Ethical Challenges Arising in the COVID-19 Pandemic: An Overview from the Association of Bioethics Program Directors (ABPD) Task Force

Abstract

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing policies for pandemics differ by institution, health system, and applicable law. Most seem to agree that a patient’s ability to benefit from treatment and to survive are first-order considerations. However, there is debate about what clinical measures should be used to make that determination and about other factors that might be ethically appropriate to consider. In this paper, we discuss resource allocation and several related ethical challenges to the healthcare system and society, including how to define benefit, how to handle informed consent, the special needs of pediatric patients, how to engage communities in these difficult decisions, and how to mitigate concerns of discrimination and the effects of structural inequities.     

Ethically Allocating COVID-19 Drugs Via Pre-approval Access and Emergency Use Authorization

Abstract

Allocating access to unapproved COVID-19 drugs available via Pre-Approval Access pathways or Emergency Use Authorization raises unique challenges at the intersection of clinical care and research. In conditions of scarcity, prioritization approaches should minimize harm, maximize benefit, and promote fairness. To promote continued data collection, patients seeking access to unproven COVID-19 drugs should receive lower priority for allocation when they decline to participate in clinical trials, either of the requested drug or other investigational products, offering a comparable balance of risks and benefits; special attention should be paid to concerns of voluntariness and distrust. In addition, institutional treatment protocols that can contribute more robust real world data should be preferred to single patient requests for access, with priority for inclusion based on traditional clinical allocation criteria relying on available evidence. Fairness demands distribution of these protocols across a diverse range of sites, particularly those serving marginalized populations, among other protections.     

论影响卫生资源分配公平性的因素

公平分配卫生资源是促进社会公正的重要方面。观念、体制与政策是影响卫生资源公平分配的重要因素。重医疗、轻预防的观念使宏观卫生资源分配失去公平,而城市尤其是大中城市优先的制度安排、按医疗项目付费方式的弊端、医疗保障体制的不公平等体制与政策因素则使微观卫生资源分配失去公平。从观念因素、体制与政策因素两个方面入手,改进卫生资源分配的公平性,是我国提高全民健康水平、促进社会公正的必由之路。     

Training Psychologists for a Future in Evolving Health Care Delivery Systems: Building a Better Boulder Model

Recent and dramatic changes in the demand for and reimbursement of psychological services and expertise in health care delivery systems have radical implications for the preparation of psychologists at the predoctoral, internship, and postdoctoral levels. In order to respond to these changes effectively and advance the profession, training programs must realize the expanded and potential role of psychological expertise in evolving health care delivery systems. In this paper, we review several limitations and unfortunate consequences of traditional training programs that have confined the scope of research and practice to the realm of mental health. We propose that future psychologists be recognized and trained from a broader perspective as behavioral scientists, prepared to operate at the highest levels of health care delivery systems. Specific recommendations for training and education are discussed.     

Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

Abstract

The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the COVID-19 pandemic is a global health injustice due to moral failures of national governments and international organizations to prepare for, prevent and control it. Global and national health communities had a moral obligation to act in accordance with the current state of knowledge of pandemic preparedness. This obligation—a positive duty to develop and implement systems to reduce threats to and safeguard individuals’ and, communities’ abilities to flourish—stems from theories of global health justice and governance. The COVID-19 pandemic revealed and amplified the fragility and deficiencies in our global and domestic health institutions and systems. Moving forward, positive public health ethics is needed to set ethical standards for building and operating robust public health systems for resilient individuals and communities.     

Balancing Legitimate Critical-Care Interests: Setting Defensible Care Limits Through Policy Development

Critical-care decision making is highly complex, given the need for health care providers and organizations to consider, and constructively respond to, the diverse interests and perspectives of a variety of legitimate stakeholders. Insights derived from an identified set of ethics-related considerations have the potential to meaningfully inform inclusive and deliberative policy development that aims to optimally balance the competing obligations that arise in this challenging, clinical decision-making domain. A potential, constructive outcome of such policy engagement is the collaborative development of an as-fair-as-possible dispute resolution process that incorporates an appropriated-justified, defensible critical-care obligation threshold.     

我国农村初级卫生保健制度发微

集中梳理和总结有关中国农民初级卫生保健,特别是农村卫生投入和补偿机制、农村公共卫生和预防保健的文献,结合实地调研中发现的问题和矛盾,分析当今中国初级卫生保健的倾向、面临的问题,和当前我国卫生资源科学、合理利用以及可持续发展的滞碍所在,从理论与实证研究的角度提出未来的工作方向和政策建议。     

Ethical Guidance for Selecting Clinical Trials to Receive Limited Space in an Immunotherapy Production Facility

Our aims are to (1) set forth a multiprinciple system for selecting among clinical trials competing for limited space in an immunotherapy production facility that supplies products under investigation by scientific investigators; (2) defend this system by appealing to justice principles; and (3) illustrate our proposal by showing how it might be implemented. Our overarching aim is to assist manufacturers of immunotherapeutic products and other potentially breakthrough experimental therapies with the ethical task of prioritizing requests from scientific investigators when production capacity is limited.     

Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward.     

Clinical Ethicists Awakened: Addressing Two Generations of Clinical Ethics Issues Involving Undocumented Patients

Because the United States has failed to provide a pathway to citizenship for its long-term undocumented population, clinical ethicists have more than 20 years of addressing issues that arise in caring for this population. I illustrate that these challenges fall into two sets of issues. First-generation issues involve finding ethical ways to treat and discharge patients who are uninsured and ineligible for safety-net resources. More recently, ethicists have been invited to help address second-generation issues that involve facilitating the presentation for care of undocumented patients. In the current environment of widespread fear of deportation in the immigrant community, ethicists are working with health care providers to address patient concerns that prevent them from seeking care. I illustrate that in both generations of issues, values implicit within health care, namely, caring, efficiency, and promotion of public health, guide the strategies that are acceptable and recommended.     

印度农村医疗的现状与对策

自印度独立以来,政府就致力于采取各种有力措施来改善人们的健康情况并已卓见成效。尽管印度政府采取了一系列的发展政策,经济、地区发展不平衡及男女不平等还是为医疗部门带来了巨大的挑战。分析印度政府在农村所面临的问题以及为解决这些问题政府颁布的新政策。     

The elderly and high technology medicine: A case for individualized,autonomous allocation

The issues involved in decision making about the aggressiveness of future medical care for older persons are explored. They are related to population trends, the heterogeneity of older persons and a variety of factors involved in individual preferences. Case studies are presented to illustrate these points, as well as a review of pertinent literature. The argument is offered that, considering these many factors, a system of flexible, individualized care by informed patient preference, is more rational than the rationing of technological services by age.     

山西省艾滋病防治政策分析

阐述了艾滋病在山西省流行的现状,探讨了艾滋病引发的社会问题,分析了艾滋病防治条例、四免一关怀政策以及艾滋病自愿咨询与检测制度的执行情况以及在执行过程中所存在的主要问题,研究了山西省艾滋病防治工作相关基金的来源和使用情况,针对山西省在艾滋病防治工作中存在的问题,提出了艾滋病防治工作与社区工作相结合的建议。     

A Decade of Clinical Psychology in Medical Settings: The Short Longer View

The progress and accomplishments of psychology in medical settings over the past decade since the publication of the Handbook of Clinical Psychology in Medical Settings (J. J. Sweet, R. H. Rozensky, & S. M. Tovian, 1991) and the subsequent founding of the Journal of Clinical Psychology in Medical Settings (JCPMS) in 1994 are highlighted. Areas of progress and accomplishments reviewed include professional developments with our field, roles and services provided by psychologists, education, training and research issues, and program administration in medical settings. The current status of, and possible changes in, medical settings is identified. Future challenges and opportunities for the profession are discussed.     

Clinical psychology in medical settings: Psychology's role in health care

The number of clinical psychologists working in medical settings has grown along with the range of services provided by psychologists to patients with a multitude of medical problems across the lifespan. Medical care cost savings brought about by these psychological interventions is highlighted along with issues of public policy and specialization of training. The opportunity for ongoing development of clinical psychology in medical settings is described as unlimited and the mission of the newJournal of Clinical Psychology in Medical Settings is presented as supporting that growth.     

Quality Improvement as a Tool for Translating Evidence Based Interventions Into Practice: What the Youth Violence Prevention Community can Learn from Healthcare

Health care has been working for the past 2 decades to improve the translation of evidence based practice (EBPs) into care. The strategies used to facilitate this, and lessons learned, can provide useful models for similar work taking place in youth violence prevention. This article discusses the history of evidence translation in health care, reviews key strategies used to support translation of evidence based practice into care, and suggests lessons learned that may be useful to similar efforts in youth violence prevention and intervention services.     

Ageism in Mental Health and Health Care: A Critical Review

Discussions of aging and mental health widely assume that ageism among mental health providers is an important factor limiting access to mental health services for older adults. Given the widespread citation of ageism as a problem, we critically review the history of the ageism construct, and evidence for its existence in both mental health and medical professionals. There is surprisingly little empirical evidence for age bias among mental health providers. Considerable evidence does suggest differential medical treatment for older adults in such diverse areas as physician–patient interaction, use of screening procedures, and treatment of varied medical problems, although it is unclear whether age bias accounts for these differences. We suggest that innovations in delivery of psychological services, such as collaborative medical/psychological care in primary care settings, may ultimately prove more useful in improving access to mental health services than efforts to combat ageism.     

The Medical Offset Effect: Patterns in Outpatient Services Reduction for High Utilizers of Health Care

Psychosocial intervention has been found to be related to subsequent reductions in health care use. Studies generally measure this “offset effect” by combining medical use categories into one outcome variable, such as outpatient doctor visits. However, using a general outcome variable may obscure more specific patterns of reduction. In an effort to identify potential “targets” for mental health intervention, outpatient care for health screening, illness visits, laboratory/X-ray, and urgent care were considered. Health care use reductions were most prominent for high utilizers and were found across a number of different types of outpatient care. With high utilizers, those who participated in MFT showed significant reductions of 68% for health screening visits, 38% for illness visits, 56% for laboratory/X-ray visits, and 78% for urgent care visits.     

Psychological science in the public arena: Three cases of dubious influence

Psychological science has a great deal to contribute to social welfare in all societies, because the world's most pressing social problems are behavioral in nature—violence, hunger, drug abuse, environmental pollution, low worker productivity, poor educational outcomes, and so forth. Thus, psychological research can inform public policies to improve approaches to these important social problems. The relationship of psychological science to public policy is often troubled, however, by misunderstandings about the role of science in the policy making process. Many scientists fear that their research results will be "misused" by others whose values differ from those of scientists. Thus, psychologists are reluctant to publish research results that can be used to support policies contrary to their own values and hesitate to ask research questions that can generate politically incorrect results. In this article, I argue that psychological science has a primary responsibility to ask dangerous questions and to report results honestly, without fear of their use; that research is not translated directly into public policies; and that psychological science should not be perverted either by fear of political consequences or by compromising truth in a quest for power. Three research examples are given to illustrate the different faces of temptation to pervert psychological science in a misguided hope that scientists' own values will be reflected in public policies.     

Psychologists in Academic Health Centers: Traditions and Innovations in Education,Science, and Practice

Psychologists, interns, and postdoctoral fellows convened in Minneapolis May 3–5, 2007 for the 3rd National Conference of the Association of Psychologists in Academic Health Centers (APAHC): “Psychologists in Academic Health Centers: Traditions and Innovations in Education, Science, and Practice.” This paper reviews the development and organization of the conference, which built upon the two previous conferences of the Association of Medical School Psychologists. The articles in this special issue are based on a selected number of the 32 conference presentations, covering a range of timely topics that reflect the conference theme. Participants’ positive perceptions and satisfaction with the conference reveal the value of such conferences focused on the activities, interests, opportunities, and challenges of psychologists who work in academic health centers (AHCs) and teaching hospitals. Moreover, the content and success of the conference underscores the importance of APAHC as an organization serving the needs and promoting the interests of psychologists affiliated with AHCs.