Medical Ethics, Moral Courage, and the Embrace of Fallibility.

Experts have an obligation to make difficult decisions rather than offloading these decisions onto others who may be less well equipped to make them. This commentary considers this obligation through the lens of drafting critical care rationing protocols to address COVID-19-induced scarcity. The author recalls her own experience as a member of multiple groups charged with the generation of protocols for how hospitals and states should ration critical care resources like ventilators and intensive care unit beds, in the event that there would not be enough to go around as the COVID-19 pandemic intensified. She identifies several obvious lessons learned through this process, including the need to combat the pervasive effects of racism, ableism, and other forms of discrimination; to enhance the diversity, equity, and inclusion built into the process of drafting rationing protocols; and to embrace transparency, including acknowledging failings and fallibility. She also comes to a more complicated conclusion: Individuals in a position of authority, such as medical ethicists, have a moral obligation to embrace assertion, even when such assertions may well turn out to be wrong. She notes that when the decision-making process is grounded in legitimacy, medical ethics must have the moral courage to embrace fallibility.

Putting ethics and clinical decision making before politics: requiring COVID-19 immunization for Solid Organ Transplantation (SOT) Candidates and their Support Team.

We recommend that vaccination for COVID-19 should be a requirement for waitlist activation for solid organ transplant (SOT). We also recommend that such vaccination be required of the primary member of the in-home support team. We argue that these requirements are consistent with current standard practices that draw on a well-established ethical framework. As a result, these recommendations should be easily received and are only controversial owing to the inflamed and politicized state of public discourse.

Treatment outcomes in patients with laryngotracheal lesions and compromised airway during and prior to the coronovirus disease 2019 pandemic: a tertiary institution's experience.

OBJECTIVE: This study aimed to compare treatment outcomes in patients with laryngeal and tracheal stenosis treated during and prior to the coronavirus disease 2019 pandemic period. METHOD: Patients treated for laryngotracheal lesions with impending airway compromise during the active pandemic period were matched with those treated for similar lesions in the preceding years in a monocentric tertiary hospital setting. RESULTS: During the pandemic period of 55 days, 31 patients underwent 47 procedures. Seven patients (2 children, 5 adults) had open airway surgery, and one had an operation-specific complication. Twenty-four patients (10 children, 14 adults) underwent 40 endoscopic interventions without any complications. Operation specific results during and prior to the pandemic were comparable. CONCLUSION: The management strategy in patients with laryngotracheal lesions and impending airway compromise should not be altered during periods of risk from coronavirus disease 2019. Avoiding a tracheostomy by performing primary corrective surgery or proceeding with a definitive decannulation would be beneficial in these patients to reduce the risk of contagion.

Machine Learning: The Next Paradigm Shift in Medical Education.

Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.

Ethical Considerations in Chemotherapy and Vaccines in Cancer Patients in Times of the COVID-19 Pandemic.

The COVID-19 situation is a worldwide health emergency with strong implications in clinical oncology. In this viewpoint, we address two crucial dilemmas from the ethical dimension: (1) Is it ethical to postpone or suspend cancer treatments which offer a statistically significant benefit in quality of life and survival in cancer patients during this time of pandemic?; (2) Should we vaccinate cancer patients against COVID-19 if scientific studies have not included this subgroup of patients? Regarding the first question, the best available evidence applied to the ethical principles of Beauchamp and Childress shows that treatments (such as chemotherapy) with clinical benefit are fair and beneficial. Indeed, the suspension or delay of such treatments should be considered malefic. Regarding the second question, applying the doctrine of double-effect, we show that the potential beneficial effect of vaccines in the population with cancer (or those one that has had cancer) is much higher than the potential adverse effects of these vaccines. In addition, there is no better and less harmful known solution.

No body is expendable: Medical rationing and disability justice during the COVID-19 pandemic.

The health threat posed by the novel coronavirus that caused the COVID-19 pandemic has particular implications for people with disabilities, including vulnerability to exposure and complications, and concerns about the role of ableism in access to treatment and medical rationing decisions. Shortages of necessary medical equipment to treat COVID-19 have prompted triage guidelines outlining the ways in which lifesaving equipment, such as mechanical ventilators and intensive care unit beds, may need to be rationed among affected individuals. In this article, we explore the realities of medical rationing, and various approaches to triage and prioritization. We discuss the psychology of ableism, perceptions about quality of life, social determinants of health, and how attitudes toward disability can affect rationing decisions and access to care. In addition to the grassroots advocacy and activism undertaken by the disability community, psychology is rich in its contributions to the role of attitudes, prejudice, and discriminatory behavior on the social fabric of society. We call on psychologists to advocate for social justice in pandemic preparedness, promote disability justice in health care settings, call for transparency and accountability in rationing approaches, and support policy changes for macro- and microallocation strategies to proactively reduce the need for rationing. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Ethical dilemmas in COVID-19 times: how to decide who lives and who dies?

The respiratory disease caused by the coronavirus SARS-CoV-2 (COVID-19) is a pandemic that produces a large number of simultaneous patients with severe symptoms and in need of special hospital care, overloading the infrastructure of health services. All of these demands generate the need to ration equipment and interventions. Faced with this imbalance, how, when, and who decides, there is the impact of the stressful systems of professionals who are at the front line of care and, in the background, issues inherent to human subjectivity. Along this path, the idea of using artificial intelligence algorithms to replace health professionals in the decision-making process also arises. In this context, there is the ethical question of how to manage the demands produced by the pandemic. The objective of this work is to reflect, from the point of view of medical ethics, on the basic principles of the choices made by the health teams, during the COVID-19 pandemic, whose resources are scarce and decisions cause anguish and restlessness. The ethical values for the rationing of health resources in an epidemic must converge to some proposals based on fundamental values such as maximizing the benefits produced by scarce resources, treating people equally, promoting and recommending instrumental values, giving priority to critical situations. Naturally, different judgments will occur in different circumstances, but transparency is essential to ensure public trust. In this way, it is possible to develop prioritization guidelines using well-defined values and ethical recommendations to achieve fair resource allocation.

Ethics of kidney care in the era of COVID-19.

The coronavirus disease 2019 pandemic presents significant challenges for health systems globally, including substantive ethical dilemmas that may pose specific concerns in the context of care for people with kidney disease. Ethical concerns may arise as changes in policy and practice affect the ability of all health professionals to fulfill their ethical duties toward their patients in providing best practice care. In this article, we briefly describe such concerns and elaborate on issues of particular ethical complexity in kidney care: equitable access to dialysis during pandemic surges; balancing the risks and benefits of different kidney failure treatments, specifically with regard to suspending kidney transplantation programs and prioritizing home dialysis, and barriers to shared decision-making; and ensuring ethical practice when using unproven interventions. We present preliminary advice on how to approach these issues and recommend urgent efforts to develop resources that will support health professionals and patients in managing them.

Re-thinking patient stability for methadone in opioid treatment programs during a global pandemic: Provider perspectives.

COVID-19 necessitated rapid changes in methadone take-home policies in opioid treatment programs (OTPs); these changes markedly contrast with existing, long-standing federal mandates on OTP rules about take-home methadone. OTP providers describe how these changes have affected clinical decision-making, equity in patient care, and workflow. We also discuss implications for medical ethics and patient autonomy. We provide suggestions for future research that will examine the impact of COVID-19 on OTP treatment and its patients, as well as the effect of making methadone take-home polices patient centered, all of which may foreshadow larger changes in the ways OTPs deliver their services.

COVID 19: prioritise autonomy, beneficence and conversations before score-based triage.

At the start of the COVID-19 pandemic, mounting demand overwhelmed critical care surge capacities, triggering implementation of triage protocols to determine ventilator allocation. Relying on triage scores to ration care, while relieving clinicians from making morally distressing decisions under high situational pressure, distracts clinicians from what is essentially deeply humanistic issues entrenched in this protracted public health crisis. Such an approach will become increasingly untenable as countries flatten their epidemic curves. Decisions regarding intensive care unit admission are particularly challenging in older people, who are most likely to require critical care, but for whom benefits are most uncertain. Before applying score-based triage, physicians must first discern if older people will benefit from critical care (beneficence) and second, if he wants critical care (autonomy). When deliberating beneficence, physicians should steer away from solely using age-stratified survival probabilities from epidemiological data. Instead, decisions must be based on individualised risk-stratification that encompasses evidence-based predictors of adverse outcomes specific to older adults. Survival will also need to be weighed against burden of treatment, as well as longer term functional deficits and quality-of-life. By identifying the robust older people who may benefit from critical care, clinicians should proceed to elicit his values and preferences that would determine the treatment most aligned with his best interest. During these dialogues, physicians must truthfully convey the emergent clinical reality, discern the older person's therapeutic goals and discuss the feasibility of achieving them. Given that COVID-19 is here to stay, these conversations aimed at achieving goal-cordant care must become a new clinical norm.

Defining clinical decision making in the provision of audio-visual outpatient care for acute upper limb trauma services: A review of practice.

The Covid-19 pandemic has accelerated the widespread adoption of technology-enabled care in the NHS.1 Moving into phase two of the response, the continuing use of audio-visual technology is expected, where appropriate, to be integral in the provision of safe, quality patient care.2 A clinical need therefore exists to identify when care can be safely delivered remotely using audio-visual technology and when there is a need for in-person contact.  At Salisbury Foundation Trust (SFT), during phase one of the NHS response to Covid-19, the decision to treat upper limb trauma patients in-person or remotely was made using clinical screening criteria. For many patients, audio-visual appointments offered a practical, time efficient way of accessing their reconstructive team for assessment, advice and post-operative care. However, a subset of patients was identified by the team as requiring at least one in-person consultation to minimize perceived clinical risk and to optimize quality outcomes.  In order to understand more fully the challenges and successes of technology-enabled care to date, a national survey of practice across hand units in the UK was conducted. We present here some of our key findings and propose the need to develop nationally agreed screening criteria to determine how and when technology enabled outpatient care can be used in the management of acute upper limb trauma. The results of this survey forms part of a series of projects currently underway looking at the efficacy of audio-visual care in upper limb trauma, including a multicentre observational study.