Journal of medical ethics
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Journal of medical ethics · Feb 2021
Solidarity is for other people: identifying derelictions of solidarity in responses to COVID-19.
The role and importance of solidarity for effective health provision is the subject of lengthy and heated debate which has been thrown into even sharper relief by the COVID-19 pandemic. In various ways, and by various authorities we have all been asked, even instructed, to engage in solidarity with one another in order to collectively respond to the current crisis. Under normal circumstances, individuals can engage in solidarity with their compatriots in the context of public health provision in a number of ways, including paying taxes which fund welfare state initiatives, and avoiding others when ill. ⋯ In this paper I examine the consequence of these failures with reference to the actions of the current British government, which has failed to deliver an effective response to the crisis. This failure has effectively devolved responsibility for responding to the crisis to people who are simultaneously more vulnerable to infection, and less able to do anything about it. I argue that such responses represent mismanagement of a public health crisis, and a rejection of important democratic and egalitarian norms and values.
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Mandatory vaccination, including for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and effectiveness is high, the expected utility of mandatory vaccination is greater than the alternatives, and the penalties or costs for non-compliance are proportionate. I describe an algorithm for justified mandatory vaccination. ⋯ I defend a payment model against various objections, including that it constitutes coercion and undermines solidarity. I argue that payment can be in cash or in kind, and opportunity for altruistic vaccinations can be preserved by offering people who have been vaccinated the opportunity to donate any cash payment back to the health service.
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Due to COVID-19's strain on health systems across the globe, triage protocols determine how to allocate scarce medical resources with the worthy goal of maximising the number of lives saved. However, due to racial biases and long-standing health inequities, the common method of ranking patients based on impersonal numeric representations of their morbidity is associated with disproportionately pronounced racial disparities. In response, policymakers have issued statements of solidarity. ⋯ And while COVID-19 hospital policies may be presented as rigidly focused on saving the most lives, many make exceptions for those deemed worthy by policymakers such as front-line healthcare workers, older physicians, pregnant women and patients with disabilities. These exceptions demonstrate creativity and ingenuity-hallmarks of policymakers' abilities to flexibly respond to urgent societal concerns-which should also be extended to patients of colour. This paper dismantles common arguments against the confrontation of racial inequity within COVID-19 triage protocols, highlights concerns related to existing proposals and proposes a new paradigm to increase equity when allocating scarce COVID-19 resources.
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Journal of medical ethics · Jan 2021
Association of medical futility with do-not-resuscitate (DNR) code status in hospitalised patients.
Guidelines recommend a 'do-not-resuscitate' (DNR) code status for inpatients in which cardiopulmonary resuscitation (CPR) attempts are considered futile because of low probability of survival with good neurological outcome. We retrospectively assessed the prevalence of DNR code status and its association with presumed CPR futility defined by the Good Outcome Following Attempted Resuscitation score and the Clinical Frailty Scale in patients hospitalised in the Divisions of Internal Medicine and Traumatology/Orthopedics at the University Hospital of Basel between September 2018 and June 2019. The definition of presumed CPR futility was met in 467 (16.2%) of 2889 patients. 866 (30.0%) patients had a DNR code status. ⋯ In the subgroup of patients with presumed futile CPR, 144 of 467 (30.8%) had a full code status, which was independently associated with younger age, male gender, non-Christian religion and non-Swiss citizenship. We found a significant proportion of hospitalised patients to have a full code status despite the fact that CPR had to be considered futile according to an established definition. Whether these decisions were based on patient preferences or whether there was a lack of patient involvement in decision-making needs further investigation.
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Journal of medical ethics · Jan 2021
Three models for the regulation of polygenic scores in reproduction.
The past few years have brought significant breakthroughs in understanding human genetics. This knowledge has been used to develop 'polygenic scores' (or 'polygenic risk scores') which provide probabilistic information about the development of polygenic conditions such as diabetes or schizophrenia. They are already being used in reproduction to select for embryos at lower risk of developing disease. ⋯ This paper does not attempt to resolve these issues. However, as with many biomedical advances, an effective regulatory regime must be in place as soon as the technology is available. If there is no regulation in place, then the market effectively decides ethical issues.