Utilitarian Principlism as a Framework for Crisis Healthcare Ethics

Accountability frameworks: A critical evolution in healthcare

Canadians face prolonged waits for primary care, specialist care, hospital care, elective surgery, and advanced imaging relative to peer countries. A root problem is unclear queue management expectations. If programs have no mandate to provide timely care, the intuitive approach to demand challenges is not to innovate and improve, but to block access, create a queue, and force patients elsewhere. Patient care accountability frameworks define program expectations and accountability zones, clarifying that every patient has an accountable healthcare home and every program has a population (accountability zone). Program accountabilities include timely patient assessment and disposition; budget, space, and nursing care for program patients; and contingency plans for surges and queues. Accountability frameworks are an evolutionary stressor that would drive strategies to expedite appropriate care in the right place, to move patients out of queues into care. This article discusses accountability, accountability frameworks, and accountability strategies to improve system-wide access.

The Ethical Obligation to Treat Infectious Patients: A Systematic Review of Reasons

During pandemics, healthcare providers struggle with balancing obligations to self, family, and patients. While HIV/AIDS seemed to settle this issue, coronavirus disease 2019 (COVID-19) rekindled debates regarding treatment refusal. We searched MEDLINE, Embase, CINAHL Complete, and Web of Science using terms including obligation, refusal, HIV/AIDS, COVID-19, and pandemics. After duplicate removal and dual, independent screening, we analyzed 156 articles for quality, ethical position, reasons, and concepts. Diseases in our sample included HIV/AIDS (72.2%), severe acute respiratory syndrome (SARS) (10.2%), COVID-19 (10.2%), Ebola (7.0%), and influenza (7.0%). Most articles (81.9%, n = 128) indicated an obligation to treat. COVID-19 had the highest number of papers indicating ethical acceptability of refusal (60%, P < .001), while HIV had the least (13.3%, P = .026). Several reason domains were significantly different during COVID-19, including unreasonable risks to self/family (26.7%, P < .001) and labor rights/workers' protection (40%, P < .001). A surge in ethics literature during COVID-19 has advocated for permissibility of treatment refusal. Balancing healthcare provision with workforce protection is crucial in effectively responding to a global pandemic.

Ethical decision-making: exploring the four main principles in nursing

Nurses are regularly confronted with moral questions and ethical dilemmas in their practice, for example where a patient's decisions about their treatment conflict with the nurse's own views. While the standards contained in the Nursing and Midwifery Council The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates provide nurses with an overarching framework to guide practice, it is important that nurses understand the four main principles that underpin ethical care - autonomy, beneficence, non-maleficence and justice. This article examines these four principles and how they relate to nurses' ethical decision-making. The author also explores how nurses' ethics were tested by the coronavirus disease 2019 (COVID-19) pandemic. Having an awareness of ethical decision-making can enhance nurses' practice by providing them with a theoretical framework for treating patients with dignity and respect.

A call for theory-inspired analysis in qualitative research: Ways to construct different truths in and about healthcare

Over the last 50 years, there has been significant development of qualitative research and related methods in healthcare. Theoretical frameworks support researchers in selecting appropriate research approaches, procedures and analytical tools. However, the implications of the choice of theory are sparsely elucidated. Based on a text excerpt from a public debate article, the study aimed to show how different theory-inspired analytical perspectives produced varied understandings of the same text. The study presented three subanalyses inspired by Bourdieu's sociological theory, Lazarus and Folkman's psychological theory and utilitarian ethics, respectively. The analyses showed that by using different theoretical analytical perspectives in inductive processes, an immediate interpretation of the text was not obvious. It became possible to spot the underlying meta-theoretical assumptions, as the interpretations were not taken for granted or indisputable. Our analyses suggest that different theoretical lenses lead to different interpretations of the same empirical material, recognising the existence of multiple truths or realities. Thus, utilising a theoretical perspective in inductive analyses can enhance transparency and rigour because the analytical optics are made explicit to the reader. This allows the reader to follow the analysis processes and comprehend from which theoretical starting point a truth arises.

Institutional Priority-Setting for Novel Drugs and Therapeutics: A Qualitative Systematic Review

BACKGROUND

There is a lack of guidance on approaches to formulary management and funding for high-cost drugs and therapeutics by individual healthcare institutions. The objective of this review was to assess institutional approaches to resource allocation for such therapeutics, with a particular focus on paediatric and rare disease populations.

METHODS

A search of Embase and MEDLINE was conducted for studies relevant to decision-making for off-formulary, high-cost drugs and therapeutics. Abstracts were evaluated for inclusion based on the Simple Multiple-Attribute Rating Techniques (SMART) criteria. A framework of 30 topics across 4 categories was used to guide data extraction and was based on findings from the initial abstract review and previous health technology assessment (HTA) publications. Reflexive thematic analysis was conducted using QSR NVivo 12 software.

RESULTS

A total of 168 studies were included for analysis. Only 4 (2%) focused on paediatrics, while 21 (12%) centred on adults and the remainder (85%) did not specify. Thirty-two (19%) studies discussed the importance of high-cost therapeutics and 34 (23%) focused on rare/orphan drugs. Five themes were identified as being relevant to institutional decision-making for high-cost therapeutics: institutional strategy, substantive criteria, procedural considerations, guiding principles and frameworks, and operational activities. Each of these themes encompassed several sub-themes and was complemented by a sixth category specific to paediatrics and rare diseases.

CONCLUSION

The rising cost of novel drugs and therapeutics underscores the need for robust, evidence-based, and ethically defensible decision-making processes for health technology funding, particularly at the hospital level. Our study highlights practices and themes to aid decision-makers in thinking critically about institutional, substantive, procedural, and operational considerations in support of legitimate decisions about institutional funding of high-cost drugs and therapeutics, as well as opportunities and challenges that exist for paediatric and rare disease populations.

Ethical Considerations of Using ChatGPT in Health Care

ChatGPT has promising applications in health care, but potential ethical issues need to be addressed proactively to prevent harm. ChatGPT presents potential ethical challenges from legal, humanistic, algorithmic, and informational perspectives. Legal ethics concerns arise from the unclear allocation of responsibility when patient harm occurs and from potential breaches of patient privacy due to data collection. Clear rules and legal boundaries are needed to properly allocate liability and protect users. Humanistic ethics concerns arise from the potential disruption of the physician-patient relationship, humanistic care, and issues of integrity. Overreliance on artificial intelligence (AI) can undermine compassion and erode trust. Transparency and disclosure of AI-generated content are critical to maintaining integrity. Algorithmic ethics raise concerns about algorithmic bias, responsibility, transparency and explainability, as well as validation and evaluation. Information ethics include data bias, validity, and effectiveness. Biased training data can lead to biased output, and overreliance on ChatGPT can reduce patient adherence and encourage self-diagnosis. Ensuring the accuracy, reliability, and validity of ChatGPT-generated content requires rigorous validation and ongoing updates based on clinical practice. To navigate the evolving ethical landscape of AI, AI in health care must adhere to the strictest ethical standards. Through comprehensive ethical guidelines, health care professionals can ensure the responsible use of ChatGPT, promote accurate and reliable information exchange, protect patient privacy, and empower patients to make informed decisions about their health care.

Civil servants' integrity in public sector: the case of Nepal

Civil servants' integrity in delivering public service is the heart and soul of public sector governance worldwide, including in Nepal. Ensuring a higher level of integrity for civil servants is complex, as it is affected by several factors. With this consideration, this study aims to examine the factors affecting the integrity of civil servants in the delivery of public services in Nepal. Data on this subject were derived from the Nepal National Governance Survey 2017/18, and analyzed using a logistic regression model. The findings revealed that citizens perceived civil servants' integrity in public service was positively affected by civil servants' compliance with rules, their responsiveness in delivering service, their service on time, their hassle-free service, and their adequate salary, whereas negatively affected by civil servants' prior network/connection with citizens and their asking or receiving a bribe for public service. Therefore, the concerned authorities should focus on these factors to build and maintain civil servants' integrity in delivering public service. Our findings provide empirical evidence for concerned authorities who can contribute to adopting innovative governance approaches and appropriate policies to build and maintain civil servants' integrity in the coming days. The study contributes to the field of integrity and public service by highlighting the factors affecting the integrity of civil servants in the delivery of public services.

The role of patients in the governance of a sustainable healthcare system: A scoping review

Patients, healthcare providers and insurers need a governance framework to establish the 'rules of use' to deliver more responsible use of services. The objective of this review was to provide an overview of frameworks and analyze the definitions of patient accountability to identify themes and potential gaps in the literature. Fifteen bibliographic databases were searched until July 2021. This included: MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, Allied and Complementary Medicine Database, Web of Science, HealthSTAR, Scopus, ABI/INFORM Global, Cochrane Library, ERIC, International Bibliography of the Social Sciences, Sociological Abstracts, Worldwide Political Science Abstracts and International Political Science Abstracts. Searches were also completed in Google Scholar. Inclusion criteria included articles focused on accountability of patients, and exclusions included articles that were not available, not written in English, with missing information, and commentaries or editorials. In total, 85530 unique abstracts were identified, and 27 articles were included based on the inclusion criteria. The results showed that patient accountability is rarely used and poorly defined. Most studies focused on what patients should be held to account for and agreed that patients should be responsible for behaviours that may contribute to adverse health outcomes. Some studies promoted a punitive approach as a mechanism of enforcement. Most studies argued for positive incentives or written agreements and contracts. While many studies recognized the value of patient accountability frameworks, there was a concern that these frameworks could further exacerbate existing socioeconomic disparities and contribute to poor health-related behaviours and outcomes (e.g., stigmatizing marginalized groups). Shared models of accountability between patients and healthcare providers or patients and communities were preferred. Before committing to a patient accountability framework for improving patient health and sustaining a healthcare system, the concept must be acceptable and reasonable to patients, providers, and society as a whole.

Reduced utilitarian willingness to violate personal rights during the COVID-19 pandemic

The COVID-19 pandemic poses many real-world moral dilemmas, which can pit the needs and rights of the many against the needs and rights of the few. We investigated moral judgments in the context of the contemporary global crisis among older adults, who are at greatest personal risk from the pandemic. We hypothesized that during this pandemic, individuals would give fewer utilitarian responses to hypothetical dilemmas, accompanied by higher levels of confidence and emotion elicitation. Our pre-registered analysis (https://osf.io/g2wtp) involved two waves of data collection, before (2014) and during (2020) the COVID-19 pandemic, regarding three categories of moral dilemmas (personal rights, agent-centered permissions, and special obligations). While utilitarian responses considered across all categories of dilemma did not differ, participants during the 2020 wave gave fewer utilitarian responses to dilemmas involving personal rights; that is, they were less willing to violate the personal rights of others to produce the best overall outcomes.

The COVID-19 pandemic and organ donation and transplantation: ethical issues

Background

The COVID-19 pandemic has had a significant impact on the health system worldwide. The organ and tissue donation and transplantation (OTDT) system is no exception and has had to face ethical challenges related to the pandemic, such as risks of infection and resource allocation. In this setting, many Canadian transplant programs halted their activities during the first wave of the pandemic.

Method

To inform future ethical guidelines related to the COVID-19 pandemic or other public health emergencies of international concern, we conducted a literature review to summarize the ethical issues.

Results

This literature review identified three categories of ethical challenges. The first one describes the general ethical issues and challenges reported by OTDT organizations and transplantation programs, such as risks of COVID-19 transmission and infection to transplant recipients and healthcare professionals during the transplant process, risk of patient waitlist mortality or further resource strain where transplant procedures have been delayed or halted, and resource allocation. The second category describes ethical challenges related to informed consent in the context of uncertainty and virtual consent. Finally, the third category describes ethical issues related to organ allocation, such as social considerations in selecting transplant candidates.

Conclusion

This literature review highlights the salient ethical issues related to OTDT during the current COVID-19 pandemic. As medical and scientific knowledge about COVID-19 increases, the uncertainties related to this disease will decrease and the associated ethical issues will continue to evolve.

Who's Getting Shots First? Dealing With the Ethical Responsibility for Prioritizing Population Groups in Vaccination

BACKGROUND

The current pandemic has raised several ethical dilemmas, related to conducting real-time trials for new treatments or vaccines or with decisions such as accessibility to vaccines.

STUDY QUESTION

Should there be a prioritization of access to the vaccine based on ethical and objective criteria or should the access be done at random?

STUDY DESIGN

To determine the ethics and reality of rationing the accessibility to anti-COVID vaccine according to the official strategies.

DATA SOURCES

The study is based on the consultation of (1) scientific articles from international databases (Google Scholar, PubMed, ProQuest, and Clarivate), (2) public health documents, and (3) official information of various governments.

RESULTS

The analyzed documents revealed that a few similarities can be observed in European countries when it comes to the first categories of people who have received the vaccine: people living in care facilities and medical staff; it can also be seen that the vaccination plan was adopted by each country for the needs and characteristics of its population, the prioritization being done in 2-14 stages; some of them divided, in their turn, into subsequent substages. Most of the states subject to the analysis assigned the medical staff in the first stage, followed by those in the sectors ensuring the maintenance of essential services, afterward by the elderly or people with comorbidities, only later to expand to other social categories.

CONCLUSIONS

Prioritization of vaccine administration is not only necessary, unavoidable, but also problematic both ethically and logistically, which should involve leaders in the field of public health, but also medical staff, regardless of their specialization. Prioritization of vaccination can not only have an impact on individual health (physical and emotional) but also on society from public health, economic, and sociocultural point of view.

COVID 19: A Cause for Pause in Undergraduate Medical Education and Catalyst for Innovation

As the world held its breath for news surrounding COVID-19 and hunkered down amidst stay-at-home orders, medical students across the U.S. wondered if they would be called to serve on the front lines of the pandemic. Medical school administrators faced the challenge of protecting learners while also minimizing harm to their medical education. This balancing act raised critical questions in medical education as institutions reacted to changing guidelines. COVID-19 has punctuated already contentious areas of medical education and has forced institutions and organizations to take quick action. From the perspectives of a recent medical school graduate and current resident (ES) and a practicing clinician-educator (SHG), we examine the pandemic's impact on undergraduate medical education through an ethical lens. First, we explore the value of medical education, what drives this value, and how COVID-19 may alter it. We next consider student choice and how shifts toward utilitarianism in healthcare during a pandemic may affect learning and career exploration. Then, we inquire how access to technology may impact the experience of medical students from diverse backgrounds and varied institutions during a rapid shift to socially distanced learning. We identify vulnerabilities for students at several phases of the journey: premedical, preclinical, clinical, and preparation for residency. Finally, we address the hidden curriculum of COVID-19, its potential erosion of empathy among current medical students, and possible long-term consequences for future physicians and patients.

A Journal of the COVID-19 (Plague) Year

The essays in this special issue of HEC Forum provide reflections that make explicit the implicit anthropology that our current pandemic has brought but which in the medical ethics literature around COVID-19 has to a great extent ignored. Three of the essays are clearly “journalistic” as a literary genre: one by a hospital chaplain, one by a medical student in her pre-clinical years, and one by a fourth-year medical student who reports her experience as she completed her undergraduate clerkships and applied for positions in graduate medical education. Other essays explore the pandemic from historical, sociological, and economic perspectives, particularly how triage policies have been found to be largely blind to structural healthcare disparities, while simultaneously unable to appropriately address those disparities. Central issues that need to be addressed in triage are not just whether a utilitarian response is the most just response, but what exactly is the greatest good for the greatest number? Together, the essays in this special issue of HEC Forum create a call for a more anthropological approach to understanding health and healthcare. The narrow approach of viewing health as resulting primarily from healthcare will continue to hinder advances and perpetuate disparities. Health outcomes result from a complex interaction of various social, economic, cultural, historical, and political factors. Advancing healthcare requires contextualizing the health of populations amongst these factors. The COVID-19 pandemic has made us keenly aware of how interdependent our health as a society can be.

Cosmetology advertising perspectives: application of ethical theories during COVID-19 crisis

In a pandemic, there are no egalitarians because all citizens cannot treat equally, and a failure to consider ethical concerns before taking action led to a massive and preventable loss of life. As a result of the pandemic, there is a strong ethical or moral imperative to consider how to help the most generous people usage healthy products. Utilitarianism and Kantian have become popular ethical theories that state the right actions that layout clear and actionable principles. This paper reviews (1) how Utilitarianism and Kantianism theories could produce benefit arguments on ethical purchases of cosmetic products from an advertising context, (2) how these theories contributed in the context of COVID-19 to help reduce any harmful health issues via advertising, and (3) Utilitarianism and Kantian theories have proven useful during the COVID-19 pandemic, according to case studies of cosmetics products and advertising in Western and Asian contexts. In addition to these two ethical theories, this paper discussed other issues. The purpose is not to argue which theory is the only relevant ethical theory but to contend with pure utilitarianism. Kantian's finding was similar to the topic argument in other ways. However, both theories reviewed as the most effective way to help societies identify and perceive the necessary costs of goods values. Before adopting utilitarian or Kantian theories, the community must clearly understand these two theories' merit values in product advertising. In such a crisis, ethical theories practices should implement in all areas because ethical challenges would determine whether or not advertisers around the world adhered to ethical standards in devising new and innovative marketing strategies, practices, or tactics for the transition to this new norm.