Tackling the COVID elective surgical backlog: Prioritising need, benefit or equality?

The National Health Service (NHS) in the UK is currently facing a significant waiting list backlog following the disruption of the COVID-19 pandemic, with millions of patients waiting for elective surgical procedures. Effective treatment prioritisation has been identified as a key element of addressing this backlog, with NHS England's delivery plan highlighting the importance of ensuring that those with ‘the clinically most urgent conditions are diagnosed and treated most rapidly'. Indeed, we describe how the current clinical guidance on prioritisation issued by The Federation of Surgical Specialty Associations serves this aim. However, whilst there are strong reasons to prioritise elective surgery in accordance with clinical need, we argue that it would be a mistake to assume that prioritisation in accordance with clinical need requires only a clinical or scientific judgement. The understanding of clinical need that we choose to employ in a prioritisation system will be grounded by some key ethical judgements. Moreover, we may also have to make trade-offs between addressing clinical need, safeguarding equality, and achieving other benefits. As the UK faces up to the backlog, it is important that surgical prioritisation guidelines enshrine a broad range of values that we believe ought to determine access to care in non-emergency circumstances. Our analysis suggests that the current approach to prioritisation is not a sufficiently nuanced way of balancing the different moral values that are operative in this context. © The Author(s) 2023.

Sars-Cov 2 Pandemic and the Principles of Medical Ethics

During the coronavirus pandemic, it was clearly seen how vulnerable society is with its entire health and sanitary security system, how vulnerable medicine is to a biological attack (whether it was natural or manufactured in a laboratory) and how chaotically society reacts as a whole, when faced with an unknown danger.It was quickly seen that medical science and technology have its limits and risks, that they do not always serve the cause of the suffering man, that biotechnology and genetic manipulation pose a major danger to humanity and that, for the simple reason that it is the product of human reason, always doubtful and hesitant. It has gone so far as to the principles of medical ethics were breached, whether we are talking about non-maleficence or beneficence, decision-making autonomy or nondiscriminatory attitude toward access to resources, with serious damage to the individual -medical system relationship.

Expert advice on vaccination against COVID-19 for patients with mental disorders.

The COVID-19 epidemic has caused serious and long-lasting health and social harm. Vaccination is considered as the most effective way to prevent the COVID-19 epidemic. Patients with mental disorders are at high risk of COVID-19 infection who are in urgent need to get protection. However, due to the particularity of their conditions, whether these patients should be vaccinated has become a tough issue that obsesses doctors, patients with mental disorders, and their families. In light of this issue, this article provides expert advice on the safety, legal and ethical issues of vaccination for patients with mental disorders to regulate the vaccination of these vulnerable populations against COVID-19.Copyright © 2022 Chinese Journal of Psychiatry. All rights reserved.

The scandals of covid-19

Where clinicians once believed "there is no harm trying,” they realise that CPR offers little benefit to patients but brings significant risk to staff as they wait for the protective equipment that was promised in the UK and globally (doi:10.1136/bmj.m1423;doi:10.1136/bmj.m1367). Adding to the scandals of unpreparedness and lack of personal protective equipment is the scandal of testing. Germany's relatively low case fatality rate is helped by an "early and high level of testing” (doi:10.1136/bmj.m1395).

Covid-19: Questions of conscience and duty for scientific advisers

England is abandoning lockdown and possibly hope of containing a second wave of covid-19. From 1 June schools will open to children other than those of key workers. Outdoor markets and car showrooms will reopen. In two weeks, it will be the turn of all non-essential retailers. This is meant to be a moment of optimism, a green recovery, centred on the health of people and the planet (doi:10.1136/bmj.m2077, doi:10.1136/bmj.m2076), backed by an effective system of testing and contact tracing and possibly informed by a public inquiry (doi:10.1136/bmj.m2052).Instead, England arrives here in a state of utter confusion (doi:10.1136/bmj.m1785). The public's confidence in the official lockdown advice is shaken. The covid-19 response is short on testing, uncertain on contact tracing, and reliant on unreliable apps (doi:10.1136/bmj.m2085). Scotland, Wales, and Northern Ireland are not following England's lead. The UK has the second highest number of covid-19 deaths of any nation and, by some calculations, the most deaths per capita.

Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned.

BACKGROUND: The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. METHODS: A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. RESULTS: All 178 respondents (response rate: 25-32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to 'team cooperation', 'team solidarity' and 'work ethic'. Lessons learned were mostly related to 'quality of care' and 'professional qualities'. CONCLUSIONS: Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals' dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. TRIAL REGISTRATION: The trial was registered on The Netherlands Trial Register, number NL9177.

Interactions between Australian cancer physicians and the pharmaceutical industry: a qualitative study.

OBJECTIVES: To understand how and why Australian cancer physicians interact with the pharmaceutical industry. DESIGN: Qualitative study using semistructured interviews, performed by a medical oncologist. Thematic analysis using a combination of deductive and inductive codes. SETTING: Given the evidence on industry influences on clinical practice and the importance to the market of oncology drugs, we sought to better understand cancer physicians' experiences. Practising consultant medical oncologists and clinical haematologists from four Australian states were interviewed over Zoom. PARTICIPANTS: 16 cancer physicians were interviewed between November 2021 and March 2022, from 37 invited (response rate 43%). Most were medical oncologists (n=12 of 16, 75%) and male (n=9 of 16, 56%). OUTCOME MEASURES: The analysis of all interviews was based on grounded theory. Transcripts were coded and then codes formed into themes with supporting quotes. The themes were then placed into categories, used to describe the broad areas into which the themes could be grouped. RESULTS: Six themes were identified that fell within two broad categories: cancer physicians' views and experiences of interactions and management of these interactions. Views and experiences included: the transactional nature of relationships, risks of research dependence, ethical challenges and varied attitudes based on interaction type. Management themes included: lack of useful guidance and reduced interactions during the COVID-19 pandemic. These led to an overarching seventh theme, on the desire for a 'middle road'. Cancer physicians identified the transactional nature of industry relationships and felt uncomfortable with several types of interactions, including those with sales representatives. Most wanted less contact with industry, and the forced separation that occurred with the COVID-19 pandemic was generally welcome. CONCLUSIONS: Cancer physicians may have difficulty balancing the perceived need to interact with industry in modern cancer care while maintaining distance to minimise conflicts of interest. Further research is needed to assess management strategies in this area.

Solidarity during the COVID-19 pandemic: evidence from a nine-country interview study in Europe.

Calls for solidarity have been an ubiquitous feature in the response to the COVID-19 pandemic. However, we know little about how people have thought of and practised solidarity in their everyday lives since the beginning of the pandemic. What role does solidarity play in people's lives, how does it relate to COVID-19 public health measures and how has it changed in different phases of the pandemic? Situated within the medical humanities at the intersection of philosophy, bioethics, social sciences and policy studies, this article explores how the practice-based understanding of solidarity formulated by Prainsack and Buyx helps shed light on these questions. Drawing on 643 qualitative interviews carried out in two phases (April-May 2020 and October 2020) in nine European countries (Austria, Belgium, France, Germany, Ireland, Italy, The Netherlands, German-speaking Switzerland and the UK), the data show that interpersonal acts of solidarity are important, but that they are not sustainable without consistent support at the institutional level. As the pandemic progressed, respondents expressed a longing for more institutionalised forms of solidarity. We argue that the medical humanities have much to gain from directing their attention to individual health issues, and to collective experiences of health or illness. The analysis of experiences through a collective lens such as solidarity offers unique insights to understandings of the individual and the collective. We propose three essential advances for research in the medical humanities that can help uncover collective experiences of disease and health crises: (1) an empirical and practice-oriented approach alongside more normative approaches; (2) the confidence to make recommendations for practice and policymaking and (3) the pursuit of cross-national and multidisciplinary research collaborations.

Integrating Bioethics and Neonatal Palliative Care in a Pandemic: The Scope of Advocacy and Online Collaboration for Exceptional Life-Sustaining Medical and Surgical Interventions in a Regional Neonatal Intensive Care Unit

Purpose of Study: The regional NICU is an essential healthcare resource for families of newborns with serious life-threatening illnesses. Mechanical ventilation, cardiovascular therapies, therapeutic hypothermia, and neonatal surgeries are common life-sustaining interventions. Our NICU serves an underprivileged population in a resource poor environment and several ethical questions frequently emerge when facing extremes of innovative therapies. The pandemic and rapidly changing institutional protocols accentuated challenges faced by frontline NICU teams caring for newborns at risk for devastating illnesses and death. Concurrently, evolving paradigms in neonatal ethics required urgent and high quality palliative care in a background of racial and socioeconomic inequities, restrictive visitation policies, and limited healthcare resources. The purpose of this study was to ensure that neonates and their families receive ethically sound care, timely referrals for innovative therapies, and specialized palliative care in the strained and uncertain environment of the COVID-19 pandemic. Methods Used: The key steps consisted of structured and impromptu discussion forums for specialized palliative care and medical ethics, perinatal case conferences and pediatrics grand rounds on virtual platforms, educational webinars for interdisciplinary teams, and improved electronic communication. Online collaboration and innovative combinations of in-person and virtual meetings were utilized for urgently Incorporating clinical updates. Summary of Results: 1. A neonate with severe HIE and postnatally diagnosed congenital diaphragmatic hernia required emergent ECMO center referral. NICU providers utilized a structured bioethics and palliative care framework for providing family support and discussing the prognostication challenges of acute illnesses. 2. Many important bioethical questions emerged while caring for infants with life-threatening chromosomal abnormalities. Ethical tension was addressed by teaching tools, quality of life and pediatrics ethics conversations, mitigation of moral distress, contemporary clinical and surgical experience, community engagement, and family perspectives. 3. Ethical conflicts are central in the decision to resuscitate neonates born between 22 and 23 weeks of gestation. To provide urgent prenatal consultations and attend high risk deliveries, we collaborated across geographically distant healthcare systems, unified management strategies and analyzed outcomes data. 4. NEC in several extremely preterm babies had devastating outcomes and the team respected each family's voice with compassionate, shared decision-making for both curative care surgeries and palliative care. Conclusion(s): The new workflows, telephone and video conferences, and redirection to telehealth based family meetings did not change important outcomes during the pandemic. Advocacy and education for integrating bioethics and palliative care were vital facets of neonatal critical care in a resource poor and ever-changing pandemic environment.

What is moral injury and how does it affect nurses?: When healthcare staff have to make care decisions that go against their values, a conflict of conscience can arise

The concepts of moral injury and moral distress came to the fore in nursing during the COVID-19 pandemic when, says mental health nurse researcher Emily Wood, healthcare professionals were being placed in difficult circumstances. They were, for example, having to make decisions about which of the sickest patients could be admitted to a limited number of intensive care beds.

Applying Jewish theology to issues in mental and physical health

Jewish theological convictions and values undergird the approaches of Judaism to all aspects of life. This article first describes five fundamental Jewish convictions about God, human beings, and the relations between them as well as the place of medicine in life. It then describes the positions taken by the three largest denominations of contemporary Judaism on end-of-life issues and the approach of Judaism to mental health issues, two aspects of medical ethics that have become especially prominent during the COVID-19 pandemic but have always been, and will always be, important aspects of human life to which religious traditions can and should give guidance.

Polarized Citizen Preferences for the Ethical Allocation of Scarce Medical Resources in 20 Countries.

Objective. When medical resources are scarce, clinicians must make difficult triage decisions. When these decisions affect public trust and morale, as was the case during the COVID-19 pandemic, experts will benefit from knowing which triage metrics have citizen support. Design. We conducted an online survey in 20 countries, comparing support for 5 common metrics (prognosis, age, quality of life, past and future contribution as a health care worker) to a benchmark consisting of support for 2 no-triage mechanisms (first-come-first-served and random allocation). Results. We surveyed nationally representative samples of 1000 citizens in each of Brazil, France, Japan, and the United States and also self-selected samples from 20 countries (total N = 7599) obtained through a citizen science website (the Moral Machine). We computed the support for each metric by comparing its usability to the usability of the 2 no-triage mechanisms. We further analyzed the polarizing nature of each metric by considering its usability among participants who had a preference for no triage. In all countries, preferences were polarized, with the 2 largest groups preferring either no triage or extensive triage using all metrics. Prognosis was the least controversial metric. There was little support for giving priority to healthcare workers. Conclusions. It will be difficult to define triage guidelines that elicit public trust and approval. Given the importance of prognosis in triage protocols, it is reassuring that it is the least controversial metric. Experts will need to prepare strong arguments for other metrics if they wish to preserve public trust and morale during health crises. Highlights: We collected citizen preferences regarding triage decisions about scarce medical resources from 20 countries.We find that citizen preferences are universally polarized.Citizens either prefer no triage (random allocation or first-come-first served) or extensive triage using all common triage metrics, with "prognosis" being the least controversial.Experts will need to prepare strong arguments to preserve or elicit public trust in triage decisions.

Utilitarian Ethical Triage Bayesian Decisions With Monetary Value During COVID-19 - A Bayesian Probability Analysis

Utilitarian ethical triage decisions with monetary value are complex and difficult to estimate, with possible benefits for a patient compared to other patients. A triage decision during an emergency combines expected economic value. It includes social and bioethical factors. A new Bayesian approach addresses risk probabilities and improves utilitarian triage decisions. Admission to the ICU (Intensive Care Unit) and the allocation of ventilators for patients depends on a risk-based comorbidity score. It considers the medical prognosis, social factors, personal and social costs. The rankings of the critical factors among patients with predefined ethical treatment success criteria depend on the likelihood of response to treatment and the patient's social circumstances. A sensitivity analysis with regression coefficients shows how the expected monetary value of patents is correlated to make a better judgment. Patient 3 in scenarios 1 and 2 is ranked consistently in priority. Low-ranked patients are placed on a waiting list as the demand for intensive care units increases dramatically with the number of patients infected with COVID-19 or its variants. The problem with utilitarianism ethics is that high net worth patients get an advantage, although disadvantaged patients with social liability are given due consideration. Furthermore, this research introduces a new hedonic Net Present Value based calculus of utilitarian ethics. © 2022 IGI Global. All rights reserved.

Surprising pandemic experiences: A confrontation between principle-based and virtue ethics, and a plea for virtue ethics training for medical students and residents. A rudimentary outline of a four-step model.

BACKGROUND: In past years, physicians have, with a certain continuity, reported increasing numbers of burnout, depression and compassion fatigue in their daily practice. These problems were attributed, not only but also, to a loss of public trust and an increase in violent behaviour of patients and family members towards medical professionals in all walks of life. Recently, however, during the breakout of the coronavirus disease 2019 (COVID-19) pandemic in 2020, there were public expressions of appreciation and respect for health care workers that almost universally have been assessed as indications of a re-establishment of public trust in physicians and appreciation for the medical professions' commitments. In other words, shared experiences of what society was in need of: the experience of a 'common good'. Those responses during the COVID-19 pandemic increased positive feelings among practicing physicians, such as commitment, solidarity, competency, and experiences concerning obligations for the common good and a sense of belonging to one and the same community for all. Essentially, these responses of raised self-awareness of commitment and solidarity between (potential) patients and medical personal point towards the social importance and power of these values and virtues. This shared domain in ethical sources of behaviour seems to hold a promise of overcoming gaps between the different spheres of doctors and patients. That promise justifies stressing the relevance of this shared domain of Virtue Ethics in the training of physicians. METHODS: In this article, therefore, we shall make a plea for the relevance of Virtue Ethics before proposing an outline of an educational programme for Virtue Ethics training for medical students and residents. Let us start by very briefly presenting on Aristotelian virtues and its relevance to modern medicine in general, and during the current pandemic in particular. RESULTS: We shall follow up this short presentation by a Virtue Ethics Training Model and the respective settings in which it takes place. This model has four steps as follows: (a) include moral character literacy in the formal curriculum; (b) provide ethics role modelling and informal training in moral character in the healthcare setting by senior staff; (c) create and apply regulatory guidelines regarding virtues and rules; and (d) assess success of training by evaluation of moral character of physicians. CONCLUSION: Applying the four-step model may contribute to strengthening the development of moral character in medical students and residents, and decrease the negative consequences of moral distress, burnout and compassion fatigue in health care personnel. In the future, this model should be empirically studied.

Moral distress among intensive care unit professions in the UK: a mixed-methods study.

OBJECTIVE: To assess the experience of moral distress among intensive care unit (ICU) professionals in the UK. DESIGN: Mixed methods: validated quantitative measure of moral distress followed by purposive sample of respondents who underwent semistructured interviews. SETTING: Four ICUs of varying sizes and specialty facilities. PARTICIPANTS: Healthcare professionals working in ICU. RESULTS: 227 questionnaires were returned and 15 interviews performed. Moral distress occurred across all ICUs and professional demographics. It was most commonly related to providing care perceived as futile or against the patient's wishes/interests, followed by resource constraints compromising care. Moral distress score was independently influenced by profession (p=0.02) (nurses 117.0 vs doctors 78.0). A lack of agency was central to moral distress and its negative experience could lead to withdrawal from engaging with patients/families. One-third indicated their intention to leave their current post due to moral distress and this was greater among nurses than doctors (37.0% vs 15.0%). Moral distress was independently associated with an intention to leave their current post (p<0.0001) and a previous post (p=0.001). Participants described a range of individualised coping strategies tailored to the situations faced. The most common and highly valued strategies were informal and relied on working within a supportive environment along with a close-knit team, although participants acknowledged there was a role for structured and formalised intervention. CONCLUSIONS: Moral distress is widespread among UK ICU professionals and can have an important negative impact on patient care, professional wellbeing and staff retention, a particularly concerning finding as this study was performed prior to the COVID-19 pandemic. Moral distress due to resource-related issues is more severe than comparable studies in North America. Interventions to support professionals should recognise the individualistic nature of coping with moral distress. The value of close-knit teams and supportive environments has implications for how intensive care services are organised.

Ethical considerations for epidemic vaccine trials

Vaccines are a powerful measure to protect the health of individuals and to combat outbreaks such as the COVID-19 pandemic. An ethical dilemma arises when one effective vaccine has been successfully developed against an epidemic disease and researchers seek to test the efficacy of another vaccine for the same pathogen in clinical trials involving human subjects. On the one hand, there are compelling reasons why it would be unethical to trial a novel vaccine when an effective product exists already. First, it is a firm principle of medical ethics that an effective treatment or vaccine should not be withheld from patients if their life may depend on it. Second, since epidemic outbreaks often emerge in settings with less-resourced health systems, there is a pronounced risk that any trial withholding an effective vaccine would disproportionately affect the vulnerable populations that historically have been exploited for biomedical research. Third, clinical trials for novel vaccines may be at odds with efforts to control active outbreaks. On the other hand, it may be justified to conduct a trial for a candidate vaccine if it is expected to have certain advantages compared with the existing product. This essay discusses key factors for comparing vaccines against epidemic pathogens, including immunological, logistical and economic considerations. Alongside a case study of the development of vaccines for Ebola, the essay seeks to establish a general framework that should be expanded and populated by immunologists, epidemiologists, economists and bioethicists, and ultimately could be applied to the case of COVID-19 vaccines.

A case of COVID-19 with pernio-like skin lesions and increased red blood cell distribution width

Heparin resistance has been observed in patients with active severe COVID-19 infection. The red blood cell distribution (RDW), a component of the complete blood count that reflects cellular volume variation, has been shown to be associated with elevated risk for morbidity and mortality in a wide range of diseases. Cutaneous manifestations, RDW, and levels of LD and D-dimer might be useful biomarkers in triage of patients with COVID-19.

Clinical Trials of Covid-19 Vaccines: Overcoming the Challenges

The COVID-19 pandemic has presented huge challenges to health care systems, the research community, and regulatory authorities worldwide. In recognition of the urgent need for safe and effective vaccines against this new coronavirus, the National Institutes of Health (NIH) worked with 5 manufacturers of promising vaccine candidates to mount the studies required to evaluate these vaccines and potentially support their deployment. The outcomes of the studies reported thus far have been far more successful than anyone would have imagined. In this session, perspectives on the issues raised in the COVID-19 vaccine development process under Operation Warp Speed will be shared by individuals playing a major role in the design, conduct, and analysis of these studies. We will hear from the lead company investigator of the Moderna trial, the first Operation Warp Speed trial to receive Emergency Use Authorization from the US Food and Drug Administration (FDA);from the NIH coordinator of the Data and Safety Monitoring Board (DSMB) convened to oversee all 5 trials;and from a member of that DSMB. SPEAKERS: Dr. Jacqueline Miller, Moderna, Inc., Lead company investigator for Moderna COVID-19 vaccine trial. Working title: Managing the evaluation of the data of a COVID-19 clinical trial: the manufacturer's perspective Dr. Sally Hunsberger, National Institute of Allergy & Infectious Diseases, NIH Coordinator of Data and Safety Monitoring Board for NIAO-sponsored trials of COVID-19 vaccines. Working title: Managing the evaluation of the data of a COVID-19 clinical trial: the NIH perspective Dr. Steven Joffe Department of Medical Ethics and Health Policy Perelman School of Medicine, University of Pennsylvania Member, NIAID COVID-19 vaccine trials Data and Safety Monitoring Board. Working title: Managing the evaluation of the data of a COVID- 19 clinical trial: a DSMB member's perspective.

Ethics in medicine: Challenges in the 21st century

The article provides an overview of important topics in contemporary medical ethics. Methodologically, it is a literature review. The article addresses only a limited selection of the problematic areas, which are, however, related to each other: digitisation of medicine, genome editing, personalised medicine as well as ethical problems and dilemmas of allocation in healthcare. The global COVID-19 pandemic has emerged as a focus and trigger. Reflections on human rights and justice in medicine are fundamental not only on the individual and social level but also on a global scale. The fundamental question is how society as a whole can be involved in the complex biopolitical and bioethical debate. The social and cultural consequences of life increasingly being understood as a technical product rather than a gift are serious. Contribution: The article also reflects on the specific contribution that Christian theology, and in particular the reformed heritage, can make to bioethical debates in modern society. The distinction between instrumental knowledge [ Verfügungswissen ] and orientational knowledge [ Orientierungswissen ] is helpful for its better understanding. A crucial result of this article is that medical treatment is repeatedly faced with ethical dilemmas. Moreover, medical progress not only creates new and better solutions to medical problems, it also raises new ethical questions that did not exist before. The purpose of medical ethics lies in identifying such dilemmas and developing ethical decision-making processes that help us to deal with such dilemmas to some extent.