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4.
J Med Ethics ; 46(8): 505-507, 2020 08.
Article in English | MEDLINE | ID: covidwho-1467731

ABSTRACT

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients' outcome within the constraints of pandemic management and its long-term outlook.


Subject(s)
Coronavirus Infections/complications , Decision Making/ethics , Ethics, Medical , General Surgery/ethics , Health Equity/ethics , Pandemics/ethics , Patient Selection/ethics , Pneumonia, Viral/complications , Betacoronavirus , COVID-19 , Coronavirus Infections/virology , Cost-Benefit Analysis , England , Ethical Analysis , Ethical Theory , Humans , Informed Consent/ethics , Moral Obligations , Pneumonia, Viral/virology , Practice Guidelines as Topic , Principle-Based Ethics , Risk Assessment , SARS-CoV-2 , State Medicine , Surgeons , Surgical Procedures, Operative
5.
J Med Ethics ; 46(8): 495-498, 2020 08.
Article in English | MEDLINE | ID: covidwho-1467727

ABSTRACT

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.


Subject(s)
Decision Making/ethics , Ethics, Clinical , Health Care Rationing/ethics , Health Equity/ethics , Health Personnel/ethics , Pandemics/ethics , Betacoronavirus , COVID-19 , Coronavirus Infections/virology , Disaster Planning , Humans , Moral Obligations , Pneumonia, Viral/virology , Poverty , Practice Guidelines as Topic , Professional-Patient Relations , Resuscitation Orders , SARS-CoV-2 , Social Values , Triage/ethics , Vulnerable Populations , Withholding Treatment/ethics
6.
J Med Ethics ; 46(8): 514-525, 2020 08.
Article in English | MEDLINE | ID: covidwho-1467726

ABSTRACT

BACKGROUND: Humanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care-a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, the WHO released a guide on 'Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises'-the first guidance on the topic by an international body. AIMS: This paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances. IMPLICATIONS: In parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance.


Subject(s)
Bioethical Issues , Delivery of Health Care/ethics , Disaster Planning , Palliative Care/ethics , Pandemics/ethics , Terminal Care/ethics , Altruism , Betacoronavirus , Bioethics , COVID-19 , Coronavirus Infections/therapy , Coronavirus Infections/virology , Critical Care , Decision Making/ethics , Emergencies , Ethics, Clinical , Global Health , Health Care Rationing , Health Equity , Health Resources , Humans , Pneumonia, Viral/therapy , Pneumonia, Viral/virology , Practice Guidelines as Topic , SARS-CoV-2 , Socioeconomic Factors , Stress, Psychological
8.
Nurs Stand ; 36(11): 40-44, 2021 11 03.
Article in English | MEDLINE | ID: covidwho-1320628

ABSTRACT

Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs. The concept of moral injury has its origins in the context of military personnel encountering ethically challenging decisions during armed conflict. The term has been applied to healthcare and moral injury is increasingly acknowledged to be a challenge for healthcare professionals. Nurses across all specialties and settings are frequently required to make or witness ethically challenging decisions about patient care. The coronavirus disease 2019 (COVID-19) pandemic has increased nurses' risk of sustaining moral injury. This article discusses the manifestations of moral injury and its associated risk factors, including the effects of the COVID-19 pandemic. It also outlines various strategies that can be used to mitigate and/or prevent moral injury in nurses.


Subject(s)
Burnout, Professional/psychology , COVID-19/psychology , Decision Making/ethics , Nurses/psychology , Patient Care/ethics , Resilience, Psychological , Stress Disorders, Post-Traumatic/psychology , Burnout, Professional/prevention & control , COVID-19/epidemiology , Humans , Occupational Health , Pandemics , SARS-CoV-2 , Shame , Workforce
10.
Semin Nephrol ; 41(3): 262-271, 2021 05.
Article in English | MEDLINE | ID: covidwho-1275709

ABSTRACT

When providing care, nephrologists are subject to various ethical duties. Beyond the Hippocratic notion of doing no harm, nephrologists also have duties to respect their patients' autonomy and dignity, to meet their patients' care goals in the least invasive way, to act impartially, and, ultimately, to do what is (clinically) beneficial for their patients. Juggling these often-conflicting duties can be challenging at the best of times, but can prove especially difficult when patients are not fully adherent to treatment. When a patient's nonadherence begins to cause harm to themselves and/or others, it may be questioned whether discontinuation of care is appropriate. We discuss how nephrologists can meet their ethical duties when faced with nonadherence in patients undergoing hemodialysis, including episodic extreme agitation, poor renal diet, missed hemodialysis sessions, and emergency presentations brought on by nonadherence. Furthermore, we consider the impact of cognitive impairment and provider-family conflict when making care decisions in a nonadherence context, as well as how the coronavirus disease 2019 pandemic might affect responses to nonadherence. Suggestions are provided for ethically informed responses, prioritizing a patient-narrative approach that is attentive to patients' values and preferences, multidisciplinarity, and the use of behavioral contracts and/or technology where appropriate.


Subject(s)
Nephrologists/ethics , Patient Compliance , Renal Dialysis/ethics , Adult , Aged , Decision Making/ethics , Female , Humans , Male , Patient-Centered Care , Personal Autonomy
11.
J Infect Dev Ctries ; 15(5): 615-617, 2021 05 31.
Article in English | MEDLINE | ID: covidwho-1262627

ABSTRACT

The nature of moral judgment is not only of longstanding philosophical interest, but also it is a matter of immediate practical concern. Currently, when the information, the advice, even the science and the sequela of the pandemic COVID-19 are all consistently and rapidly changing, it creates inconsistency in our decision making. Nevertheless, we lack of a detailed scientific understanding of how people make moral decisions. The letter is an effort aimed at understanding moral decision-making during the present pandemic of COVID-19.


Subject(s)
COVID-19/psychology , Decision Making/ethics , Retrospective Moral Judgment , COVID-19/epidemiology , Humans , Pandemics , Public Health/standards , SARS-CoV-2 , Saudi Arabia
12.
Acad Med ; 96(6): 798-801, 2021 06 01.
Article in English | MEDLINE | ID: covidwho-1243531

ABSTRACT

The glaring racial inequities in the impact of the COVID-19 pandemic and the devastating loss of Black lives at the hands of police and racist vigilantes have catalyzed a global reckoning about deeply rooted systemic racism in society. Many medical training institutions in the United States have participated in this discourse by denouncing racism, expressing solidarity with people of color, and reexamining their diversity and inclusion efforts. Yet, the stagnant progress in recruiting, retaining, and supporting racial/ethnic minority trainees and faculty at medical training institutions is well documented and reflects unaddressed systemic racism along the academic pipeline. In this article, the authors draw upon their experiences as early-career physicians of color who have led and supported antiracism efforts within their institutions to highlight key barriers to achieving meaningful progress. They describe common pitfalls of diversity and inclusion initiatives and call for an antiracist approach to systems change. The authors then offer 9 recommendations that medical training institutions can implement to critically examine and address racist structures within their organizations to actualize racial equity and justice.


Subject(s)
African Americans/psychology , COVID-19/psychology , Preceptorship/methods , Racism/prevention & control , African Americans/ethnology , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/virology , Cultural Diversity , Decision Making/ethics , Humans , Minority Groups/psychology , Preceptorship/statistics & numerical data , SARS-CoV-2/isolation & purification , Social Inclusion , Social Justice , United States/ethnology
14.
BMC Med Ethics ; 22(1): 28, 2021 03 22.
Article in English | MEDLINE | ID: covidwho-1147083

ABSTRACT

BACKGROUND: The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. DISCUSSION: Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. CONCLUSION: We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.


Subject(s)
COVID-19 , Critical Care/ethics , Decision Making/ethics , Health Care Rationing/ethics , Intensive Care Units , Pandemics , Triage/methods , Cooperative Behavior , Emotions , Ethics, Medical , Health Resources , Humans , Medical Futility , Prognosis , SARS-CoV-2 , South Africa , Triage/ethics
15.
J Med Ethics ; 47(2): 108-112, 2021 02.
Article in English | MEDLINE | ID: covidwho-985734

ABSTRACT

One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer's complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium-a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al's investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives.


Subject(s)
Decision Making/ethics , Ethics, Clinical , Health Care Rationing/ethics , Health Equity/ethics , Social Justice , Triage/ethics , Delivery of Health Care/ethics , Ethical Analysis , Health Priorities/ethics , Health Status , Humans , Morals
16.
Med Decis Making ; 41(4): 408-418, 2021 05.
Article in English | MEDLINE | ID: covidwho-1117298

ABSTRACT

OBJECTIVE: To explore the key patient attributes important to members of the Australian general population when prioritizing patients for the final intensive care unit (ICU) bed in a pandemic over-capacity scenario. METHODS: A discrete-choice experiment administered online asked respondents (N = 306) to imagine the COVID-19 caseload had surged and that they were lay members of a panel tasked to allocate the final ICU bed. They had to decide which patient was more deserving for each of 14 patient pairs. Patients were characterized by 5 attributes: age, occupation, caregiver status, health prior to being infected, and prognosis. Respondents were randomly allocated to one of 7 sets of 14 pairs. Multinomial, mixed logit, and latent class models were used to model the observed choice behavior. RESULTS: A latent class model with 3 classes was found to be the most informative. Two classes valued active decision making and were slightly more likely to choose patients with caregiving responsibilities over those without. One of these classes valued prognosis most strongly, with a decreasing probability of bed allocation for those 65 y and older. The other valued both prognosis and age highly, with decreasing probability of bed allocation for those 45 y and older and a slight preference in favor of frontline health care workers. The third class preferred more random decision-making strategies. CONCLUSIONS: For two-thirds of those sampled, prognosis, age, and caregiving responsibilities were the important features when making allocation decisions, although the emphasis varies. The remainder appeared to choose randomly.


Subject(s)
Attitude to Health , COVID-19/therapy , Critical Care , Decision Making/ethics , Health Care Rationing , Intensive Care Units , Pandemics , Adolescent , Adult , Aged , Aged, 80 and over , Australia , Ethics, Clinical , Female , Health Care Rationing/ethics , Health Care Rationing/methods , Humans , Latent Class Analysis , Male , Middle Aged , Patient Admission , Public Opinion , SARS-CoV-2 , Surveys and Questionnaires , Triage , Young Adult
17.
J Med Internet Res ; 23(3): e24883, 2021 03 11.
Article in English | MEDLINE | ID: covidwho-1112561

ABSTRACT

BACKGROUND: Effective communication during a health crisis can ease public concerns and promote the adoption of important risk-mitigating behaviors. Public health agencies and leaders have served as the primary communicators of information related to COVID-19, and a key part of their public outreach has taken place on social media platforms. OBJECTIVE: This study examined the content and engagement of COVID-19 tweets authored by Canadian public health agencies and decision makers. We propose ways for public health accounts to adjust their tweeting practices during public health crises to improve risk communication and maximize engagement. METHODS: We retrieved data from tweets by Canadian public health agencies and decision makers from January 1, 2020, to June 30, 2020. The Twitter accounts were categorized as belonging to either a public health agency, regional or local health department, provincial health authority, medical health officer, or minister of health. We analyzed trends in COVID-19 tweet engagement and conducted a content analysis on a stratified random sample of 485 tweets to examine the message functions and risk communication strategies used by each account type. RESULTS: We analyzed 32,737 tweets authored by 118 Canadian public health Twitter accounts, of which 6982 tweets were related to COVID-19. Medical health officers authored the largest percentage of COVID-19-related tweets (n=1337, 35%) relative to their total number of tweets and averaged the highest number of retweets per COVID-19 tweet (112 retweets per tweet). Public health agencies had the highest frequency of daily tweets about COVID-19 throughout the study period. Compared to tweets containing media and user mentions, hashtags and URLs were used in tweets more frequently by all account types, appearing in 69% (n=4798 tweets) and 68% (n=4781 tweets) of COVID-19-related tweets, respectively. Tweets containing hashtags also received the highest average retweets (47 retweets per tweet). Our content analysis revealed that of the three tweet message functions analyzed (information, action, community), tweets providing information were the most commonly used across most account types, constituting 39% (n=181) of all tweets; however, tweets promoting actions from users received higher than average retweets (55 retweets per tweet). When examining tweets that received one or more retweet (n=359), the difference between mean retweets across the message functions was statistically significant (P<.001). The risk communication strategies that we examined were not widely used by any account type, appearing in only 262 out of 485 tweets. However, when these strategies were used, these tweets received more retweets compared to tweets that did not use any risk communication strategies (P<.001) (61 retweets versus 13 retweets on average). CONCLUSIONS: Public health agencies and decision makers should examine what messaging best meets the needs of their Twitter audiences to maximize sharing of their communications. Public health accounts that do not currently employ risk communication strategies in their tweets may be missing an important opportunity to engage with users about the mitigation of health risks related to COVID-19.


Subject(s)
COVID-19/epidemiology , Decision Making/ethics , Public Health , Social Media/trends , Canada/epidemiology , Humans , SARS-CoV-2/isolation & purification
19.
Clin J Oncol Nurs ; 25(1): 61-68, 2021 Feb 01.
Article in English | MEDLINE | ID: covidwho-1084208

ABSTRACT

BACKGROUND: The disruption in the supply chain of resources and interruptions in cancer treatments caused by the pandemic presented tremendous challenges to the healthcare system. OBJECTIVES: This article describes the National Academy of Medicine-defined states of medical and nursing care delivery for which local plans should be drawn and the shifting and evolving systems framework that can guide decisions to optimize the crisis standards of care. METHODS: A case study is presented to describe the process of shifting the state of medical and nursing care delivery and bioethical nursing considerations during the pandemic and beyond. FINDINGS: An evolving and shifting systems framework for crises rooted in deontology, principlism, and the ethics of care model provide meaningful guidance for establishing priorities for patient care.


Subject(s)
COVID-19/nursing , Decision Making/ethics , Delivery of Health Care/ethics , Neoplasms/nursing , Oncology Nursing/ethics , Oncology Nursing/standards , Pandemics/ethics , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Pandemics/prevention & control , Practice Guidelines as Topic , SARS-CoV-2
20.
HEC Forum ; 33(1-2): 73-90, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1083437

ABSTRACT

The Covid-19 pandemic has presented major challenges to society, exposing preexisting ethical weaknesses in the modern social fabric's ability to respond. Distrust in government and a lessened authority of science to determine facts have both been exacerbated by the polarization and disinformation enhanced by social media. These have impaired society's willingness to comply with and persevere with social distancing, which has been the most powerful initial response to mitigate the pandemic. These preexisting weaknesses also threaten the future acceptance of vaccination and contact tracing, two other tools needed to combat epidemics. Medical ethicists might best help in this situation by promoting truth-telling, encouraging the rational adjudication of facts, providing transparent decision-making and advocating the virtue of cooperation to maximize the common good. Those interventions should be aimed at the social level. The same elements of emphasizing cooperation and beneficence also apply to the design of triage protocols for when resources are overwhelmed. A life-stages approach increases beneficence and reduces harms. Triage should be kept as simple and straightforward as reasonably possible to avoid unwieldly application during a pandemic.


Subject(s)
COVID-19/prevention & control , Ethicists , Pandemics/prevention & control , Physical Distancing , Professional Role , Cooperative Behavior , Decision Making/ethics , Humans , Resource Allocation/ethics , SARS-CoV-2 , Triage/ethics , Truth Disclosure/ethics
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