Will coronavirus change the way we talk about death? Dr Paul Keeley. En The Spectator.
“Every generation has an event that defines it. For my father, it was the Second World War. For his father, the First World War. Some might have thought Brexit would have been ours, but the coronavirus pandemic puts politics into perspective. There is no doubt that 2020 will be viewed by historians in the same way 1918 is now: as the year of the plague. Tens of thousands have died and the death toll continues to rise sharply. The global economy is in tatters. The world is in lockdown. But if any good can come from coronavirus it might be in the way in which we come to think – and talk – about death. It's been said that in Britain today we view death in the way Victorians did sex; as one of life's great unmentionables. Might our current predicament change that?”
The duty to treat: where do the limits lie? Julian Sheather, John Chisholm. En BMJ Opinion
“Doctors are dying. The combination of a novel virus, no treatment, and inadequate supplies of personal protective equipment (PPE) is putting frontline health workers at risk of serious harm. The question arises: when does work-based risk become unacceptable? Does a point come when health professionals have a right not to treat seriously ill patients if their PPE is inadequate?”
Balint groups could be one way to prevent burnout during covid-19. Vijay Pattni, Jeff Phillips, and Rajnish Saha. En BMJ Blog.
“Encouraging staff to use informal support mechanisms, like a Balint group, in addition to high quality psychological and wellbeing services, helps to foster team spirit and cohesion. Providing opportunities for staff to reflect regularly on their experiences, rather than using single session debriefs, also has the potential to foster resilience, reduce burnout, and lower the risk of post-traumatic stress disorder.”
What does good care look like in a pandemic? A Statement of Principles for Residential Care Settings. Michael Dunn, Ann Gallagher and Nipa Chauhan. En JME BLOG.
“It is crucial that the ethical principles that underpin and motivate these strategic approaches are considered directly in the day-to-day practice of residential care work. Such principles will not address the strategic failures evident in the under-provision of equipment or support. Nor will they deal with the systemic problems that are resulting from the problematic separation of health and social care service responses in the UK at this time. However, by reflecting on and discussing these principles, we think that staff members can be empowered to think constructively about how they can do the right thing for their residents and colleagues. We believe the following ethical principles should undergird residential care practice in the current pandemic: harm reduction; non-abandonment; caring fairly; and maintaining agency and dignity.”
What the Coronavirus Crisis Reveals About American Medicine. By Siddhartha Mukherjee. En The New Yorker.
“Medicine isn’t a doctor with a black bag, after all; it’s a complex web of systems and processes. It is a health-care delivery system—providing antibiotics to a child with strep throat or a new kidney to a patient with renal failure. It is a research program, guiding discoveries from the lab bench to the bedside. It is a set of protocols for quality control—from clinical-practice guidelines to drug and device approvals. And it is a forum for exchanging information, allowing for continuous improvement in patient care. In each arena, the pandemic has revealed some strengths—including frank heroism and ingenuity—but it has also exposed hidden fractures, silent aneurysms, points of fragility. Systems that we thought were homeostatic—self-regulating, self-correcting, like a human body in good health—turned out to be exquisitely sensitive to turbulence, like the body during critical illness. Everyone now asks: When will things get back to normal? But, as a physician and researcher, I fear that the resumption of normality would signal a failure to learn. We need to think not about resumption but about revision.”
Is the Government using its own ethical framework? Elaine Gadd. En Nuffield Council of Bioethics Blog
“The ethical framework is designed to be used in a structured way by people who may not have formal training in ethics, to ensure that key ethical issues are identified.
The framework’s overarching principle is of equal concern and respect, which is then separated out into eight principles: respect, minimising harm, fair, work together, reciprocity, keeping things in proportion, flexibility and good decision-making.”
“Following the science” in the COVID-19 pandemic. John Dupré. En Nuffield Council of Bioethics Blog
“Policy must be based on a mixture of goals, costs and facts. Leaving aside costs for the moment, a common idea is that policy-makers decide on the goals and scientists provide them with facts relevant to achieving those goals. Even this simple model immediately makes clear why one could not just follow the science. If the goal is to minimise the loss of life then scientists will try to discover how much social distancing and so on will continue to contribute to this end. If the goal is to minimise economic disruption, very different facts will be required. If, as is more likely, some balance will be struck between the importance of these policy goals, a more complex set of options will need to be provided by scientific experts. None of these options amounts to just “following the science”.”
Is it wrong to prioritise younger patients with covid-19? Dave Archard, Arthur Caplan, William F and Virginia Connolly Mitty. En BMJ
“Yes (Dave Archard): Prioritisation—that is, deciding who should and should not receive potentially life saving treatment—is inevitable once demand for such treatment exceeds the supply of resources. Various guidelines for making such decisions have been made public, in the UK and elsewhere, and from official organisations, advisory bodies, and academics.
No (Arthur Caplan):As protective gear, ventilators, beds, and staff remain scarce in many healthcare settings during the covid-19 pandemic, much attention has focused on what principles ought to be followed in allocating these resources. The question of what role age ought to play has set off both concern and contentious debate.”
Pandemic Ethics: Why Lock Down of the Elderly is Not Ageist and Why Levelling Down Equality is Wrong. Julian Savulescu and James Cameron. En Practical Ethics Blog, university of Oxford.
“One strategy is a staged relaxation of lockdown. This post explores whether a selective continuation of lockdown on certain groups, in this case the aged, represents unjust discrimination. The arguments extend to any group (co-morbidities, immunosuppressed, etc.) who have significantly increased risk of death.”
Your country needs you’: The ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19. Michael Dunn, Mark Sheehan, Joshua Horden, Helen Turnham and Dominic Wilkinson. En JME Blog
This opinion piece raises a main question: how should we determine which health professionals are redistributed? And three secondary questions:
What constitutes a justifiable process for deciding which staff is chosen to be reassigned?
What reassignment models for making these decisions are fair and justifiable?
What is due to those reassigned to high-risk clinical roles?
Health Care Professionals Are Under No Ethical Obligation to Treat COVID-19 Patients. Udo Schuklenk. En JME Blog
Are doctors obliged to treat from the commitment of their profession? by taking an oath for the public good? Could a kind of "compulsory service" be considered as discussed in Germany? These are some of the questions asked by Udo Schuklenk.
On Being an Elder in a Pandemic. Larry R. Churchill. En The Hasting center
Do the elderly have special obligations during a pandemic, that is, something more than the duty we all have for hand washing, social distancing, timely self-quarantining, and most recently, wearing a face mask?
Larry Churchill answers: “My position is grounded in a lifespan approach to ethics. The basic idea is that ethics must be rethought at various stages in life and that what might have counted as virtuous or responsible during one phase might be irrelevant or even counterproductive at a later stage. For example, autonomy and productivity, which were cardinal virtues in my youth and middle age, are increasingly unimportant. Things I now value highly are convivial friendships, kindness, and humor, and the essential moral tasks are now integrity and bearing a series of inevitable losses with some degree of dignity. Allowing the moral values I earlier prized to remain prominent into my mid-70s would be a sign of arrested moral development.”
Religious Rituals During the Coronavirus Pandemic: Insights From Islamic Bioethics. Mohammed Ghaly. En Bioethics.net
“During the times of massive crises like the current coronavirus pandemic, individuals and communities consult their “moral systems” looking for support and coping mechanisms. For religious communities, congregational rituals make an integral part of these coping mechanisms, which strengthen their relationship with God, the Omnipotent, who can provide the best support. However, mounting scientific evidence espoused with WHO guidelines, urged people and governments to postpone or cancel mass gatherings because they entail risks of spreading the new virus. In the beginning, Muslim religious scholars seemed divided, and sometimes even confused, about how to incorporate new scientific data within the long-established religio-ethical discourse on congregational rituals. This article is meant to give a historical and analytical account of what happened in this regard and how Muslims religious scholars try to engage with available scientific information.”
Confronting Disability Discrimination During the Pandemic. Katie Savin and Laura Guidry-Grimes. En The Hasting Center Report.
“People with chronic conditions and disabilities, who can be particularly vulnerable to COVID-19 infection, face longstanding barriers and inequities in health care. As hospitals and public health authorities devise and share triage protocols allocating scarce critical-care resources, people with disabilities are expressing alarm that these protocols devalue them and exacerbate long-entrenched ableism in health care”
Extraordinary times: coping psychologically through the impact of covid-19. Caroline Walker, Clare Gerada. En BMJ Opinion
Anxiety, grief, guilt or traumas are common emotions in health professional during the pandemia. The article proposes a simple set of solutions which can be used by everyone.
“If you are feeling anxious, overwhelmed and uncertain: plant both feet on the ground, take a few deep breaths and think about what you do know and what you can do today
If you are feeling guilty, remember it is because you are a compassionate and caring person and you simply want to help, remember we are all doing our bit to fight covid-19 no matter how small and no matter what it is we do
If you are feeling grief, try to ride the waves of emotion, express them safely, be patient and kind to yourself, this will likely take many months to pass
If you are feeling traumatised, connect with your loved ones more often, try not to avoid fearful situations, remember this is normal and will likely pass quite soon and limit your less healthy coping behaviours (such as excessive use of alcohol)”
The moral obligations of our health care workers in a pandemia. Gary Mason. The globe and mail.
Interesting reflection on the moral obligation of health professionals: “It would be wrong for society to believe that our health-care workers have an unequivocal moral obligation to take care of us at any and all costs. Because that releases us, and our governments, from the obligations we have to ensure our hospitals are ready for any eventuality with which they may be confronted.”
The Slow Dragon and the Dim Sloth: What can the world learn from coronavirus responses in Italy and the UK? Marcello Ienca and David Shaw. En The BMJ
“Italy was caught off guard, but rapidly imposed strict measures to attempt to contain the spread of the virus. If the lesson from Italy is “be vigilant”, the lesson from the UK is “be logical” – but only by being both can governments respond effectively to this crisis.”
“Derrotar” la “infecció”. Mar Rosas. A Diari ARA
Mar Rosas, research coordinator at the Ethics Chair at Ramon Llull University, reflects on the value of language and narrative in the field of health, and in particular on the COVID 19 pandemic. The warlike narrative, often used for example in the field of oncology, is very present in the pandemic narrative.
Dia 12 del covid-19. Esther Giménez-Salinas. A Diari ARA
Beyond liberty: social values and public health ethics in responses to COVID-19. John Coggon. En Nuffield Council of Bioethics Blog.
“Legal and policy responses to COVID-19 rest on and express the balance of different basic values and principles. Earlier and current regulatory approaches bring into sharp relief how liberty must be understood and weighed against other values. This is for the sake of liberty itself, but crucially too for other compelling aspects of social justice.”
The Coronavirus Pandemic and the Ethics of Triage. RJ Snell. En Lozier Institute.
Some basic ethical principles are proposed, as a general framework of orientation in decision making.
The Moral Cost of Coronavirus. Joshua Parker and Mikaeil Mirzaali. In Journal of Medical Ethics Blog
Interesting reflection at the Journal of Medical Ethics Blog, about the ethical foundation when a triage is needed, that is, when there is a severe mismatch between supply and demand for resource allocation. It is essentially a matter of ethics and distributive justice.
In the commentary, it is said that Italy had opted for a utilitarian approach: "the principle of maximizing profits for the largest number". This assignment should be aimed to “those patients with the highest chance of therapeutic success''. And it is explained how different American bioethicists have also suggested that utilitarianism is somehow the best answer to rationing in the face of coronavirus. Utilitarianism thus seems to be the necessary and proportionate answer. But that means for front-line physicians a huge change in the way they practice medicine.
But this approach neglects, according to the authors, that physicians often make moral decisions regarding deonthological norms, and, because medicine takes place through interactions between individuals, physicians tend to maximize options for each individual patient. Indeed, "these moral values are at the heart of practicing medicine and a significant part of a doctor’s moral identity. This is a pricipally different way of thinking about ethics the doctor-patient relationship to utilitarian ways of thinking. ''
In the face of the need to move toward utilitarian decisions, the two most important burdens that physicians bear are moral responsibility and moral hazard. These are the moral costs of the pandemic.
Flattening the Curve, Then What?. Mark A. Rothstein. In The Hasting Center
We are hearing a lot of times these days the phrase "we have to flatten the curve". This reflection refers to other needs as well as flattening the curve.
On the one hand, increase available resources such as coronavirus tests, hospital and ICU beds, ventilators, personal protective equipment and trained healthcare workers. In short, we need greater surge capacity.
Flattening the curve means delaying the spread of infection and increasing the time needed to impose social distance measures. The economic and social consequences are distressing to contemplate, so flattening the curve is not a long-term strategy.
Public health measures can only be successful if there is a high degree of social solidarity, which requires trust in public health agencies and their leaders.
The life and death decisions of covid-19. Daniel Sokol. In The BMJ Blogs
If healthcare systems, primarily intensive care units, arrive to saturation, a key point is which patients should be given priority. Daniel Sokol states that this is important for ethical, social and legal reasons. The standard rule “first come, first served” is maybe familiar, impartial, equitable, and fair, but it has its exceptions. The next criterion would be that of greatest need (with profitability), but it would not be enough to solve the covid-19 problem either.
Sokol proposes that "for every candidate patient, there must be a careful assessment of their medical condition, their prognosis, and the likely burden that treatment will impose on the healthcare system. This requires both clinical expertise and an understanding of the current capacity of the hospital and perhaps the region. A scoring system that incorporates the various criteria is sensible". He also proposes that certain groups of people, such as doctors and other key workers, should be given preferential treatment.
Ethics in these pandemic times may require us to endure sacrifices on our personal freedom or comfort. Daniel Sokol. In The BMJ Blogs
Covid-19 has raised a number of ethical issues that concern individuals, organizations and governments. On a personal level, ethics in these times of pandemic may require us to endure sacrifices on our personal freedom or comfort, such as social distanceing or avoiding a visit to the doctor. At the organization and employer levels, there are moral (and legal) duties toward those who work for them and the broader public. And health systems are in a particularly challenging situation. France, for example, has put in place "ethical support units" in hospitals to help doctors determine which patients to prioritise if resources are lacking. To resolve the ethical conundrums of Covid-19, twhat matters most is the fairness and integrity of the decision-making process. If that is done right, with no relevant factors ignored, the final decision can hardly be attacked as ethically indefensible.
Am I Part of the Cure or Am I Part of the Disease? Keeping Coronavirus Out When a Doctor Comes Home. Christian Rose. In The New England Journal of Medicine
Interesting reflection on the healthcare professionals, at the same time care and risk. "The irony is that despite health workers’ being “the glue that holds the health system and outbreak response together,” per Tedros Ghebreyesus, director-general of the WHO, 41% of the Covid-19 cases in Wuhan resulted from hospital-related transmission.2 Health care providers are at increased risk for developing the condition and spreading it.3 Work stress is believed to weaken their immune systems, and close, intimate care of patients can lead to exposure to a higher viral load. (...)
As a colleague and I go through the 17 steps for donning personal protective equipment and the subsequent 11 steps for safely doffing it in the back corner of the ED, Coldplay’s “Clocks” comes through on my overnight playlist: Am I a part of the cure, or am I part of the disease? We wonder whether our commitment to our community puts our families at risk at home. But who would manage the triage tents, resuscitate the respiratory failures, and manage the intensive care units if health care professionals steered clear? Who would study the disease spread, investigate novel therapies, develop the disaster plans, or manage all the other health issues that continue to occur without regard for the virus?"
When the problem is urgent and important. Matt Morgan. In The BMJ
The article begins with Eisenhower's phrase "what is important is seldom urgent and what is urgent is seldom important", but this time we face an urgent and important challenge. Health systems in many countries are about to meet unprecedented demand, and we may soon face a situation where the demand for intensive care exceeds capacity. Tha author is an honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination.
The Toughest Triage — Allocating Ventilators in a Pandemic. Robert D. Truog, Christine Mitchell, George Q. Daley. In The New England Journal of Medicine
The Covid-19 pandemic has led to severe shortages of many essential goods and services, but it is specially worrying the lack of beds and ventilators at ICU. This shortage makes necessary developing proritization criteria.