an Unworkable Strategy.

I was a member of the Massachusetts advisory working group that wrote the Commonwealth's crisis standards of care guidance for the Covid-19 pandemic, and I was proud of the work we did, thinking carefully about whether age should matter and whether priority should be given to essential workers if there was a scarcity of medical resources, about whether protocols should address issues of structural racism, and so forth. But as a critical care physician, I have concluded that, no matter how sophisticated the ethical analysis, the fundamental approach we proposed was flawed and virtually impossible to implement. All the existing allocation protocols that states developed are based on the assumption that clinicians will be faced with the task of selecting which patients will be offered a ventilator from among a population of patients who are each in need of one. The protocols then assign patients a priority category, and the protocols specify "tie-breaking" criteria to be used when necessary. The problem with this approach for ventilator allocation is that it has no relationship whatsoever to what happens in the real world.

Critical Ethics: How to Balance Patient Autonomy With Fairness When Patients Refuse Coronavirus Disease 2019 Testing.

OBJECTIVES: A cornerstone of our healthcare system's response to the coronavirus disease 2019 pandemic is widespread testing to facilitate both isolation and early treatment. When patients refuse to undergo coronavirus disease testing, they compromise not only just their own health but also the health of those around them. The primary objective of our review is to identify the most ethical way a given healthcare system may respond to a patient's refusal to undergo coronavirus disease 2019 testing. DATA SOURCES: We apply a systematic approach to a true clinical case scenario to evaluate the ethical merits of four plausible responses to a patient's refusal to undergo coronavirus disease testing. Although our clinical case is anecdotal, it is representative of our experience at our University Tertiary Care Center. DATA EXTRACTION: Each plausible response in the case is rigorously analyzed by examining relevant stakeholders, facts, norms, and ethical weight both with respect to individuals' rights and to the interests of public health. We use the "So Far No Objections" method as the ethical approach of choice because it has been widely used in the Ethics Modules of the Surgical Council on Resident Education Curriculum of the American College of Surgeons. DATA SYNTHESIS: Two ethically viable options may be tailored to individual circumstances depending on the severity of the patient's condition. Although unstable patients must be assumed to be coronavirus disease positive and treated accordingly even in the absence of a test, stable patients who refuse testing may rightfully be asked to seek care elsewhere. CONCLUSIONS: Although patient autonomy is a fundamental principle of our society's medical ethic, during a pandemic we must, in the interest of vulnerable and critically ill patients, draw certain limits to obliging the preferences of noncritically ill patients with decisional capacity.

Ethical connotations of the treatment of COVID-19 disease.

The current situation of the COVID-19 pandemic has brought entirely new challenges to the health care professionals as well as to the general public, and together with them a number of new problems that the society needs to deal with. One of the groups of new challenges are undoubtedly ethical issues. For physicians in their daily practice, it is important to realize the significant role of ethical aspects during an epidemic or pandemic. The article aims to acquaint health care professionals with ethical principles in general, with their distinctiveness and application in the course of infectious diseases, and with the main ethical aspects of the COVID-19 treatment during the pandemic. One of the most important topics of the subject-matter experts discussions, which took place in connection with preparation of recommendations for the allocation criteria of scarce resources in the provision of health care services in the context of the COVID-19 pandemic, is particularly the allocation of scarce resources based on age and discrimination. The intention of the article is to support healthcare professionals to fulfil their responsibilities in providing health care services in a professional and equitable way that does not conflict with any legal obligations.

Experiencing Community in a Covid Surge.

As I organize a pile of ethics consult chart notes in New York City in mid-April 2020, I look at the ten cases that I have co-consulted on recently. Nine of the patients were found to be Covid positive. The reasons for the consults are mostly familiar-surrogate decision-making, informed refusal of treatment, goals of care, defining futility. But the context is unfamiliar and unsettling. Bioethicists are in pandemic mode, dusting off and revising triage plans. Patients and potential patients are fearful-of the disease itself and of the amplification of health disparities and inequities. There is much to contemplate, but as I go through my cases, I worry about disability, about biases and racist stereotypes. In this pandemic, historically marginalized communities are at risk of further disenfranchisement.

Responding to Covid-19: How to Navigate a Public Health Emergency Legally and Ethically.

Few novel or emerging infectious diseases have posed such vital ethical challenges so quickly and dramatically as the novel coronavirus SARS-CoV-2. The World Health Organization declared a public health emergency of international concern and recently classified Covid-19 as a worldwide pandemic. As of this writing, the epidemic has not yet peaked in the United States, but community transmission is widespread. President Trump declared a national emergency as fifty governors declared state emergencies. In the coming weeks, hospitals will become overrun, stretched to their capacities. When the health system becomes stretched beyond capacity, how can we ethically allocate scarce health goods and services? How can we ensure that marginalized populations can access the care they need? What ethical duties do we owe to vulnerable people separated from their families and communities? And how do we ethically and legally balance public health with civil liberties?

Scarcity in the Covid-19 Pandemic.

As we write, U.S. cities and states with extensive community transmission of Covid-19 are in harm's way-not only because of the disease itself but also because of prior and current failures to act. During the 2009 influenza pandemic, public health agencies and hospitals developed but never adequately implemented preparedness plans. Focused on efficiency in a competitive market, health systems had few incentives to maintain stockpiles of essential medical equipment. Just-in-time economic models resulted in storage of only those supplies needed then. At the same time, global purchasing in search of lower prices reduced the number of U.S. suppliers, with hospitals dependent on foreign companies. There is still a possibility that the pandemic will be manageably bad rather than unmanageably catastrophic in this country. Immediate, powerful, and sustained federal action could make the difference.