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04/06/2020 - 8:07pm

The Columbia University Bioethics Programs invites you to: "Health & Human Rights in the Era of Covid-19: What are the Ethical Issues?" 

• Unni Karunakara, MBBS, MPH, DrPH, former International President, Médecins Sans Frontières/Doctors Without Borders...

04/06/2020 - 1:18pm

by Daniel W. Tigard, Ph.D.

As our evening entertainment during the recent weeks of social distancing, my wife and I have been watching the TV rendition of The Handmaid’s Tale, based upon Margaret Atwood’s important novel. It is a captivating yet disturbing story of a dystopian future in which a mysterious disease brings about alarming drops in human fertility rates. As a result, a powerful fundamentalist religious sect seizes control of what was the United States, enslaves and rapes the young women who remain fertile, and institutes a highly segregated social order complete with color-coded uniforms for the differentiated members of society: blood red for the handmaids, an elegant blue for the esteemed wives, and so on.…

04/06/2020 - 12:05pm

By Daniel Aaron

The U.S. government has ratified a record-breaking $2 trillion stimulus package just as it has soared past 100,000 coronavirus cases and 1,500 deaths (as of March 27). The U.S. now has the most cases of any country—this despite undercounting due to continuing problems in testing Americans on account of various scientific and policy failures.

Coronavirus has scared Americans. Public health officials and physicians are urging people to stay at home because this disease kills. Many have invoked the language of war, implying a temporary battle against a foreign foe. This framing, though it may galvanize quick support, disregards our own systematic policy failures to prevent, test, and trace coronavirus, and the more general need to solve important policy problems.

Coronavirus is an acute problem at the individual level, but nationally it represents a chronic concern. No doubt, developing innovative ways to increase the number of ventilators, recruit health care workers, and improve hospital capacity will save lives in the short-term — despite mixed messages from the federal government. But a long-term perspective is needed to address the serious problems underlying our country’s systemic failures across public health.

We are treating coronavirus like an acute disease

Scholars are discussing how to distribute scarce health care resources ethically when need is high and rationing is inevitable. Many Americans are angry that health care workers do not have enough protective masks and gloves, ventilators, or hospital beds. People agree that there is a coronavirus crisis. On the other hand, some officials have said they would jettison public health measures in favor of economic growth. For example, President Trump, worried about stock prices, wanted the U.S. “opened up and just raring to go by Easter.” (He has since extended social distancing guidelines through the end of April.)

These battles largely take place on the acute side of public health. One the one hand, health care workers are occupied with rising patient loads. They may be consumed in advocating for patients’ acute needs, in ensuring they have the supplies for safe medical practice. And acute measures are needed to flatten the U.S. curve. But these arguments are self-undermining: The more the curve is flattened, the more coronavirus becomes a chronic problem. This conundrum highlights the need of finding new ways of talking about coronavirus other than an acute “war,” lest a perception take hold that once the “war” is over, we can move on.

Some journalists and scholars have written on coronavirus as a long-term public health problem, but these stories have been far from the focus of COVID-19 media coverage. Beth Cameron wrote a perspective piece in the Washington Post entitled “I ran the White House pandemic office. Trump closed it.” The article covers the 2018 closure of a White House office tasked with preventing a future outbreak. Similarly, a 2019 federal simulation called the “Crimson Contagion” revealed a list of “high-level, cross-cutting issues” within the ability of the federal government to respond to a pandemic, including problems with funding, organization, and communication. And although health care is essential to treating and managing coronavirus, 45% of U.S. adults are inadequately insured. We were systematically unprepared from a public health standpoint.

A “chronic” approach to coronavirus is possible

Arguably the best response to the pandemic was in South Korea. The country began developing a test early, in mid-January, before the acute harms began. Then, public health authorities aggressively tested people with mild or no symptoms who were suspected of being infected. Tens of thousands of people were quarantined. And it worked. Although South Korea appears to be one of the countries with the most cases, its data may be the most accurate, and its curve has been flattened. No doubt, this is because South Korea began its response months ago and consistently took swift action on behalf of public health. South Korea  also has had universal health coverage since 1989. As former FDA Commissioner Scott Gottlieb tweeted, “South Korea is showing #COVID19 can be beat with smart, aggressive public health.” This systemic approach might have obviated some acute need in the U.S. for ventilators and personal protective equipment (PPE).

We are obsessed with acute problems

In America, we tend to address acute problems and ignore the chronic. This bias came to the fore in August 2019, when the U.S. had a vaping epidemic in which thousands were hospitalized and sixty-eight people died. The disease was named EVALI—e-cigarette, or vaping, product use-associated lung injury. The illnesses were largely found to be related to the additive vitamin E acetate. Soon, cases tapered off, and much of the attention to vaping and e-cigarettes quickly faded. However, there continues to be a mounting epidemic of e-cigarette use among youth, which started as early as 2011, and now 27.5% of high-school students use e-cigarettes. Our failure to pay attention to this problem for eight years, and our fleeting concern during a period of 2019, highlights that we, as a country, have failed to take concern with the chronic problem of youth nicotine addiction.

Similar patterns can be seen in other public health issues. We underinvest in sound, evidence-based nutrition policies. We spend $19 per person annually on public health, compared with nearly $11,000 per person on health care. About 20% of Americans postpone preventive care due to cost, and this figure is three-times higher for people below 200% of the federal poverty line than for those above. We discourage people from seeing the doctor by charging them deductibles and copays, which are harder to pay for poor people. Money allocated to public health by the Affordable Care Act has been siphoned away to other causes. The remaining funds may be lost in a legal case that threatens to invalidate the Affordable Care Act.

Why are other public health disasters, like the opioid epidemic, not a “war?” Why is there no war against climate change?

Chronic, complex issues do not command enough attention in the United States. Acute, discrete concerns take precedence.

Conclusion

There are marvelous people working on chronic disease and long-term public health issues. They should be commended. But our focus on the acute is a systemic problem. We have yet to disentangle the social, governmental, and corporate regulatory structure that creates and perpetuates public health crises.

The battles to obtain more ventilators and PPE are worth having. However, we also need a response to the chronic “disease” underlying the coronavirus.

The post Why COVID-19 is a Chronic Health Concern for the US appeared first on Bill of Health.

04/06/2020 - 11:10am

by Joseph Stramondo, Ph.D.

While I have warned against using quality of life criteria when developing triage protocol, what about the strategy of using as a criterion the likelihood of whether a patient will survive COVID-19 even with aggressive treatment? On the face of it, this seems safer from ableist bias than the previously examined quality of life criterion. After all, even Ne’eman – who defends the view that the best way to avoid ableist bias is for people to be cared for on a first come first served basis, regardless of other factors – admits that patients should not be provided with futile care that will not actually save their life from the virus. …

04/06/2020 - 10:00am

Three otherwise healthy patients go to the emergency department with severe acute respiratory failure. Only one ventilator, required to sustain life until the worst of the coronavirus infection has passed, is available. Who gets the vent?

That’s what “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic,” Viewpoint just published in the Journal of the American Medical Association (JAMA), addresses. Douglas White, MD, MAS, Endowed Chair for Ethics in Critical Care Medicine at the University of Pittsburgh School of Medicine and Bernie Lo, MD, from the University of California, San Francisco, wrote the Viewpoint, which links to a full policy document that’s been in the works since 2009. It is being implemented in several states and can easily be adapted to any hospital, Dr. White said in a Webinar on March 27.

The impending shortage of ventilators during a surge of viral infections evokes the scene in William Styron’s 1979 novel (and 1982 film) Sophie’s Choice. Upon arriving at Auschwitz, Meryl Streep’s character, a young Polish Catholic mother, must choose which of her two children would be gassed immediately and which would be allowed to live. The decision haunts her for the rest of her days.

Intensivists – physicians trained in critical care medicine – now face the dilemma of choosing who gets the ventilator. There’s precedent, in allocating organs for transplant and, more generally, slots in clinical trials. But nothing has happened at this scale and in this time frame, the looming tsunami of need. Said Dr. White:

In traditional medical ethics, it’s a treating physician’s obligation to address the well-being of individual patients and to respect the preferences of the patient. In a public health emergency, ethics shifts from an individual patient to focus on maximizing the well-being and outcomes of a population of patients.

Triage

The rationing framework replaces the old way of eliminating certain groups of individuals with a 1 to 8 scale, the lower number indicating higher priority in getting the ventilator. Previous protocols removed people with severe chronic lung disease, end-stage kidney disease, heart failure, metastatic cancer, severe cognitive impairment, and in some places, simply old age.

The “multiprinciple allocation framework” applies the score of  1 to 8  to everyone. It is based on projecting what will happen after a patient survives being on the ventilator.

“Just getting the most patients out of the ICU is not enough. If they get out and they have weeks or months left to live, we are not capturing all the things we think are important. No single principle adequately captures the values we take into account when we make these decisions,” Dr. White explained.

The process begins with triage, a staple of disaster medicine.

First, people who have previously stated that they would not want mechanical ventilation in the face of catastrophic or end-stage illness would be asked if they still feel that way. If so, they’re taken out of consideration. A second Viewpoint in the March 25 online JAMA, from J. Randall Curtis, MD, MPH, of the University of Washington, Seattle and colleagues, emphasizes the importance of knowing someone’s DNR wishes.

Second, a team separate from the doctors directly treating the patients makes the triage decisions. “That (treating) doctor has an obligation to the patient right in front or her or him and is knee-deep in keeping patients alive,” Dr. White said. The triage team coordinates with other hospitals, perhaps moving a patient to a facility with an available ventilator before starting down the Sophie’s choice pathway.

Third comes the 1-8 scale that reduces a complex comparison to two general criteria:

  • likelihood of survival after hospital discharge
  • number of life-years gained.

“It compares folks who are most likely to survive after discharge and life years gained to those who have almost no chance of surviving after discharge and accruing life years,” Dr. White explained. Decisions are resource-driven rather than by exclusion of groups, he added.

To assign the scores, doctors consult commonly-used “severity of illness” rating scales to compare just how sick the patients are. That may entail a bit of apples-to-oranges comparisons though. Is a person who recently underwent chemo more likely to survive a prolonged ventilator stint than someone who’s had a recent heart attack?

As the states wrestle with  triage protocols, the fear that certain groups will receive lower status persists, even with use of rating scales and the best intentions. The Arc of the United States, for example, which advocates for people with intellectual and developmental disabilities, has reportedly filed complaints with the Health and Human Services (HHS) department’s Office of Civil Rights (OCR) about possibly impending plans in Washington state, Alabama, and Tennessee. “We’re in the process of opening investigations right now,” said Roger Severino, director of OCR, in a briefing with reporters on March 28.

The 3 competing patients revisited

Returning to the three hypothetical patients competing for one ventilator, assume that they all score a 2. Next, two other factors come into play.

“The ‘life cycle principle’ states that all other things being equal, priority is given to the person who has had the least chance to live through life. If one person is 20 and the other two elderly, there would be a strong argument to give priority to the younger patient. It’s not because anyone has more worth or value than anyone else,” said Dr. White.

The second tiebreaker is ‘critical worker status,’ using what Dr. White calls the “concept of instrumental value.” That is, health care workers and those who enable them to work, who fall ill, receive priority:

Nurses, respiratory therapists, doctors, and the people who clean the rooms between patients in the ICU – by prioritizing these individuals we may augment the response of the health care system and save more lives. For the risks these individuals are taking the health system should ensure they’re taken care of if they get sick.

Ventilator math and a crystal ball

Stress on the health care system to provide enough ventilators emerges from two factors: the huge number of infected people, and the fact that the sickest need to be on a vent about twice as long as people being treated for other respiratory conditions: up to 12 days.

A peculiarity of COVID-19 that impacts ventilator allocation is that some patients seem to do okay once taken off the vent, and then crash.

“There are subgroups who, when we extubate, look good initially and pass the parameters (for discontinuation) and then they get hypoxic and require reintubation. The rate is higher than we’re used to,” said Michelle N. Gong, MD, professor of Medicine and Epidemiology and Population Health at Albert Einstein College of Medicine and Chief of Critical Care Medicine at the Montefiore hospital group in New York City, at an earlier JAMA webinar.

Dr. White agrees. “COVID-19 requires a long duration of ventilation for improvement. It’s important that when we reassess a patient that we don’t release her or him too early. The first 96 hours is too soon to get a signal that separates those who will survive from those who will die. This is really challenging and we don’t yet have good empirical data. So we err on the side of longer ventilation than shorter.”

If patients destined to crash can be identified, their “spot” can go to someone of equivalent distress not likely to die when taken off the ventilator.

The unthinkable: taking a vent from one to save another

Does Sophie’s choice extend to removing people already on ventilators who aren’t doing as well as others who are waiting?

“If we get to a point where there are far more patients who need vents than there are vents, after triage we would pick from among those present every day. But we’ll also need to reassess patients on vents to see if they are improving or if their prognosis is worse than those in the queue. If so, we would need to withdraw mechanical ventilation for those with poor progress in order to give it to patients who are waiting and have better prognosis,” Dr. White said.

The setting is strikingly different from the more typical situation of a family deciding to take an end-stage cancer patient who’s been sick for many months off of a ventilator when others aren’t waiting. A need for ventilators to fight a COVID-19 infection that detonated just days earlier, in many people, is a different beast entirely.

And so ever-evolving assessment tools, like the 1-8 scale, are being developed and deployed to help clinicians and bedside bioethicists make these tough decisions.

No one likes to talk about these sorts of situations, but the conversations are being forced. The doctors in Italy likely made Sophie’s Choices, Dr. White admits, clearly uncomfortable.

Sharing ventilators?

Can ventilators be split, like sticking two straws into a can of Coke? Not easily, say experts.

“From a technical standpoint, that’s not something most hospitals will know how to do,” Dr. White said.

The reason is that each patient is different. “It’s an incredible calculation problem to figure out how to appropriately ventilate patients with different lung characteristics with one ventilator. Some have stiff lungs while others have compliant lungs. It would be great to see that capability, of sharing vents, developed, but we’re not there yet,” Dr. White added.

Bioethicists are also discussing ways that a family can remain connected when a COVID-19 patient is taken off a ventilator.

The best-case scenario is having enough PPE for loved ones to use so they can be at the bedside. The next best solution is a remote bedside vigil via video. “We try to somehow allow the family to be with the patient and have some closure,” Dr. White said.

Choices are going to be necessary, akin to Sophie’s.

**This blog was originally posted on the Genetic Literacy Project at https://geneticliteracyproject.org/2020/04/01/sophies-choice-in-the-time-of-coronavirus-deciding-who-gets-the-ventilator/

04/06/2020 - 7:00am

By Jonathan M. Marron and Paul C. McLean

One of us is a sports fan, childhood cancer doctor, and bioethicist. The other is a former sportswriter drawn to medical ethics since the cure of his only child. If sports and ethics have something in common, it’s the value of a level playing field. Fairness matters. There’s a coin toss: heads or tails. Fairness, not favoritism.

We view the doctor-patient relationship through slightly different lenses, but it’s precious either way. It’s a relationship — above all else — built on trust. And that relationship, a cornerstone of healthcare, is suddenly like an already vulnerable person facing an uncertain prognosis. If the doctor-patient relationship is to survive the novel coronavirus (COVID-19) pandemic, it will require a unified team, trust, and a level playing field, regardless of how much money or influence you have.

What does sports have to do with this?

An early inflection point in public awareness about COVID-19 was when professional basketball player Rudy Gobert tested positive for coronavirus. This quickly led to cancelling the remainder of the basketball season and was a sign to many that this was more than just “another flu.” Shortly after, it was reported that professional basketball players, many symptom-free, were tested. At a time when many are hearing from their doctors that almost no tests are available, it can only inspire distrust to see how easy it can be for those with means.

There are many troubling aspects of the player testing. They’re among the least likely to fall victim to the most severe effects of COVID-19; they are strong, young, healthy, and wealthy enough to afford it when their league cancelled the rest of the season. This is not the case for many patients with symptoms and known exposures coming to clinics and emergency departments. Clinicians cannot test many of these patients because of a severe shortage of testing kits. The argument that testing of professional athletes was performed through private companies (and therefore doesn’t represent them having preferential access) doesn’t hold water either, since neither clinicians nor the public can readily access testing, even through these companies.

The government’s mishandling of this crisis is worthy of blame for the shortage in testing supplies, but who has access to testing is a very different question.

One reason social distancing has become vital to the effort to slow and limit the spread of COVID-19 is because testing has been so lacking. So how can testing be readily available to certain celebrities? Why have they been privileged in this way? How could someone of lesser privilege and access NOT see this as proof that their lives don’t matter as much and that the system doesn’t care about them?

These inequities could have ramifications far after COVID-19 is eradicated, as those who couldn’t get tested (but saw those with money and influence do so easily) will not soon forget. Memory of this mistreatment will follow them into their relationship with the healthcare system, perhaps for years to come. We run the risk of this being yet another item on the list of times we have failed our most vulnerable, leading to further systemic — but understandable — distrust in the medical system.

One of us is from Chicago originally, the other from Los Angeles. Now we’re both in Boston. All big-time sports towns, and all with world-class medical institutions in the process of becoming overwhelmed by COVID-19.

It’s worth remembering that NBA legend Magic Johnson profoundly changed public attitudes about HIV when he was diagnosed and retired in 1991. Perhaps the news of Rudy Gobert and then Kevin Durant testing positive for COVID-19 may be seen in a similar light someday: for having helped the public take the coronavirus pandemic seriously.

But as public concern has grown, availability and accessibility of testing has not followed suit. In response to questions about inequitable access to COVID-19 testing, President Trump said: “Perhaps that’s been the story of life.” This may be among the only truths he has uttered regarding coronavirus, but just because this has too often been the “American Way” doesn’t mean that it should persist now under the most dire of circumstances. We MUST do better.

No pro basketball team has been more successful over the last decade than the Golden State Warriors, a team that laudably choose not to arrange special coronavirus tests for its players. “We’re not better than anybody, not worse,” said the team’s director of basketball operations, Bob Myers. “Just a basketball team.”

Maybe fairness and equity will always be more aspirational than real. But at some point, games will return and coronavirus will be gone, survived by its impact on doctors, patients, and (mis)trust.

And the doctor-patient relationship?

It’s a coin toss.

 

Jonathan M. Marron MD MPH is a pediatric oncologist, researcher, and bioethicist at the Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and the Harvard Medical School Center for Bioethics.  @JonMarronMD

Paul C. McLean is an author, parent, and Ethics Associate at Boston Children’s Hospital. @PaulCMcLean

The post The Long-Term Harm of Favoritism in COVID-19 Testing appeared first on Bill of Health.

04/06/2020 - 2:30am

"Crip Camp” is now available on Netflix. Reviewers describe it as "one of the most important and most honest films about disability."

04/06/2020 - 2:30am

"Crip Camp” is now available on Netflix. Reviewers describe it as "one of the most important and most honest films about disability."

The Netflix description states: "A groundbreaking summer camp galvanizes a group of teens with disabilities to help build a movement, forging a new path toward greater equality."

04/05/2020 - 4:00am

In 1981, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research released its seminal report, Defining Death. Two years later, in 1983, the Commission released a separate report summing up all its prior reports.

...

04/05/2020 - 4:00am

In 1981, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research released its seminal report, Defining Death. Two years later, in 1983, the Commission released a separate report summing up all its...