The harm principle, personal identity and identity-relative paternalism.

Is it ethical for doctors or courts to prevent patients from making choices that will cause significant harm to themselves in the future? According to an important liberal principle the only justification for infringing the liberty of an individual is to prevent harm to others; harm to the self does not suffice.In this paper, I explore Derek Parfit's arguments that blur the sharp line between harm to self and others. I analyse cases of treatment refusal by capacitous patients and describe different forms of paternalism arising from a reductionist view of personal identity. I outline an Identity Relative Paternalistic Intervention Principle for determining when we should disallow refusal of treatment where the harm will be accrued by a future self, and consider objections including vagueness and non-identity.Identity relative paternalism does not always justify intervention to prevent harm to future selves. However, there is a stronger ethical case for doing so than is often recognised.

Home-Based Care Provider Perspectives on Care Refusal During the COVID-19 Pandemic.

Acute and chronic disease management continues to shift toward a health care in the home model, yet literature discussing continuity of home-based care services during public health emergencies, such as infectious disease pandemics, is scant. In the current study, we used semi-structured telephone interviews with 27 home-based care providers (HBCPs) from Medicare-certified home health care agencies located in eight U.S. counties to explore older adults' decision making around home-based care service continuation during the coronavirus disease 2019 (COVID-19) pandemic. Four themes emerged, including two related to older adults' decision making around refusal of in-home care and two related to HBCPs' responses to care refusals. Fear of COVID-19 infection motivated older adults to make care-related decisions that were incongruent with their health needs, including refusal of care in the home, despite receiving education from HBCPs. These data highlight a need for tools to help HBCPs better support patients through decision-making processes about care continuation during COVID-19 and future infectious disease pandemics. [Journal of Gerontological Nursing, 49(1), 35-41.].

Medical avoidance among marginalized groups: the impact of the COVID-19 pandemic.

Medical avoidance is common among U.S. adults, and may be emphasized among members of marginalized communities due to discrimination concerns. In the current study, we investigated whether this disparity in avoidance was maintained or exacerbated during the onset of the COVID-19 pandemic. We assessed the likelihood of avoiding medical care due to general-, discrimination-, and COVID-19-related concerns in an online sample (N = 471). As hypothesized, marginalized groups (i.e., non-White race, Latinx/e ethnicity, non-heterosexual sexual orientation, high BMI) endorsed more general- and discrimination-related medical avoidance than majoritized groups. However, marginalized groups were equally likely to seek COVID-19 treatment as majoritized groups. Implications for reducing medical avoidance among marginalized groups are discussed.

COVID-19 vaccine mandates: what are the current European public perspectives?

The article aims to elaborate on European policy choices for the prevention of SARS­CoV­2 contagion, with a close focus on the rules and regulations enacted in Italy so far. European states have ruled out generalized vaccination mandates but have so far preferred to exert a form of "moral suasion", through the introduction of a digital certificate which can only be granted to those who are vaccinated, cured of COVID-19 or tested negative through an antigen test in the previous 48 hours. Italy has applied this tool, dubbed "Green Pass", very rigorously: many daily activities, including going to work, are only allowed for those who have the certificate. A one-year Green Pass is issued after vaccination, although data show that vaccine protection may subside gradually over about six months; the cost of the antigen tests every 48 hours is to be borne by the patient. Testing the unvaccinated is essential to contain the spread of the infection, but it would have been more logical to mandate that all the unvaccinated undergo regular testing (for example every ten days), instead of imposing a test every 48 hours only to be allowed to engage in some activities. The authors stress that in order to minimize the risk of future possible pandemics, prevention strategies are needed, and poor countries need to be enabled to vaccinate their populations in order to prevent new variants from developing. The pledges made by world leaders in that regard during the recent G20 summit must therefore be honored, for the sake of global health that never in our lifetime has been so threatened.

[Steinert's disease and refusal to treatment]. / Enfermedad de Steinert y rechazo de la actuación médica.

TITLE: Enfermedad de Steinert y rechazo de la actuación médica.

Assessment of Communication Strategies for Mitigating COVID-19 Vaccine-Specific Hesitancy in Canada.

Importance: Ensuring widespread uptake of available COVID-19 vaccinations, each with different safety and efficacy profiles, is essential to combating the unfolding pandemic. Objective: To test communication interventions that may encourage the uptake of less-preferred vaccines. Design, Setting, and Participants: This online survey was conducted from March 24 to 30, 2021, using a nonprobability convenience sample of Canadian citizens aged 18 years or older, with quota sampling to match 2016 Canadian Census benchmarks on age, gender, region, and language. Respondents completed a 2-by-2-by-2 factorial experiment with random assignment of brand (AstraZeneca or Johnson & Johnson), information about the vaccine's effectiveness against symptomatic infection (yes or no), and information about the vaccine's effectiveness at preventing death from COVID-19 (yes or no) before being asked about their willingness to receive their assigned vaccine and their beliefs about its effectiveness. Exposures: Respondents were randomly assigned a vaccine brand (AstraZeneca or Johnson & Johnson) and information about the vaccine's effectiveness against symptomatic COVID-19 infection (yes or no) and at preventing death from COVID-19 (yes or no). Main Outcomes and Measures: Respondents' self-reported likelihood of taking their assigned vaccine if offered (response categories: very likely, somewhat likely, not very likely, or not at all likely, scaled 0-1) and their beliefs about their assigned vaccine's effectiveness (response categories: very effective, somewhat effective, not very effective, or not at all effective, scaled 0-1) were measured. Results: A total of 2556 Canadian adults responded to the survey (median [IQR] age, 50 [34-63] years; 1339 women [52%]). The self-reported likelihood of taking an assigned AstraZeneca or Johnson & Johnson vaccine was higher for respondents given information about their assigned vaccine's effectiveness at preventing death from COVID-19 (b, 0.04; 95% CI, 0.01 to 0.06) and lower among those given information about its overall effectiveness at preventing symptomatic transmission (b, -0.03; 95% CI, -0.05 to 0.00), compared with those who were not given the information. Perceived effectiveness was also higher among those given information about their assigned vaccine's effectiveness at preventing death from COVID-19 (b, 0.03; 95% CI, 0.01 to 0.05) and lower among those given information about their assigned vaccine's overall efficacy at preventing symptomatic infection (b, -0.05; 95% CI, -0.08 to -0.03), compared with those who were not given this information. The interaction between these treatments was neither substantively nor statistically significant. Conclusions and Relevance: These findings suggest that providing information on the effectiveness of less-preferred vaccines at preventing death from COVID-19 is associated with more confidence in their effectiveness and less vaccine-specific hesitancy. These results can inform public health communication strategies to reduce hesitancy toward specific COVID-19 vaccines.

A cross-sectional questionnaire study in a phototherapy unit during COVID-19.

BACKGROUND: In March 2020, social isolation measures were imposed in Brazil to contain the spread of the novel coronavirus (SARS-CoV-2), requiring health services to implement contingency plans. The main objective of the study was to verify the status of the disease, self-reported by patients who discontinued phototherapy, during a period of social isolation. METHODS: All patients receiving phototherapy at the Santa Casa de Porto Alegre, Brazil, prior to the implementation of social distancing measures were eligible for inclusion in the study. 86 patients answered a questionnaire during a medical evaluation. RESULTS: 95% of patients who stopped phototherapy reported a worsening of disease status. Only 19% of patients continued to attend phototherapy sessions during the social isolation period. CONCLUSION: The COVID-19 pandemic led most patients to stop phototherapy, resulting in the perception of increased disease severity in an outpatient sample in southern Brazil.

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic.

Importance: Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. Objective: To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. Design, Setting, and Participants: A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. Exposures: A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Main Outcomes and Measures: Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. Results: A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir). Conclusions and Relevance: In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

Respect for individual autonomy and a collective benefit: Arguments in favor of compulsory SARS-CoV-2 vaccination among health care professionals. / Respeto por la autonomía individual y el beneficio colectivo: argumentación a favor de la vacunación obligatoria contra el SARS-CoV-2 para el personal de la salud.

With the development of SARS-CoV-2 vaccines, a new aspect to be taken into consideration in the midst of the pandemic is vaccine refusal. Since vaccination is voluntary, it is necessary to deal with the fact that some health care team members refuse to receive it. Here I put forward different bioethical arguments: Kantian deontology and the principles of universalizability, humanity, and autonomy; Mill's utilitarianism, with selfprotection as the sole end for which humankind is authorized to interfere with its members' freedom of action; Beauchamp and Childress' principlism and the concepts of beneficence and autonomy; Varo Baena's principle of opportunity; and the principle of solidarity resulting from the ethics of human rights. The contributions of contemporary philosophers like Roberto Espósito, Jean-Luc Nancy, and Alberto Giubilini are also included. Two counterarguments are presented: nonmaleficence and counter-production. Lastly, I suggest that, since common good (in this case, public health) is the intimate and final determining factor of individual freedom and is the same for all, it is above any individual benefit.

Con la llegada de las vacunas contra el SARSCoV- 2, un nuevo aspecto a tener en cuenta en la pandemia es el rechazo a la vacunación. Como la recepción de la vacuna, es voluntaria, se plantea cómo abordar la situación de los miembros del equipo de salud que la rechazan. Se exponen argumentos bioéticos de diversas corrientes: el deontologismo kantiano y lo conceptos de universalidad, humanidad y autonomía; el utilitarismo de Mill, con la autoprotección como único fin por el cual la humanidad está habilitada para interferir con la libertad de acción de sus miembros; el principismo de Beauchamp y Childress y los conceptos de beneficencia y autonomía; el principio de oportunidad de Varo Baena; y el principio de solidaridad, derivado de la ética de los derechos humanos. Se incluyen aportes de filósofos contemporáneos como Roberto Espósito, Jean-Luc Nancy y Alberto Giubilini. Se exponen dos contrargumentos: el de no maleficencia y el de contraproducencia. Por último, se plantea que, dado que el bien común (la salud pública, en este caso) es el determinante íntimo y último de la libertad individual e igual para todos, está por encima del beneficio individual.