Relational ethical approaches to the COVID-19 pandemic.

Key ethical challenges for healthcare workers arising from the COVID-19 pandemic are identified: isolation and social distancing, duty of care and fair access to treatment. The paper argues for a relational approach to ethics which includes solidarity, relational autonomy, duty, equity, trust and reciprocity as core values. The needs of the poor and socially disadvantaged are highlighted. Relational autonomy and solidarity are explored in relation to isolation and social distancing. Reciprocity is discussed with reference to healthcare workers' duty of care and its limits. Priority setting and access to treatment raise ethical issues of utility and equity. Difficult ethical dilemmas around triage, do not resuscitate decisions, and withholding and withdrawing treatment are discussed in the light of recently published guidelines. The paper concludes with the hope for a wider discussion of relational ethics and a glimpse of a future after the pandemic has subsided.

Ought Conscientious Refusals to Implement Reverse Triage Decisions be Accommodated?

Although one can argue that they do not represent a radical departure from existing practices, protocols for reverse triage certainly step beyond what is ordinarily done in medicine and healthcare. Nevertheless, there seems to be some degree of moral concern regarding the ethical legitimacy of practicing reverse triage in the context of a pandemic. Such concern can be taken as a reflection of the moral antipathy some exhibit towards current practices of withdrawing treatment-that is, when withdrawal of treatment is arguably in the best interests of patients-and a rejection of the purported normative insignificance of withholding and withdrawing. Given that the relevance of the psychological attitudes of some healthcare professionals to the moral assessment of withdrawing and withholding treatment continues to be debated, it would seem that some thought should be given to the introduction and implementation of reverse triage decisions in response to a pandemic. This brief paper will consider if provision should be made for healthcare professionals to conscientiously refuse to participate in reverse triage.

Saving the most lives-A comparison of European triage guidelines in the context of the COVID-19 pandemic.

In March 2020, the rapid increase in severe COVID-19 cases overwhelmed the healthcare systems in several European countries. The capacities for artificial ventilation in intensive care units were too scarce to care for patients with acute respiratory disorder connected to the disease. Several professional associations published COVID-19 triage recommendations in an extremely short time: in 21 days between March 6 and March 27. In this article, we compare recommendations from five European countries, which combine medical and ethical reflections on this situation in some detail. Our aim is to provide a detailed overview on the ethical elements of the recommendations, the differences between them and their coherence. In more general terms we want to identify shortcomings in regard to a common European response to the current situation.

Withdrawing critical care from patients in a triage situation.

The advent of COVID-19 has been the occasion for a renewed interest in the principles governing triage when the number of critically ill patients exceeds the healthcare infrastructure's capacity in a given location. Some scholars advocate that it would be morally acceptable in a crisis to withdraw resources like life support and ICU beds from one patient in favor of another, if, in the judgment of medical personnel, the other patient has a significantly better prognosis. The paper examines the arguments for and against this approach from the point of view of natural law theory, especially using the principle of double effect. We conclude that it is inadmissible to withdraw life-saving medical interventions from patients who are still benefiting from them, on the sole grounds that other patients might benefit more. Those who are currently using such technology should only interrupt their treatment if, in the judgment of medical personnel and, if possible, taking into account the wishes and needs of the patient and his family, the treatment is deemed futile, burdensome, or disproportionate.

Withdrawal of intensive care during times of severe scarcity: Triage during a pandemic only upon arrival or with the inclusion of patients who are already under treatment?

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID-19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time-limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care.

Who Gets Scarce Medical Resources during a COVID-19 Pandemic? Let's not beat about the Bush.

Except for such rare situations where it might be determined absence of physician's imputability, physicians cannot ̳save the most lives while respecting the legal rights of the patient' without violating the overarching principle ̳every human life has equal value'. Arguing to the contrary is a conscious hypocritical attitude, or in other words, a fiction. Medical law and ethics long since carry with its various fictions. Furthermore, in a public health emergency such as the current COVID-19 crisis, medical law and ethics change and shift the focus from the patient-centered model towards the public health-centered model. Under these particular circumstances, this fiction becomes striking, and it can no longer be swept under the rug. As health emergencies can happen anywhere, anytime, the patient prioritization in circumstances of limited resources should be accepted. Medical law and ethics should back away from strict commitment to placing paramount emphasis on the value of human life. It is time for medical law and ethics to leave taboo-related hypocritical attitudes, and venture to make a historic compromise. To do so, three principles should be met: subsidiarity, proportionality, and consensus and social proof.

Allocating medical resources fairly:the CSG bioethics guide.

On April 12, 2020, a bioethics guide for allocating scarce hospital resources during the current Covid-19 pandemic was posted on the website of the Consejo de Salubridad General(CSG) of the Government of Mexico. The guide, entitled Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia, was intended as a preliminary document, but the website posting did not describe it as a first step in the process. The publicity resulted in a wide array of comments and criticisms. That first version posted on the CSG website contained an age-based criterion for breaking a tie between two or more medically eligible patients who needed of a ventilator: younger patients would have prefer-ence over older ones. The final version of the guide eliminated that criterion and instead, relied on the leading public health principle, "save the most lives", without regard to personal characteristics other than the possibility of benefitting from the scarce medical resources.

El 12 de abril de 2020, se publicó en el sitio web del Consejo de Salubridad General (CSG) del Gobierno de México una guía de bioética para asignar recursos hospitalarios escasos durante la actual pandemia de Covid-19. La guía titulada Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia pretendía ser un documento pre-liminar, pero la publicación en el sitio web no lo describió como un primer paso en el proceso. La publicación resultó en una amplia gama de comentarios y críticas. La primera versión publicada en el sitio web del CSG contenía un cri-terio basado en la edad para romper el empate entre dos o más pacientes médicamente elegibles que necesitaran un ventilador: los pacientes más jóvenes tendrían preferencia sobre los de mayor edad. La versión final de la guía eliminó ese criterio y, en cambio, se basó en el principio principal de salud pública, "salvar la mayoría de las vidas", sin tener en cuenta las características personales que no sean la posibilidad de beneficiarse de los escasos recursos médicos.

[Bioethics guide on scarce medical resource allocation in Mexico]. / Guía bioética de asignación de recursos de medicina crítica del Consejo de Salubridad General en México.

The bioethical inquiry about allocating fairly scarce health resources is not new, all countries around the world that were seriously afflicted by SARS-CoV-2 have issued triage guidelines in order to address the dilemmas raised by the pandemic. There is no question about the need to create bioethical guidelines, since its creation provides a degree of certainty that fair and ethical decisions are taken. This also prevents that decisions are made in solitary and maybe motivated by corrupted actions. In Mexico, the creation of this guideline was a proactive and preventive measure to what was unavoidable, the exponential contagion phase of the pandemical scenario caused by Covid-19. On April 30, 2020 the General Sanitary Council published the Bioethical Guide to Allocate Scarce Resources on Critical Care Medicine in Emergency Situation. This guide has at its core that principle of utmost importance in social justice which main thesis is: "All lives have the same value". The aim of this contribution is to provide the ethical and legal principles established in the aforementioned bioethi-cal guideline. In sum, a brief exploration of the ethical reasons that support a specific way to allocate scarce health resources is provided, as well as the foundations of the procedural part from a human rights-based approach.

El tema bioético sobre la asignación de recursos escasos no es nuevo, todos los países que han sido gravemente afectados por el SARS-CoV-2 han tenido que desarrollar y utilizar guías de triaje. Esto resulta más adecuado pues así la asignación de recursos limitados se hace de manera ética y justa, y no de manera discrecional y abierta a la corrupción. En México, en anticipación a la fase exponencial de la pandemia por SARS-CoV-2, el 30 de abril el Consejo de Salubridad General publicó la Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia. Dicha guía tiene como base criterios de justicia social y parte de la tesis: todas las vidas tienen el mismo valor. Este texto tiene como objetivo propor-cionar las razones bioéticas y biojurídicas que conforman esta guía de triaje en nuestro país. En resumen, proporciona una breve exploración de las razones éticas que justifican cierta manera específica de asignar recursos escasos en medicina crítica, así como del sustento procedimental apegado a los estándares en materia de derechos humanos.

Ethical dilemmas in clinical care during COVID-19 pandemic.

In a short span of a few weeks, the COVID-19 pandemic has affected the entire world like no other event in modern history. Healthcare institutions and providers have been at the forefront of containing the ravages of this disease, and are experiencing unprecedented challenges. Medical decision making has become all the more complex because of the moral weight of difficult decisions that need to be made. This paper discusses three areas where ethical decision making is extremely important: dealing with those patients with COVID-19 who no longer have access to their doctors; following ethical criteria for assigning risky duties to healthcare professionals; and in making life and death decisions while allocating scarce resources. This paper describes a national level guidance document for the COVID-19 pandemic that is designed to facilitate ethical decision-making.

"We're Not Ready, But I Don't Think You're Ever Ready." Clinician Perspectives on Implementation of Crisis Standards of Care.

Background: The COVID-19 pandemic has highlighted health care systems' vulnerabilities. Hospitals face increasing risk of periods of scarcity of life-sustaining resources such as ventilators for mechanical respiratory support, as has been the case in Italy as of March, 2020. The National Academy of Medicine has provided guidance on crisis standards of care, which call for the reallocation of scarce medical resources to those who will benefit most during extreme situations. Given that this will require a departure from the usual fiduciary duty of the bedside clinician, we determined and mapped potential barriers to the implementation of the guidelines from stakeholders using an implementation science framework. Methods: A protocol was created to operationalize national and state guidelines for triaging ventilators during crisis conditions. Focus groups and key informant interviews were conducted from July-September 2018 with clinicians at three acute care hospitals of an urban academic medical center. Respiratory therapists, intensivists, nursing leadership and the palliative care interdisciplinary team participated in focus groups. Key informant interviews were conducted with emergency management, respiratory therapy and emergency medicine. Subjects were presented the protocol and their reflections were elicited using a semi-structured interview guide. Data from transcripts and notes were categorized using a coding strategy based on the Theoretical Domains Framework. Results: Participants anticipated that implementing this protocol would challenge their roles and identities as clinicians including both their fiduciary duty to the patient and their decision-making autonomy. Despite this, many participants acknowledged the need for such a protocol to standardize care and minimize bias as well as to mitigate potential consequences for individual clinicians. Participants identified the question of considering patient quality of life in triage decisions as an important and unresolved ethical issue in disaster triage. Conclusion: Clinicians' discomfort with shifting roles and obligations could pose implementation barriers for crisis standards of care.

The BMA COVID-19 ethical guidance: a legal analysis.

The paper considers the recently published British Medical Association Guidance on ethical issues arising in relation to rationing of treatment during the COVID-19 Pandemic. It considers whether it is lawful to create policies for the rationing and withdrawal of treatment, and goes on to consider how such policies might apply in practice. Legal analysis is undertaken of certain aspects of the Guidance which appear to misunderstand the law in respect of withdrawing treatment.