[Medical priority setting in pandemics and the ethics of discrimination]. / Medizinische Priorisierung in Pandemien und der ethische Diskriminierungsbegriff.

Definition of the problem: As we have all learned in recent years, a pandemic can produce shortages in intensive care units. In our jurisdiction, this has led to a ruling by the federal constitutional court, according to which the lawmaker has to provide better protection for persons with disabilities in the event of medical priority setting. Arguments: From an ethical perspective, this task requires a choice among various competing accounts on what exactly it is that makes a case of discrimination morally problematic. In addition, these accounts require amendments in order to encompass instances of indirect discrimination. Conclusion: As this article demonstrates by appeal to a number of concrete triage criteria, a moderate account of discrimination does the best job of focusing attention on the core of the current issues. Among these issues are the extent to which perceptions of persons with specific pre-existing challenges generally have an impact on the structure of their social interactions.

Non-invasive prenatal testing (NIPT): does the practice discriminate against persons with disabilities?

The most well-known goal of non-invasive prenatal testing (NIPT) is still to determine whether or not a fetus has trisomy 21. Since women often terminate the pregnancy upon a positive result, there is concern that the use of NIPT contributes to discrimination against persons with disabilities. If this concern is justified, it could have an impact on the wider social acceptability of existing testing practices and their potential further expansion. This paper demonstrates four different versions of the discrimination worry, indicates how international policy papers have reacted to them, and identifies the ethically most relevant feature of the concern.

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.

Trust and altruism--organ distribution scandals: do they provide good reasons to refuse posthumous donation?

A recent organ distribution scandal in Germany raises questions of general importance on which many thousands of lives may well depend. The scandal in Germany has produced reactions that are likely to occur whenever and wherever distribution irregularities occur and become public knowledge. After it had become known that physicians in three German hospitals were in the habit of manipulating records in order to fast-track their patients' cases, the country experienced a decrease of available organs by a staggering 40% in October 2012. Even though this loss of trust by donors and their families is understandable, and potentially a legitimate form of protest against wrongful distribution, the withdrawal of agreement to serve as a posthumous donor in response to irregularities also inevitably results in avoidable poor outcomes for highly vulnerable individuals. In this paper, we provide a moral analysis of such dilemmas and make recommendations as to the way forward.

Blood Products and the Commodification Debate: The Blurry Concept of Altruism and the 'Implicit Price' of Readily Available Body Parts.

There is a widespread consensus that a commodification of body parts is to be prevented. Numerous policy papers by international organizations extend this view to the blood supply and recommend a system of uncompensated volunteers in this area--often, however, without making the arguments for this view explicit. This situation seems to indicate that a relevant source of justified worry or unease about the blood supply system has to do with the issue of commodification. As a result, the current health minister of Ontario is proposing a ban on compensation even for blood plasma--despite the fact that Canada can only generate 30 % of the plasma needed for fractionation into important plasma protein products and has to purchase the rest abroad. In the following, I am going to suggest a number of alternative perspectives on the debate in order to facilitate a less dogmatic and more differentiated debate about the matter. Especially in light of the often over-simplified notions of altruism and commodification, I conclude that the debate has not conclusively established that it would be morally objectionable to provide blood plasma donors with monetary compensation or with other forms of explicit social recognition as an incentive. This is especially true of donations for fractionation into medicinal products by profit-oriented pharmaceutical companies.