[Efficiency is not enough. Ethical analysis and recommendations for the allocation of scarce resources in a pandemic situation]

[Prioritization of health resources in contexts of scarcity. SESPAS Report 2022]

La pandemia de COVID-19 ha supuesto un desafío tanto clínico como jurídico y bioético. Se desarrollan estos tres pilares fundamentales en el abordaje de la priorización de recursos sanitarios en pandemia: criterios clínicos, marco legal correspondiente y principios éticos aplicables. Inicialmente se aplicaron criterios clínicos para identificar a los pacientes con mejor pronóstico de supervivencia, combinando una evaluación clínica y el uso de variables de pronóstico a corto y largo plazo. Sin embargo, la decisión de priorizar la atención de un paciente sobre otro tiene una carga jurídico-política, que presenta el riesgo de caer en la discriminación ya que están en juego derechos fundamentales. Los criterios de priorización deben basarse en principios que reflejen como filosofía vehicular la que hemos asumido constitucionalmente como Estado social y democrático de Derecho, que no responde al utilitarismo, sino al personalismo. Cualquier filosofía de distribución de recursos tiene que tener presente la perspectiva científica, constitucional y, con ellas, las de los derechos fundamentales y los principios bioéticos. En la priorización de los recursos deberían consolidarse principios éticos como el respeto a la dignidad de las personas, el principio de necesidad (igual necesidad, igual acceso al recurso), el principio de equidad (que aconseja priorizar a los grupos de población más vulnerables), la transparencia (fundamental en la confianza de la sociedad) y el principio de reciprocidad (que exige proteger a los sectores de la población que asumen más riesgos), entre otros.

Bioethical Concerns During the COVID-19 Pandemic: What Did Healthcare Ethics Committees and Institutions State in Spain?

Objectives: Each new wave of the COVID-19 pandemic invites the possible obligation to prioritize individuals' access to vital resources, and thereby leads to unresolved and important bioethical concerns. Governments have to make decisions to protect access to the health system with equity. The prioritization criteria during a pandemic are both a clinical and legal-administrative decision with ethical repercussion. We aim to analyse the prioritization protocols used in Spain during the pandemic which, in many cases, have not been updated.

Method: We carried out a narrative review of 27 protocols of prioritization proposed by healthcare ethics committees, scientific societies and institutions in Spain for this study. The review evaluated shared aspects and unique differences and proffered a bioethical reflection.

Results: The research questions explored patient prioritization, the criteria applied and the relative weight assigned to each criterion. There was a need to use several indicators, being morbidity and mortality scales the most commonly used, followed by facets pertaining to disease severity and functional status. Although age was initially considered in some protocols, it cannot be the sole criterion used when assigning care resources.

Conclusions: In COVID-19 pandemic there is a need for a unified set of criteria that guarantees equity and transparency in decision-making processes. Establishing treatment indications is not the aim of such criteria, but instead prioritizing access to care resources. In protocols of prioritization, the principle of efficiency must vary according to the principle of equity and the criteria used to guarantee such equity.

Intensive care unit professionals during the COVID-19 pandemic in Spain: social and work-related variables, COVID-19 symptoms, worries, and generalized anxiety levels

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 outbreak has been identified as a pandemic and global health emergency. It presents as a severe acute respiratory disease. The rapid dissemination of the disease created challenges for healthcare systems and forced healthcare workers (HCWs) to deal with many clinical and nonclinical stresses. The aim of our research is to describe work conditions, symptoms experienced by HCWs, worries about contagion, and generalized anxiety symptoms and compare those findings across regions in Spain.

METHODS

This cross-sectional study was conducted using an online survey. Critical care units throughout Spain were included. The sample comprised HCWs working in intensive care units from March to May 2020. We assessed work variables, physical symptoms, worries about contagion, and anxiety (generalized anxiety disorder-7 questionnaire).

RESULTS

The final sample comprised 448 surveys. Among the respondents, 86.9% (n=389) were nursing professionals, and 84.8% (n=380) were women. All participants cared for coronavirus disease 2019 (COVID-19) patients during the study period. Workload during the pandemic in Madrid was judged to be higher than in other regions (P<0.01). The availability of personal protective equipment was found to be higher in Cataluña. The most frequently experienced symptom was headaches (78.1%). Worries about self-infection and the possibility of infecting others received mean scores of 3.11 and 3.75, respectively. Mean scores for generalized anxiety levels were 11.02, with 58.7% of the professionals presenting with generalized anxiety syndrome during the assessment.

CONCLUSIONS

In this study, we found high levels of anxiety among HCWs caring directly for COVID-19 patients, which could produce long-term psychological alterations that still need to be assessed.